Prevention is key to keeping men who have sex with men (MSM) protected from Human Immunodeficiency Virus (HIV). Despite new and innovative HIV prevention resources such as pre-exposure prophylaxis (PrEP), factors such as education level, employment status, number of sexual partners, and access to health resources may inhibit certain populations from using PrEP. The purpose of this cross-sectional study was to examine the association between education level, employment status, number of sexual partners, and access to health resources and the use of PrEP among MSM. The fundamental cause theory was used to examine how socioeconomic barriers are associated with the use of PrEP among MSM in the United States. Secondary data from 217 surveys were collected from the Public Library of Science. Findings from multiple regression analyses indicated that employment status, access to health resources, and number of sexual partners were not associated with use of PrEP among MSM. Those who had at least some high school or a high school diploma were 3.98 times more likely to be likely to extremely likely to use PrEP, compared to those who had less than a high school education (OR = 3.98, p = .048). Those who had some college were 6.91 more likely to be likely to extremely likely to use PrEP, compared to those who had less than a high school education (OR = 6.91, p = .028). Findings may be used to assist public health professionals in identifying factors that prevent the use of PrEP. By addressing these health threats, and social barriers, specialists could have the ability to increase HIV prevention activity in populations that are more susceptible to being infected with HIV and may decrease HIV infections not only within the MSM population but also in other populations.

The overall aim of this thesis was to obtain an understanding of the dynamics of the HIV epidemic by estimating prevalence and exploring the relationship between HIV-related knowledge, attitudes, behavior, and HIV status in Nicaragua. Structured questionnaires were administered to adults from a health and demographic surveillance system in León, Nicaragua (Papers I–III). In-depth interviews and a survey were conducted among men who have sex with men (MSM, Paper IV). Blood sampling for HIV was carried out among 2,204 men and women (Paper I). Bivariate and multivariate analyses, including adjusted prevalence ratio (Papers I, II, IV), factor analysis, Cronbach’s alpha, and hierarchical regression analysis (Paper III) were performed. Thematic analysis was used with qualitative data (Paper IV). The prevalence of HIV in the general population was 0.35% (95% CI, 0.17–0.73). Those who have taken a HIV test were more likely to be females, younger, living in an urban setting, have a higher level of education, be married or cohabiting, and have no religious affiliation. HIV-related knowledge was lower among members of the general population than among MSM. Unprotected sex was reported more times with regular partners than with casual partners. Findings suggested that consistency of condom use and emotional attachment (steady relations) were inversely related. Stigma and discrimination were reported high in the general population; they appeared to be negatively associated with HIV-related knowledge, self-perception of HIV risk, HIV testing, and willingness to disclose HIV status in the event of being HIV-positive. Findings demonstrated an increasing tolerance towards same-sex attractions. MSM have a better understanding of HIV transmission than men and women of the general population. Although seven out of ten MSM and six out of ten women were concerned about becoming infected with HIV, inconsistent condom use was common. This study confirmed that Nicaragua has a low prevalence but high risk for HIV infection and transmission. Results underscore that social, behavioral, and cultural factors contribute to retard progress in achieving the Millennium Development Goals on reducing gender inequality and combating HIV/AIDS. Addressing these challenges depends not only on successful behavior change interventions, but requires a culturally gender-appropriate strategy.

