A Pilot Cognitive Behavior Therapy Group Intervention to Address Coping with Discrimination Among HIV-Positive Latino Immigrant Sexual Minority Men

Abstract

Discrimination is thought to be a key driver of health disparities that affect people with multiple intersecting devalued identities, such as HIV-positive Latino sexual minority men (SMM). Ineffective coping with the stress of discrimination (e.g., rumination, substance use) may lead to worse long-term mental and physical health. Within the context of a community partnership, we developed a nine-session, community-based, cognitive behavior therapy group intervention to address coping with discrimination among HIV-positive Latino immigrant SMM. In Study 1, we assessed anticipated intervention acceptability via semi-structured interviews with 28 HIV-positive Latino SMM and ten social service providers and administrators; we used interview data to develop the manualized intervention. In Study 2, we assessed acceptability, feasibility, and preliminary effects in a pre-post, non-randomized intervention evaluation with two intervention groups of HIV-positive Latino SMM (n = 30, average age = 48.5, SD = 10.3). In semi-structured interviews, key stakeholders were enthusiastic about the proposed intervention. In the non-randomized evaluation, feasibility was evidenced by moderate levels of intervention attendance (five sessions on average); reasons for missed sessions (e.g., illness, scheduling conflict with work) were unrelated to the intervention. Linear regressions showed preliminary effects for decreased negative emotional coping responses to discrimination pre-to-post intervention (i.e., feeling less anger, sadness, powerlessness, helplessness, and shame on two subscales; b (SE) = −0.23 (0.10), p = .03; b (SE) = −0.25 (0.11), p = .03). Our intervention holds promise for reducing disparities by empowering Latino SMM to leverage innate resilience resources to improve their health in the face of discrimination.

INTRODUCTION

In the United States, HIV-related disparities persist among Latino-identified individuals, especially Latino sexual minority men (SMM). In 2017, Latino people had HIV diagnosis rates 3.2-times higher than Whites, and Latino SMM accounted for 75% of all HIV diagnoses among Latino people.¹ Latino people, especially immigrants, tend to be diagnosed with HIV at a late disease stage, leading to larger disparities for Latino immigrants in particular.^2,3

Correlational data suggest that discrimination contributes to HIV-related disparities.⁴ Among HIV-positive Latino SMM, discrimination is related to medication non-adherence, medication side effects, and AIDS symptoms.^5,6 The chronic stress of discrimination may weaken immune function, leading to worse HIV outcomes, including increased viral load and greater mortality risk.⁷ Behavioral stress responses may be exhibited as ineffective coping, including avoidance-related health behaviors like sexual risk or non-adherence.⁸ Avoidance and escape coping strategies, which can include avoiding perceived perpetrators and using substances, for example, generally lead to worse health.^9,10 Emotion regulation, that is, managing emotional responses to stress, can prolong distress through rumination,^11,12 or be effective, by leading to social support-seeking or problem-solving.¹³

Cognitive behavior therapy (CBT) interventions have been developed to improve coping with stress and, in turn, mental health among people with HIV.^14,15 In a prior study, we used a community-based participatory research (CBPR) approach to apply these prior CBT approaches to develop a group intervention to reduce stress-related effects of discrimination among HIV-positive Black SMM; we found significant effects of the intervention on improved coping,¹⁶ and participants reported positive attitudes about the intervention in qualitative and quantitative assessments. However, this intervention was uniquely tailored to Black SMM. Thus, in the present study, we developed a parallel yet unique intervention tailored for Latino SMM, with content on immigration-related discrimination and other Latino-specific factors—and to conduct a preliminary evaluation of acceptability, feasibility, and effects.¹⁷ The intervention for Latino SMM was named Siempre Seguiré (“I will always keep going,” or “I will continue being”) by community stakeholders after a line in a popular Spanish-language song that is seen as a message of empowerment in Latino gay communities. The song has the underlying theme that people do not need to change who they are and should be true to themselves.

