The document discusses considerations for achieving UNAIDS goals of diagnosing, treating, and suppressing HIV. It notes that current global rates are lower than targets. Interventions need to maximize reach among marginalized populations like people who inject drugs, sex workers, and men who have sex with men. A person-centered approach is advocated that considers psychological, social, and structural factors using a syndemic framework. An intervention in Tijuana called "Healthy Connections" that provided navigation and adherence support showed promising results in linking people to care and increasing ART pickup rates. The role of mediators and moderators is discussed to understand how and for whom interventions are most effective.

2. Social Behavioral
(Re)Considerations to
Achieve UNAIDS Goals
Eileen V. Pitpitan, PhD
Assistant Professor
Division of Infectious Diseases and
Global Public Health

3. Are we reaching the groups of
people that need to be
reached?
Marginalized populations
2
1

4. Are we considering the
multitude of HIV risk factors that
need to be targeted in HIV
prevention and interventions?
Psychological, social, and
structural factors
Person-centered approach
3
2

5. 90-90-90
Diagnosed
On Treatment
Virally Suppressed
4

6. 75-79-81
Diagnosed
On Treatment
Virally Suppressed
5

7. “
… It also represents a
momentous opportunity to lay
the foundation for a healthier,
more just and equitable world
for future generations.
6

8. 7
Maximizing reach
Focus on
marginalized,
disadvantaged
populations1

9. People who inject drugs (PWID)
8
Men who have sex with men
(MSM)
Female sex workers (FSW)Transgender women (TW)

10. HIV in Tijuana, Mexico
9
Concentrated epidemic
Located along a major drug trafficking route
Sex tourism / commercial sex work
2nd highest HIV prevalence in Mexico
PWID: 4% (Magis-Rodriguez et al., 2005)
FSW: 6% (Patterson et al., 2008)
MSM: 20% (Pitpitan et al., 2015)
Transgender women: 22% (Salas-Espinoza et al., 2017)

11. Smith et al. (2015).
10
Proportion of
PLWH from key
populations in
Tijuana meeting
treatment targets

12. Behavioral HIV prevention
11
Primary
prevention with
individuals at-risk for HIV
Secondary prevention
with people living with
HIV
o Access (link to)
care
o Stay (retain) in
care
o Adhere to
treatment
Behaviors
o Condom use
o Injection risk
behavior
Behaviors

13. 12
Person-centered
Focus on multilevel
psychological, social,
structural variables2

14. Synergy + Epidemic = Syndemic
Biopsychosocial perspective
13
Syndemic Theory
Singer, M. (1994). AIDS and the health crisis of the US urban poor: The perspective of critical medical
anthropology. Social Science and Medicine, 39, 931-948.

15. HIV & Syndemics
Research
14
d
Poor
mental
health
Substance
Use
Violence
Resource
Instability
Stigma
Poor mental
health
Substance Use
ViolenceResource
Instability
Stigma
o Factors that had been
studied in silos (Stall et
al., 2003)

16. 15
Is the combination of these
problems associated with risky
sexual behavior?

17. HIV & Syndemics among MSM
in Tijuana
16
Pitpitan, Smith, Goodman-
Meza, et al. (2016). AIDS and
Behavior.
d
Poor
mental
health
Substance
Use
Violence
Resource
Instability
Stigma
Depressive
Symptoms
Lifetime
History of
Drug Use
Lifetime
History of
Abuse
Sexual
Compulsivity
Internalized
Homophobia

18. Methods
17
Participants
o 191 adult men who reported oral or anal sex with another man in the past year
Measures
Syndemic variables:
Depressive symptoms: Beck Depression Inventory II
Lifetime history of drug use: 11 y/n items (specific drugs)
Lifetime history of abuse: 3 y/n items (sexual, physical, emotional)
Sexual compulsivity: 10 Likert-type items
Internalized homophobia: 9 Likert-type items
Syndemic load: Sum of the syndemic variables
Sexual risk behavior: Anal sex without a condom in past 2 months (y/n)