The digital divide is a core issue of the information society. It refers to the division between those who have access to, or are comfortable using, information and communication technology (ICT) (the "haves") and those who do not have access to, or are not comfortable using ICT (the "have-nots"). The digital divide is a complex phenomenon. The majority of studies to date have examined the digital divide from a socio-economic perspective. These studies have identified income, education and employment as the key factors in determining the division between the "haves" and the "have-nots". Very little research has explore the psychological, social or cultural factors that contribute to digital inequality in community. The current study filled this gap by using Bandura's social cognitive theory (SCT) to examine the psychological barriers that prevent individuals from integrating ICT into their everyday lives. SCT postulates that a person will act according to their perceived capabilities and the anticipated consequences of their actions. Four studies have explored the digital divide using SCT. Because of limitations in the research design these studies have shed only limited light onto current understanding of digital inequality in community. The current research was the first study exploring the digital divide that (i) incorporated both socio-economic and socio-cognitive factors, (ii) used a community context that ensured the recruitment of participants who represented the full spectrum of the general population, and (iii) was conducted in both the US and Australia. Data was gathered via self administered questionnaires in two communities: Brisbane, Australia and San Jose, USA. Completed questionnaires were obtained from 330 and 398 participants from the US and Australia, respectively. Hierarchical regression analysis was used to explore the research question: what influence do socio-cognitive factors have in predicting internet use by members of the general population when the effects of socio-economic factors are controlled? The results of this analysis revealed that attitudes do matter. The US study found that socio-economic factors were not statistically significant predictors of internet use. The only factor that found to be a significant predictor of use was internet self efficacy. In short individuals with higher levels of internet self efficacy reported higher levels of internet use. Unlike the US study, the Australian study found that by themselves several socio-economic factors predicted internet use. In order of importance these were age, gender, income and ethnicity. However, the study also revealed that when socio-economic factors are controlled for, and socio-cognitive variables included into the analysis, it is the socio-cognitive and not the socioeconomic variables that are the dominant (in fact the only!) predictors of internet use. The research illustrated that the digital divide involves more than just the availability of resources and funds to access those resources. It incorporates the internal forces of an individual that motivates to them to use or integrate ICT into their lives. The digital divide is not just about ICT such as computers and the internet. It is about people. As such, the key to solving the issue of digital inequality is not going to be found with corporate or government funds providing physical access to technology. Instead, the key to solving digital inequality is inside the individual person. The alternative view of the digital divide presented in this research is by no means intended to minimise the role played by socio-economic factors. Indeed, the socioeconomic perspective has helped shed light on a very real social issue. What this research has done is suggest that the digital divide is more complex and more involved than has been imagined, and that further and different research is required if genuine insights and real steps are going to be made in establishing an information society for all.

The thesis is based on scene designs for the play Lady from the sea. I focused on the concept of the game from the perspective of the actual playwright, Henrik Ibsen. To get a wider range of designs I decided to choose a modern staging by Robert Wilson and Luboš Hrůza. My goal was to accommodate the production as a source of inspiration and guidance on how to dispose the scene in my own design.

Background: Syphilis infection has recently resurfaced as a significant public health problem. Although there has been a tremendous amount of research on the epidemiology of syphilis, there has been limited work done to synthesize the extensive body of research and systematically estimate patterns of disease within high-risk groups in the Americas. The purpose of this systematic review and meta-analysis is to (1) summarize recent patterns of syphilis infection in North and South America among four high-risk groups (MSM, transgender women, sex workers, and incarcerated individuals) from 1980 to 2016, (2) identify and differentiate regional geographic epidemiologic characteristics, and (3) compare the epidemics of the economically developed countries of North America from the developing countries and public health systems of Latin America and the Caribbean. Methods/design: Primary studies reporting syphilis prevalence and/or incidence in at least one of the four high-risk groups will be identified from Medline/PubMed, Embase, Lilacs, SciELO, The Cochrane Library, Web of Science, Scopus, ProQuest, CINAHL, Clase, and Periódica, as well as "gray" literature sources (conference abstracts, country reports, etc.). Studies published from 1980 through 2016 will be included. Data will be extracted from studies meeting inclusion and exclusion criteria and a random effects meta-analysis of prevalence and incidence estimates will be conducted. Heterogeneity, risk of bias, and publication bias will be assessed. Pooled prevalence and incidence estimates will be calculated for comparisons based on geographic region, risk factors, and time period. Discussion: Our systematic review and meta-analysis aims to contribute to an improved understanding of global epidemiologic patterns of syphilis infection in most-at-risk populations. Through systematic classification of the existing literature, and comparison of disease patterns across regional, temporal and socio-behavioral differences, we hope to improve public health surveillance and improve efforts to control the spread of disease across the Americas. Systematic review registration: PROSPERO CRD42016047306.

