Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people living with HIV (PLWH). Interventions to support ART adherence are increasingly focused on the household as a source of social support. This review aims to examine the social and structural determinants of support for ART adherence within households and families in low- and middle-income countries (LMICs). The review methodology followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Seven databases were searched for peer-reviewed literature. The terms searched thematically covered (1) ART adherence, (2) household and family and (3) support and care. Thirty-three studies conducted in 15 LMICs were selected and a mixed methods synthesis was undertaken. Social and structural determinants affected the type, quality and amount of support for PLWH of all ages, which affected PLWH’s ART adherence. Gender norms affected the type of support that household members give to PLWH. Education moderated household support for ART adherence through literacy and language skills. Cultural context, religious beliefs, and social norms reinforced or undermined household support for ART adherence. Stigma affected disclosure, generated secrecy around giving medication and impeded access to support from the community. Supporting PLWH exacerbated economic hardship for household members. Health system dysfunction negatively impacted trust and communication between household members and health professionals. Intersecting social and structural determinants particularly affected the care given by household members who were older, female, with little education and low socioeconomic status. Household members were able to overcome some of these barriers when they received support themselves. Household interventions to support PLWH’s ART adherence should take structural factors into account to have maximum impact.

Since the start of the SARS-CoV-2 pandemic, levels of loneliness have increased among the general population and especially among sexual minorities, such as gay men and other men who have sex with men, who already experienced more problems with social isolation before the pandemic. We analyzed how the disruption of the social network and social support structures by containment measures impact loneliness among gay and other men having sex with men. Our sample consisted of gay and other men having sex with men who had in person communication with family as well as heterosexual friends and homosexual friends before the lockdown (N = 461). Multivariate regression analyses were performed with social provisions (social interaction and reliable alliance) and loneliness as dependent variables. A change from in-person communication with gay peers before the pandemic to remote-only or no communication with gay peers during the pandemic, mediated by change in social integration, was related to an increased feeling of loneliness during the pandemic compared with before the pandemic. There were some unexpected findings, which should be interpreted in the specific social context of the SARS-CoV-2 pandemic. On average, social integration and reliable alliance among MSM increased during the lockdown, even though in-person communication decreased and loneliness increased. Our results show it is critical to maintain a view of social support and social loneliness as lodged within larger social and cultural contexts that ultimately shape the mechanisms behind them.

Background: Obtaining a representative sample is a substantial challenge when undertaking health research among hidden and hard-to-reach populations such as men who have sex with men Web-based respondent-driven sampling (WEB RDS) was developed to overcome such sampling challenges and to create population estimates based on network and sampling characteristics. Despite a decade of research, it remains unclear whether WEB RDS is suitable for sampling hidden populations such as men who have sex with men. Objective: This study aims to evaluate how viable the WEB RDS methodology is for obtaining a nationwide sample of men who have sex with men, suitable for population inference of sexual health characteristics, in Belgium. Methods: We adapted the Medical Resource Council process evaluation framework for interventions, to evaluate an empirical WEB RDS. Viewing “WEB RDS” as a complex intervention with respondent-driven recruitment as the aim, we evaluated indicators of context, implementation, mechanisms of impact, and performance. We analyzed the data using a mixed methods approach that integrated findings from quantitative analysis, such as RDS diagnostics, and qualitative thematic analysis. Results: Sampling did not reach a sufficient sample size (n=193) to compensate for an RDS design effect of 3 and the number of recruitment waves was low (waves=7). A visual examination of the convergence and bottleneck plots indicates that many more waves of recruitment would be needed for population estimates to become independent of the seeds. However, producing further waves was impeded by challenges inherent to the research context and process. Men who have sex with men and their community organization representatives indicated that, in Belgium, men who have sex with men are overresearched, with low motivation for the topic of sexual health and digital etiquette dictating not sharing survey links. A moderate reward of €10-€30 (US $11.2-$33.6) with a dual incentive structure was insufficient to overcome these barriers. Conclusions: This study indicates that WEB RDS, even with a moderate incentive, is not a viable sampling strategy for obtaining valid population estimates of sexual health traits of men who have sex with men in Belgium. The study emphasizes the need to understand men who have sex with men research motivation and topic saliency. Additionally, the study highlights the importance of digital etiquette. Finally, the study showcases the use of the adapted Medical Research Council framework for evaluating WEB RDS methodology.