19. 18
0.0
10.0
20.0
30.0
40.0
50.0
60.0
0 (n=33) 1 (n=55) 2 (n=48) 3 (n=33) 4 (n=16) 5 (n=6)
Syndemic Load
Proportion engaging in risky sexual behavior by syndemic load
OR=1.74, p<.001
Mantel-Haenszel χ2 test for linear-by linear association
(17.18, p < .001)

20. 19
Women who engage in alcohol use in South Africa
(Pitpitan, Kalichman, Eaton, et al. 2013, Annals of Behavioral Medicine)
Male clients of FSW in Tijuana
(Pitpitan, Strathdee, Semple, et al., 2015, American Journal of Public Health)
PWID, FSW, MSM/TW living with HIV in Tijuana
(Pitpitan & Smith, 2017, abstract presented at CFAR Research Day)
PWID living with HIV in Russia
(Pitpitan, Lunze, Cheng, et al., in preparation)
Syndemic load among other key populations

21. 20
0.0
10.0
20.0
30.0
40.0
50.0
60.0
0 (n=33) 1 (n=55) 2 (n=48) 3 (n=33) 4 (n=16) 5 (n=6)
Syndemic Load
Resilience
Risk

22. 21
0
10
20
30
40
50
60
70
80
90
0 (n=33) 1 (n=55) 2 (n=48) 3 (n=33) 4 (n=16) 5 (n=6)
Engagedinriskysex(past2months)
Syndemic Load
OR=1.91*
(B= 0.65)
OR=1.56*
(B= 0.45)
OR=3.02*
(B= 1.11)
“Outness” as a moderator

23. 22
HIV prevention
interventions
Multi-faceted
Focusing on the person
Not the disease

24. Conexiones Saludables (Healthy
Connections)
A multi-faceted intervention
HIV-positive PWID, MSM/TW, FSW in
Tijuana
HIV treatment and care
Access and stay
ART adherence
23Funding sources: 2014 CENSIDA Grant, Mexican Ministry of Health; 2015 Developmental Grant from the SD
Center for AIDS Research (CFAR; P30 AI036214).

25. Conexiones Saludables
(Healthy Connections)
24
Community needs assessment (n=8)
Challenges
Logistical barriers
Police harassment, stigma, social support
Increasing access to health insurance
Expanded treatment access for co-morbidities
Improving adherence to existing services
Pitpitan, Mittal, & Smith. Under review.

26. 25
d
Poor
mental
health
Substance
Use
Violence
Resource
Instability
Stigma
Conexiones
Saludables
Peer
Navigation

27. 26
d
Poor
mental
health
Substance
Use
Violence
Resource
Instability
Stigma
Healthcare
Navigation
Tele-
medicine
ART DeliveryAdherence
Counseling
Peer
Empowerment
Sessions Conexiones
Saludables
Peer
Navigation

28. Conexiones Saludables
(Healthy Connections)
27
Pilot with out-of-care PLWH (n=20)
PWID: n=6 (30%)
FSW: n=5 (25%)
MSM: n=12 (60%); TW (n=3, 15%)
Mean years since diagnosis: 5 years (SD = 6.7)
4 passed away from AIDS-related complications
Smith, Cazares, Magis-Rodriguez, Smith, Castaneda, & Pitpitan. In preparation.

29. Conexiones Saludables
(Healthy Connections)
28
Delayed Control Phase
(n=20)
Intervention Phase (n=20) p
Smith, Cazares, Magis-Rodriguez, Smith, Castaneda, & Pitpitan. In preparation.

30. Conexiones Saludables
(Healthy Connections)
29
Delayed Control Phase
(n=20)
Intervention Phase (n=20) p
n % n %
Saw an HIV care
provider within 3mo
14 70.0 17 85.0 0.013
Start ART within 3mo 11 55.0 14 70.0 0.332
ART pick-up 100% 3 15.0 7 35.0 0.021
Smith, Cazares, Magis-Rodriguez, Smith, Castaneda, & Pitpitan. In preparation.