In developing the intervention, we drew on intersectionality theory, an analytic framework that attempts to identify how interlocking systems of power impact societally marginalized individuals—a concept which emerged from Black feminist scholarship and activism.¹⁸ Consistent with recommendations for intersectionality research,^19–21 we placed participants’ voices at the center of our inquiry, by conducting formative research in which we elicited participants’ experiences with discrimination, as well as their responses to discrimination from intersecting identities, in qualitative semi-structured interviews. We then based our intervention development efforts on these narratives, using participants’ stories to create examples to illustrate central concepts, such as effective and ineffective responses to discrimination. In addition, in the intervention, we acknowledged participants’ discrimination experiences and responses to discrimination in the context of the whole of their identities, rather than discussing separately each group identity, and discrimination from each identity, recognizing that their salient identities (and, thus, experiences with and responses to discrimination) likely vary across situations and over time, and that they possess multiple oppressed identities, with each complicating the experience of the others.

Based on intersectionality theory, we posited that stigma’s effects would be amplified among HIV-positive Latino SMM, who are at the nexus of several devalued, marginalized social identities from which they face stigma, including Latino ethnicity, potential immigrant identity, and sexual minority identity. Under minority stress theory, identity concealment, defined as nondisclosure of sexual orientation and HIV-serostatus, and internalized homophobia, defined as shame from internalization of negative stereotypes compound with the stress of discrimination among SMM of color, resulting in greater decrements in mental and physical health than might be experienced by non-SMM of color.^22,23

METHODS: FORMATIVE RESEARCH

Community–Academic Partnership

Across all study phases, we used a CBPR approach²⁴ in the context of a longstanding, interdisciplinary, community–academic partnership team that included members of the population under study. The community partner was Bienestar Human Services, Inc., a community-based organization that offers culturally congruent HIV services to a predominately Latino immigrant population in Los Angeles County, California. All study activities took place on-site at the community-based organization. Table 1 shows the specific ways in which the study design incorporated CBPR principles.²⁵

TABLE 1.

Application of Key Principles of CBPR to Present Research

CBPR Principle	Application to Siempre Seguiré Intervention Development and Pilot Study
Recognize community unit of identity	• Define community as HIV-positive Latino immigrant sexual minority men in Los Angeles County
Build on existing strengths/resources	• Draw on an ongoing community–academic partnership, as well as existing resources within the trusted community organizational partner, including weekly HIV support group structure, client base, capacity for programs, and service structure
Facilitate collaborative, equitable partnership in all research phases	• Engage community partners as full investigators on leadership team who are co-leaders on planning, grant-writing, intervention development, implementation, evaluation, and dissemination • Create forums for ongoing community participation through community advisory board of community expert clients and regular updates to community organization leadership (director and deputy director, manager of programs)
Promote co-learning and capacity-building among all partners	• Train community members to collect data for formative research and intervention pilot evaluation • Build knowledge among academic team members about community priorities and needs, and integrate this information into the intervention • Develop the intervention as a partnership, in which academic partners learn to develop interventions that are feasible and acceptable to communities, and community partners learn how to manualize interventions, how to conduct CBT interventions, and how to study intervention efficacy
Achieve balance between research and action for mutual benefit	• Maintain awareness of community members’ expressed needs to develop an intervention that addresses discrimination and medical mistrust, and their health effects among clients • Design the intervention with dissemination planned through existing structures to increase feasibility, such as through existing weekly community support group structure
Emphasize local public health relevance; attend to multiple determinants of health	• Attend to multiple determinants of health in the intervention, by targeting changes in individual coping skills and HIV-related behaviors; in the social network (by increasing social support, through group cohesion); in the organization (by increasing capacity for evidence-based support group programming); and in the social system (via content about addressing structural factors through activism)
Involve cyclical and iterative process	• Conduct multiple pilot groups in order to obtain feedback and revise the intervention in real time
Disseminate findings to all partners	• Sustain active dissemination throughout research, including interpretation of preliminary results and co-authoring of manuscripts by the community–academic team • Disseminate findings to partners through the community-based organization’s community advisory board and in local community presentations (e.g., to the local Ryan White HIV Commission)
Involve long-term commitment by all partners	• Commitment by all partners to sustain the intervention (if found effective), by attending to sustainability in intervention development (e.g., ensure that intervention resources needed are comparable to other ongoing support group programs) • Commitment to continue the partnership, which preceded this project (starting in 2009) and continues through other projects