This study assessed the relationship of variables from the Theory of Planned Behavior (TPB) with intentions to use condoms at next sex and action planning for condom use for main partners and for casual partners among an online of men who have sex with men (MSM) in a Midwestern state. The purpose of this study was to investigate variables of TPB among an online sample of HIV negative, Midwestern MSM and assess significant predictors of intentions separately by casual partners and main partners. Next, action planning was assessed as a potential variable to address the intention-behavior gap. The sample was recruited through an online social networking site, a lesbian, gay, bisexual, transgender (LGBT) - themed statewide newspaper and website. Participants completed an online survey that took 15-20 minutes to complete. Items assessed variables related to the TPB as well as action planning, stages of change, alternative strategies to reduce risk of HIV, and demographic variables including age, urban or rural residence, and HIV status. The results revealed that all TPB variables were strongly, significantly related for both casual and for main partners. The final regression models to predict intentions to use condoms at next sex accounted for 62% of the variance for main partners and 68% for casual partners. The regression models to predict action planning differed by partner type. For main partners, perceived behavioral control and intentions were significant predictors and explained 40% of the variance in action planning. For casual partners, self-efficacy was the significant predictor in the final model and explained 72% of the variance. Potential reasons for the differences in models by partner type for action planning are offered. Action planning is suggested as a potential mediating variable between intention and behavior that requires further research. Implications for HIV prevention interventions with MSM are discussed in light of reduced funding for low incidence states.

Black Same-Gender Loving Men (BSGLM) are a population at the juncture of multiple marginalized identities, which may make it difficult to successfully form their identity due to experienced racism and heterosexism from communities to which they belong. Current paradigms of racial/ethnic and sexual identity do not fully capture the complexities of identity development among BSGLM. Moreover, there is scant literature available detailing what the process of identity development looks like among this population and which factors influence identity development among BSGLM. As such, the current study used an exploratory sequential mixed methods design to first discover what healthy identity looks like among BSGLM and which factors influence the process of developing a healthy identity. The study then empirically tested the elucidated factors in order to understand which of them influence identity development among BSGLM. First, a sample of BSGLM living in the U.S. (n = 19) were recruited via online and interviewed for the qualitative phase of the study about their identity development process. Using a Grounded Theory approach, the qualitative data revealed three unique components of healthy identity among BSGLM (e.g., self-affirmation, freedom from social conventions, having unconditional acceptance) and 13 factors that either inhibited or facilitated their identity development process. Qualitative findings were subsequently used to create a survey battery to quantitatively explore the relationships between the identified factors and components of healthy identity among another sample of BSGLM. The generated survey battery was administered to another sample of BSGLM living in the U.S. (n = 54) recruited from social media and organizations that service BSGLM. Bivariate correlations and multiple regression analyses examined inhibiting and facilitating factors as predictors of healthy identity. Findings revealed that minority stress-related factors were robust predictors of healthy identity. Specifically, rejection sensitivity from one’s family negatively predicted self-affirmation, frustration with concealing one’s sexual identity positively predicted freedom from social conventions, and experiencing threats/violence positively predicted unconditional acceptance. Results from the study may contribute to the refinement of identity development models among BSGLM and inform clinical interventions that bolster identity development among BSGLM such as transdiagnostic interventions that target minority stress and identity-related concerns.

