Strengthening resilience to reduce HIV risk in Indian MSM: a multicity, randomised, clinical efficacy trial

Abstract

Background Men who have sex with men (MSM) in India are extremely marginalised and stigmatised, and therefore experience immense psychosocial stress. As current HIV prevention interventions in India do not address mental health or resilience to these stressors, we aimed to evaluate a resilience-based psychosocial intervention in the context of HIV and sexually transmitted infection (STI) prevention. Methods We did a multicity, randomised, clinical efficacy trial in Chennai (governmental tuberculosis research institute) and Mumbai (non-governmental organisation for MSM), India. Inclusion criteria were MSM, aged 18 years or older, who were at risk of HIV acquisition or transmission, defined as having any of the following in the 4 months before screening: anal sex with four or more male partners (protected or unprotected), diagnosis of an STI, history of transactional sex activity, or condomless anal sex with a man who was of unknown HIV status or serodiscordant. Participants were required to speak English, Tamil (in Chennai), or Hindi (in Mumbai) fluently. Eligible individuals were randomly assigned (1:1) to either a resilience-based psychosocial HIV prevention intervention, consisting of group (four sessions) and individual (six sessions) counselling alongside HIV and STI voluntary counselling and testing, or a standard-of-care control comprising voluntary counselling and testing alone. The primary outcomes were number of condomless anal sex acts with male partners during the past month (at baseline and 4 months, 8 months, and 12 months after randomisation), and incident bacterial STIs (at 12 months after randomisation). Resiliencerelated mediators included self-esteem, self-acceptance, and depression. Recruitment is now closed. This trial is registered with ClinicalTrials.gov, NCT02556294.

LGBQ-affirmative cognitive-behavioral therapy for young gay and bisexual men’s mental and sexual health: A three-arm randomized controlled trial.

“…One of these interventions, delivered in India, involves supportive counseling focused on self-acceptance and self-esteem through group peer support and modularized counseling sessions focused on specific minority stress experiences (e.g., coming out). Compared to standard HIV testing and counseling, this intervention was associated with stronger reductions in HIV transmission risk behavior, depression, self-esteem, and self-acceptance (Safren, Thomas, et al, 2021;Safren et al, 2014). The other intervention, called Effective Skills to Empower Effective Men (ESTEEM), systematically adapted cognitive-behavioral therapy (CBT) to address young SMM's cognitive, affective, and behavioral reactions to minority stress that have been shown to elevate risk for numerous adverse psychosocial health outcomes (Hatzenbuehler, 2009;Meyer, 2003).…”

The cost-effectiveness of a resilience-based psychosocial intervention for HIV prevention among MSM in India

“…Participants in the intervention arm attended an average of 4.8 individual sessions and 2.5 group sessions, or a total of 7.3 sessions out of the 10 sessions offered [19]. The intervention resulted in a 38% [95% confidence interval (95% CI) 20–52] reduction in CAS with insertive partners of serodiscordant or unknown HIV status [19]. Because the trial was not powered to evaluate a reduction in HIV incidence, we extrapolated these behavioral outcomes to HIV-related outcomes using data from the EXPLORE trial [20].…”

“…The trial protocol for the psychosocial intervention included six individual counseling sessions and four group counseling sessions over a 10-week period. During the trial, 608 men were enrolled, 85% of whom completed a 12-month assessment [19]. Participants in the intervention arm attended an average of 4.8 individual sessions and 2.5 group sessions, or a total of 7.3 sessions out of the 10 sessions offered [19].…”

“…The base case intervention effectiveness is a 38% reduction in CAS with insertive partners of serodiscordant or unknown HIV status (i.e. a risk ratio of 0.62) [19]. This benefit is represented in the model as a decrease in each intervention participant's probability of HIV infection.…”

Gender minority stress and access to health care services among transgender women and transfeminine people: results from a cross-sectional study in China

“…Increasing the quality of gender affirming medical care, establishing standard operating protocols for medical professionals, and removing barriers to these services are important next steps. In terms of stressors associated with sexual health care access, we suggest integrating mental health services with sexual health interventions and care [ 41 – 43 ]. Sexual health services could integrate mental health components by directly providing counseling services, providing referrals to psychological services, and organizing community engagement activities for the transgender and gender diverse people [ 42 , 44 , 45 ].…”