Qualitative Methods and Analysis

Acceptability can be measured in terms of anticipated attitudes about the intervention structure and content.^17,26 Thus, prior to conducting the pilot intervention study, a trained bilingual research assistant conducted the one to two hour semi-structured Spanish-language interviews with 30 HIV-positive Latino immigrant adult men and ten providers of HIV social services to Latino SMM. The interviewer was a Latina woman with a BA in Sociology, who had no prior relationship with participants. Latino SMM were recruited via flyers, and providers who were known stakeholders in the community, who worked in the fields of medical and/or social services delivery to Latino SMM, either as a direct provider or a manager/supervisor, were contacted directly and offered participation. Most participants were interviewed at the offices of the community-based organization that served as the study setting; some stakeholders were interviewed at their place of work. All procedures for both the formative research and the pilot were approved by the institutional review board of the Los Angeles County Department of Public Health.

Interviews assessed anticipated acceptability, that is, how potential participants who were not in the intervention pilot cognitively and emotionally reacted to a description of the intervention and considered the intervention to be appropriate, using an operationalization of the prospective acceptability construct from the theoretical framework of intervention acceptability. Note that a prior manuscript on these qualitative interview data examined within- and between-group discrimination experiences, as well as coping with such experiences, finding that social support was a major coping strategy for discrimination.²⁷

Interviews were transcribed in Spanish and then translated from Spanish to English by a second research assistant, after which the translations were spot checked by a study investigator. To code anticipated acceptability, we conducted a qualitative content analysis, allowing for themes to emerge through a bottom-up, iterative coding process, and managed the data with Dedoose (Version 7.0.23). Two investigators independently reviewed every transcript and then developed a preliminary codebook that included descriptions, inclusion/exclusion criteria, and example quotes for 11 primary themes (Table 2). The two investigators then jointly coded 13 transcripts and established inter-rater reliability (Kappa = .96) with a randomly selected set of 33 excerpts (of 164 total excerpts; 20%). After achieving reliability, one coder coded the remaining interviews. Of the 40 interviews, 38 (28 clients and ten providers) provided usable data (with a clear recording for transcription) on acceptability. Results were used to refine and further develop the intervention.

TABLE 2.

Anticipated Acceptability Coding Scheme, Relevant Interview Questions, and Example Quotes

