Feasibility, acceptability, and preliminary efficacy of an adapted group-based and online HIV prevention intervention for immigrant sexual minority men in the US

Project Summary In 2014, the immigrant population in the United States (US) was 42 million and is projected to reach 78 million by 2060, a growth of 85%; an estimated 3% of immigrants identify as sexual and gender minorities. Evidence shows that sexual minority men (SMM) may be particularly likely to immigrate, whether by choice or force, in

search of social and sexual freedoms that are not available in their home countries. Among the general SMM population, stigma at the individual, interpersonal, and structural levels, and subsequent minority stress reactions (e.g., internalized stigma, identity concealment, expectations of and actual discrimination experiences) contribute

to co-occurring HIV and mental health risks. Sexual minority stressors negatively influence SMM’s sexual and mental health, in particular SMM of color. The experiences of Arab immigrant SMM may be different from other groups, in particular because of their exposure to high structural stigma and potentially lethal homophobia, high

risk to HIV, and poor mental health in their home countries, which then intersects with their current US context of strong anti-Arab and anti-immigration rhetoric that has intensified in the past 2 decades. Despite this confluence of risks, there are no interventions that address the magnitude of intersectional stigma on HIV risk

and mental health among Arab immigrant SMM. Theoretically informed interventions can buffer against the health risks of stigma when tailored to address minority stress reactions among SMM; however, most interventions do not account for multiple and intersecting sources of stigma, and none focus on immigration-

related stigma, especially as it is experienced by Arab immigrant SMM. Our intervention, ESTEEM (Effective Skills to Empower Effective Men), a minority stress focused cognitive-behavioral therapy (CBT) has shown strong efficacy in improving mental, behavioral, and HIV (e.g., condom use and pre-exposure prophylaxis [PrEP])

health outcomes among SMM. Our preliminary interviews with Arab immigrant SMM (N=16) suggest intervention preferences for an online group delivery format that connects SMM with shared experiences, irrespective of their current geographical location, thus facilitating greater reach and effective recruitment, to be led by trained

counselors that share similar identities (Arab, immigrant, and/or sexual minority). Following the ADAPT-ITT model, this study aims to adapt and pilot-test the ESTEEM intervention to target the underlying mechanisms linking first-generation (i.e. foreign-born) Arab immigrant SMM’s intersectional minority stressors to co-occurring

HIV risks and poor mental health outcomes. In Aim 1, we will seek input from multiple stakeholders using qualitative interviews with 15 mental health experts and 15 Arab immigrant SMM, and adapt ESTEEM for online group delivery and for Arab immigrant SMM in the US. In Aim 2, we will randomize 60 participants to receive 10

weekly, 90-minute online-based group sessions, either immediately (immediate intervention group, n=30) or after 3 months (waitlist control group, n=30) to evaluate intervention acceptability and feasibility and to determine preliminary efficacy on primary (HIV-risk behavior) and secondary (mental health) outcomes.