Background: Social networks, norms, and discussions about sexual health may inform sexual practices, influencing risk of human immunodeficiency virus (HIV) or sexually transmitted infection (STI) acquisition. To better understand social networks of Peruvian men who have sex with men (MSM) and transgender women (trans women), we examined key social network members (SNMs), participant perceptions of these network members’ opinions toward sexual health behaviors, and associations between network member characteristics and condomless anal intercourse (CAI). Methods: In a 2017 cross-sectional study, a convenience sample of 565 MSM and trans women with HIV-negative or unknown serostatus was asked to identify three close SNMs; describe discussions about HIV and STI prevention with each; and report perceived opinions of condom use, HIV/STI testing, and partner notification of STIs. Generalized estimating equations evaluated relationships between SNM characteristics, opinions, and discussions and participant-reported CAI. Results: Among participants who identified as MSM, 42.3% of key SNMs were perceived to identify as gay. MSM “never” discussed HIV and STI prevention concerns with 42.4% of heterosexual SNMs, but discussed them “at least once weekly” with 16.9 and 16.6% of gay- and bisexual- identifying SNMs, respectively. Among participants who identified as trans women, 28.2% of key SNMs were perceived as heterosexual; 25.9%, as bisexual; 24.7%, as transgender; and 21.2%, as gay. Trans women discussed HIV/STI prevention least with cis-gender heterosexual network members (40.2% “never”) and most with transgender network members (27.1% “at least once weekly”). Participants perceived most of their close social network to be completely in favor of condom use (71.2% MSM SNMs, 61.5% trans women SNMs) and HIV/STI testing (73.1% MSM SNMs, 75.6% trans women SNMs), but described less support for partner STI notification (33.4% MSM SNMs, 37.4% trans women SNMs). Most participants reported CAI with at least one of their past three sexual partners (77.5% MSM, 62.8% trans women). SNM characteristics were not significantly associated with participant-reported frequency of CAI. Conclusions: Findings compare social support, perceived social norms, and discussion patterns of Peruvian MSM and trans women, offering insight into social contexts and sexual behaviors. Trial registration: The parent study from which this analysis was derived was registered at ClinicalTrials.gov (Identifier: NCT03010020) on January 4, 2017. / National Institutes of Health / Revisión por pares

Personalized cognitive counseling (PCC) is an evidence-based intervention designed to modify HIV-related risk behavior. We assessed the impact of PCC on sexual behavior, drinking expectancy, and incidence of sexually transmitted infections (STIs) in a 6-month randomized controlled trial among 153 HIV-uninfected men who have sex with men (MSM) and transgender women (TW) in Peru. Study retention was ≥ 90%, with three HIV infections (3 Control) and 19 cases of GC/CT (10 Control, 9 PCC) at 6 months. There was a decline in condomless receptive anal intercourse in the Control (0.74, 95% CI 0.60-0.91; p < 0.01) and PCC arms (0.72, 0.55-0.94; p = 0.02) at 6-month follow-up. There was a decrease in drinking expectancy at 6 months among participants endorsing alcohol use in the PCC arm (0.89, 0.83-0.96; p < 0.01), versus no change in the Control arm (0.98, 0.92-1.04; p = 0.54). PCC was efficacious in reducing drinking expectancy and HIV risk among MSM and TW in Peru. / National Institutes of Health / Revisión por pares

Background: HIV- and MSM-related stigma are well documented as common for Chinese men who have sex with men (MSM) living with HIV, yet there is sparse literature on intimate partner violence (IPV) and its relationship with stigma in this vulnerable population. To evaluate the association between HIV-stigma and stigma related to homosexuality and IPV among newly HIV-diagnosed MSM in China. Methods: Data were collected in the baseline survey among newly HIV-diagnosed Chinese MSM in a randomized clinical trial via face-to-face interviews. Univariate logistic and multivariate logistic regression analyses were performed to assess the associations between IPV and HIV- and MSM-related stigma. Results: Of 367 newly HIV-diagnosed Chinese MSM, 23.7% experienced any IPV, including 16.6% physical, 7.4% psychological and 5.2% sexual IPV. Positive associations were found between HIV- and MSM-related stigma and IPV. Men with high HIV-related stigma (score ≥ 27) were 1.67 times as likely to experience any IPV as those with low stigma (adjusted odds ratio [AOR]: 1.67, 95% confidence interval [CI]: 1.02-2.76). Men with high MSM-related stigma (score ≥ 6) were 1.99 times as likely to experience any IPV as those with low stigma (AOR: 1.99, 95% CI: 1.18-3.36). Conclusions: HIV- and MSM-related stigmas was positively associated with IPV experiences among newly diagnosed MSM in China. The manner in which stigma may exacerbate IPV, and/or the influence of IPV on worsening stigma should be further evaluated. The high prevalence of IPV and stigma in this population suggests that interventions should be taken to reduce stigma and prevent this risky behavior among MSM.