Primary Theme	Relevant Interview Question(s)	Latino SMM Example Quotes	Key Stakeholder Example Quotesa
General Attitudes about the Proposed Program	We are thinking of offering a program in which we have group sessions for Latino men living with HIV, to discuss ways to cope with discrimination as well as how to overcome mistrust of the healthcare system and healthcare workers or HIV medications. The program would last about eight sessions, and it would include group discussions about similar experiences, and take-home activities to help reinforce what was learned in the groups. It would be conducted like a support group, but it would be more structured than a typical support group, so that the conversations stay on topic. • What are your initial thoughts about such a program? • Clients only: Would you be interested in hearing more or attending this kind of a group? Why or why not? • Do you think people living with HIV would be interested in attending such a program? Why or why not?	“. . . because all of these experiences people have can happen to anyone. We can all go through a process of discrimination for the same reason as the other person. That is why it is good to be alert, to prevent yourself from going through that. That is why it is important to be mindful about discrimination.” (42-year old gay man)	“I think that it’s very much needed and . . . addressing some of the issues that are not often addressed. So, when we talk about people with HIV and adhering to their medication, we often think that they are lacking knowledge around the benefits of treatment without looking at the other factors or the social constraints that prevent them from accessing care and treatment.” (Administrator, Social Services Organization)
Acceptability of Potential Topics	What topics do you think should be covered (or not covered) in a program like this? Probes: • Disclosure of HIV to different people • Disclosure of sexual orientation to different people • Getting helpful social support and figuring out who you can rely on • Spirituality and religion as a source of strength • Challenges in healthcare as a Latino immigrant man with HIV • Healthy ways of coping with and responding to discrimination • Mistrust of healthcare and medical treatment	Immigration-related Issues: “. . . many people, since we don’t have documents, we believe . . . that there is no help for you . . . Many go to the doctor and they even die, or they go when they are already very sick.” (63-year old gay man) HIV Disclosure: “Well, that topic would be good because there are some people that don’t disclose to their families or their best friends, nor anyone [that they are HIV-positive] . . . it’s out of fear of being rejected.” (39-year old gay man) Sexual Orientation Disclosure: “. . . I believe it’s about teaching them or giving them suggestions on how to disclose and discuss if this is a good idea to reveal your sexual orientation when speaking about discrimination.” (42-year old gay man) Medical Mistrust: “. . . if the person does not feel well with the medication they are taking or it causes you to feel more sick, then it is something that needs to be talked about, and this also affects a lot of people that don’t speak English because a lot of them don’t have an open communication with their doctor or pharmacists. I think this would be important to talk about.” (51-year old gay man)	Immigration-related Issues: “I think the intervention sounds great. I think that the way it would be successful, and the way people would go for it is you can talk about immigration . . . things that are more relevant I think would be more successful.” (Mental Health Provider) Medical Mistrust: “I think that’s a great topic because I have run into clients that tell me that they don’t trust their doctor, or their doctor would brush them off or not ask them questions or not even be able to communicate with them because of the language barriers, but when that happens, you don’t trust your doctor. You don’t trust the system. So, it’s very important that they feel confident in whichever provider that they’re seeing that they have their best interest at heart.” (Program Supervisor)
Facilitator Characteristics	• What kind of person do you think would be the best facilitator for this program? Probes: A peer? A social worker or counselor? A psychologist or psychiatrist? • How important is it that the person is a member of your community—that is, Latino, male, immigrant, and so forth?	Importance of Shared Experiences: “I think that an ideal person . . . is [someone] living or going through the same, like, let’s say, maybe someone gay, positive, so this person can understand us better, right? (63-year old gay man) Importance of Trained Facilitators: “I think, my ideal opinion would be someone [who has] more experience and more access to information . . .” (46-year old gay man)	Importance of Peer Facilitators: “Ideally, I’d have two facilitators, . . . one definitely like a psychologist, social worker, but definitely a peer has to be involved . . . People will be more trusting of the topics and the curriculum that’s being provided. Otherwise, they might assume, ‘What do you know? You don’t know what I go through.’ They . . . might just be a little bit more closed off or put up barriers rather than if they see someone who comes from their background who was . . . an immigrant, is HIV-positive, is Latino, then they might be like, ‘Okay, well you know where were coming from, so I’m willing to hear you out.’” (Program Supervisor)
Take-Home Activities	As part of the program, we will ask participants to complete homework activities in between the groups, on their own. For example, when people experience discrimination, we might ask them to write down what happened and how they felt, and then bring their summary back to discuss at the group. • What other kinds of take-home activities would you suggest? • Do you think that people would be willing to do these kinds of activities outside of the group? • What do you think would make people more likely to do these kinds of activities? • What things do you think might get in the way of people completing activities like this?	In Favor of Take-Home Activities: “Yes, because [take-home activities are] a way of blowing off steam and of venting out the trauma one has within. There are people that have the ease of expressing themselves, and there are people that don’t . . . Maybe a way to dispel shame, I don’t know how to say it, but there are people that don’t like talking in front of people.” (51-year old gay man) Concerns Regarding Take-Home Activities: “. . . There are people [who] are kind of reluctant to write, for homework, I think, it’s personal . . . When I go to the groups and they pass around all those forms that we have to fill out, that are also missing, because I know that to get funds for the agency you all need that, but the majority say, ‘Ay! I’m tired of writing and filling out those papers’. “It’s because of stress, and I think that people come to the group and don’t want to have that commitment of writing and filling out forms, like homework. So, it creates like an obligation for them, and there are people that can suddenly say, ‘No, I’m not going to go because I have to be doing some homework’.” (63-year old gay man)	In Favor of Take-Home Activities: “. . . as a therapist I strongly believe in some theories and I strongly believe in journaling. I strongly believe that if you were sexually abused by someone, then how do you heal? You tell them to write that personal letter. So all of that stuff with journals . . . I really believe it works. The problem is getting our Latino community to believe that it really heals or that it begins to start a healing process. That I think is the challenging part because I have had projects in my group and they just don’t do it, and it’s like they don’t do it because they don’t believe or maybe I didn’t sell it good enough, but I think [journaling] is a great activity . . . but it’s about getting them to see the value of it.” (Mental Health Provider) Concerns Regarding Take-Home Activities: “. . . we also need to [take into] consideration their literacy level. Most of these individuals usually complete a third-grade level education. So, we can ask them but if they are not very comfortable in their writing abilities, I don’t know if that would present a barrier.” (Upper-level Administrator)