31. 30
Behavioral interventions to reduce HIV risk
Vestibulum
congue
tem
pus
Mediators and moderators
Pare down or ramp up interventions to their most
effective elements
Which subgroups to target
Briefer, cheaper, and more impactful
interventions
MacKinnon & Luecken (2008); MacKinnon (1994)

32. 31
Mediators and
Moderators of HIV
Prevention Intervention
Efficacy

33. Mujer Mas Segura Intervention
for FSW who inject drugs
584 FSW who inject drugs
Tijuana and Cuidad Juarez
4 arm trial targeting but condom use and
injection drug risks
The injection risk intervention significantly
reduced injection risk behavior in Cd. Juarez
32
Pitpitan, Patterson,
Abramovitz, et al.
(2015). Health
Psychology.
Strathdee et al. (2013). PLoS ONE.

34. Conditional process modeling (i.e.,
moderated mediation)
Simultaneously test mediation and
moderation
33
Pitpitan, Patterson,
Abramovitz, et al.
(2015). Health
Psychology.
Preacher, Rucker, & Hayes (2007).
How (mediation) and for whom
(moderation)?

35. 34
X M Y
Z
How (mediation) and for whom
(moderation)?

36. Self-efficacy as hypothesized
mediator
35
A robust determinant of behavior and driver of behavior change (Bandura,
1997, 2001)
Exercise (e.g., Lubans et al., 2008; Dishman et al., 2004)
Condom use (e.g., Bryan et al., 1996; O’Leary et al., 2008)
Safe injection self-efficacy has not been well examined, and only one
study has tested it as a driver of an injection risk intervention (STRIVE Study,
Latka et al., 2008)

37. Self-efficacy as hypothesized
mediator
36
Injection risk
intervention
Safe injection
self-efficacy
Injection risk
behavior

38. Social structural moderator
37
FSWs and PWID are exposed to multiple harms that independently
increase risk for HIV
Police behavior
Police syringe confiscation is associated with risky injection
practices (e.g., Beletsky et al., 2012; Werb et al., 2008)
May interact with the goals of an intervention

39. Social structural moderator
38
Injection risk
intervention
Safe injection
self-efficacy
Injection risk
behavior
Police syringe
confiscation

40. Measures
o Safe injection self-efficacy (6 Likert-type items,
α = .90)
o Police syringe confiscation: Has a police officer
taken your needle(s) or syringe(s) in past 4 mo.
(y/n)
o Injection risk behavior (Receptive needle
sharing in past 4 mo.) (y/n)
39
Pitpitan, Patterson,
Abramovitz, et al.
(2015). Health
Psychology.

41. Results
40
Injection risk
intervention
Safe injection
self-efficacy
Receptive needle
sharing
Police syringe
confiscation
B = .05,
ns
OR= .48***
B = .80**
Pitpitan, Patterson, Abramovitz, et al. (2015). Health Psychology.
Bootstrapped indirect effects (5,000
samples):
Police confiscated syringe: p = .04 Did not
confiscate: p=.55

42. Conclusions / Take-home messages
41
Need to engage key, marginalized populations into HIV prevention and
treatment
Must consider the many factors that influence behavioral and health
outcomes
Person-centered approaches
Must capitalize on the intervention data at hand to maximize impact

43. 42
Acknowledgements
Participants
Collaborators & Mentors
Laramie Smith, Carlos-Magis Rodriguez, Thomas Patterson, Rebeca Cazares, David Goodman-Meza,
Steffanie Strathdee, Lisa Eaton, Shirley Semple, Seth Kalichman, Kathy Sikkema, David MacKinnon
Community and Clinic Partners
PrevenCasa, Centro SER, CAPASITS, Christie’s Place, Family Health Centers San Diego, San Diego
Comprehensive Treatment Centers
Grant Support
NIDA Diversity Supplement Award (R01DA029008-04S1); Career Development Award (K01DA036447-
01); R01 Award (R01DA042666); Pilot Grant from Centro Nacional para la Prevención y Control del
VIH/SIDA, Mexican Ministry of Health; SD Center for AIDS Research Developmental Grant

44. 43
THANK YOU