The thesis explores the critical role of peer relationships in the health of Men who have Sex with Men (MSM). It highlights that MSM face unique mental and sexual health challenges. The thesis underscores that peer relationships can mitigate these negative health outcomes by providing social support, reducing feelings of loneliness, providing intimacy, fostering a sense of community and providing social norms around protection against HIV. Peer communication is identified as a vital component in maintaining mental health among MSM. The thesis discusses how peer relationships offer social integration and intimacy. These relationships are not only crucial for mental well-being but also play a significant role in promoting sexual health. Peer networks facilitate the sharing of social norms about safe sex practices and HIV prevention methods, such as Pre-Exposure Prophylaxis (PrEP). First, the thesis investigates how the shift from in-person communication before the COVID-19 pandemic to remote communication during the pandemic affected social integration and loneliness. It finds that the lack of in-person contact with peers led to increased feelings of loneliness and decreased social support, highlighting the importance of in-person interactions for mental health of MSM. Second, the pandemic also intensified the need for sexual and emotional intimacy among MSM, which was harder to achieve due to social distancing measures, negatively impacting mental health. Third, the thesis explores how social norms at the individual, interpersonal, and community levels influence PrEP uptake among MSM. It finds that positive attitudes towards PrEP, supportive peer reactions, and the perception that many peers use PrEP are associated with higher intentions to use PrEP. Conversely, the belief that PrEP use is inappropriate for certain relationships and the perception of having safer sex than peers are barriers to PrEP uptake. Finally, the thesis addresses the methodological challenges of researching hidden populations like MSM. It evaluates the viability of Web-based Respondent Driven Sampling (WEB RDS) for obtaining representative samples of MSM. The findings suggest that while WEB RDS can reach diverse subpopulations, it faces significant barriers such as survey fatigue, low motivation for the topic, and digital etiquette norms that discourage sharing survey links. In conclusion, the thesis emphasizes that peer relationships are crucial for the mental and sexual health of MSM. Strong peer networks can provide social integration and intimacy, reduce loneliness, and promote healthy sexual behaviours. Understanding and leveraging these relationships can lead to more effective health interventions and better health outcomes for MSM.

BACKGROUND Obtaining a representative sample is a substantial challenge when undertaking health research among hidden and hard-to-reach populations such as men who have sex with men Web-based respondent-driven sampling (WEB RDS) was developed to overcome such sampling challenges and to create population estimates based on network and sampling characteristics. Despite a decade of research, it remains unclear whether WEB RDS is suitable for sampling hidden populations such as men who have sex with men. OBJECTIVE This study aims to evaluate how viable the WEB RDS methodology is for obtaining a nationwide sample of men who have sex with men, suitable for population inference of sexual health characteristics, in Belgium. METHODS We adapted the Medical Resource Council process evaluation framework for interventions, to evaluate an empirical WEB RDS. Viewing “WEB RDS” as a complex intervention with respondent-driven recruitment as the aim, we evaluated indicators of context, implementation, mechanisms of impact, and performance. We analyzed the data using a mixed methods approach that integrated findings from quantitative analysis, such as RDS diagnostics, and qualitative thematic analysis. RESULTS Sampling did not reach a sufficient sample size (n=193) to compensate for an RDS design effect of 3 and the number of recruitment waves was low (waves=7). A visual examination of the convergence and bottleneck plots indicates that many more waves of recruitment would be needed for population estimates to become independent of the seeds. However, producing further waves was impeded by challenges inherent to the research context and process. Men who have sex with men and their community organization representatives indicated that, in Belgium, men who have sex with men are overresearched, with low motivation for the topic of sexual health and digital etiquette dictating not sharing survey links. A moderate reward of €10-€30 (US $11.2-$33.6) with a dual incentive structure was insufficient to overcome these barriers. CONCLUSIONS This study indicates that WEB RDS, even with a moderate incentive, is not a viable sampling strategy for obtaining valid population estimates of sexual health traits of men who have sex with men in Belgium. The study emphasizes the need to understand men who have sex with men research motivation and topic saliency. Additionally, the study highlights the importance of digital etiquette. Finally, the study showcases the use of the adapted Medical Research Council framework for evaluating WEB RDS methodology.

The COVID-19 crisis gave rise to measures such as physical distancing, sheltering in place, and social bubbles that impacted sexual lives profoundly. One group particularly badly impacted by COVID-19 containment, and at risk of sexual and mental health consequences as a result, comprised gay, bisexual and other men who have sex with men -- many of whom were more likely to live alone, to have had multiple partners before the epidemic, and some of whom were lacking in peer support for their mental health. This study investigated how members of this group living in Flanders (Belgium) experienced sex and sexuality during the COVID-19 epidemic. We conducted 29 in-depth interviews with gay, bisexual and other men who have sex with men who practised consensual nonmonogamy and/or sociosexuality, and used reflexive thematic analysis to analyse the data. Interviewees provided a nuanced and emotionally resonant account of sex as a pathway to intimacy, rather than just a physical act. In their descriptions, Intimacy was framed as a protective factor against the mental health challenges exacerbated by pandemic isolation.