^aKey Stakeholders included administrators of community-based organization programs (mangers, supervisors, directors) and non-medical providers (mental health provider, HIV and outreach counselor, support group facilitator).

RESULTS: FORMATIVE RESEARCH

Anticipated Acceptability

Example quotes from the semi-structured interviews regarding anticipated acceptability are shown in Table 2. All but one of the client interviewees were enthusiastic about the potential program and viewed it as an important opportunity to learn and connect with others. One participant stated that he was less enthusiastic because he did not believe that discrimination existed and, thus, did not see the value of the program.

Interviewees were asked about a range of potential intervention session topics; almost all felt it would be helpful to discuss coping with discrimination, especially regarding immigration status, HIV status, and sexual orientation disclosure, and medical mistrust. Interviewees also suggested including outside speakers (e.g., lawyers, doctors, social workers) to discuss navigating discrimination related to legal status and substance use.

Interviewees agreed that the facilitator should have characteristics in common with participants (gay/bisexual, male, Latino, immigrant), and that the facilitator should be professionally trained with specific skills in facilitating group learning. Several providers noted the benefits of including peer facilitators as well as professionally trained facilitators.

Participants showed mixed attitudes about having take-home activities. Although participants acknowledged that such activities would be valuable in helping to process discrimination events, they also were skeptical that Siempre Seguiré attendees would complete the activities, as evidenced by quotes from both clients and providers.

Intervention Development

The formative research indicated high acceptability of the intervention among potential participants and providers, including use of CBT to address coping with discrimination. Thus, we developed the intervention for Latino SMM in a way that was culturally congruent, integrating narratives of discrimination experiences and coping strategies as examples to illustrate concepts throughout the intervention manual. In particular, because seeking social support was a major coping strategy discussed in the interviews, we selected a group format, which helps to provide validation through selective affiliation, defined as interaction with individuals with similar intersecting identities, who struggle with similar challenges—an effective, self-protective, problem-focused coping strategy.²⁸ In addition, because support groups are commonly used in community-based organizations, we believed that a support group format would be both feasible and familiar to participants. A support group format also was consistent with our proposed use of CBT, which is usefully conducted in groups because antecedents or consequences of many problem behaviors are interpersonal, and because participants can learn skills by modeling experiences of other group members.²⁹

Based on feedback from participants and providers, we included psychoeducation about discrimination in order to enable participants to identify any experienced identity-based maltreatment. Specifically, the facilitators defined discrimination, raised awareness about health disparities resulting from discrimination, and acknowledged historical and current structural discrimination, which can lead to medical mistrust, as well as mental health issues, substance use, and poverty. We selected two facilitators for the group, a professional mental health provider and an identity-matched peer, a Latino SMM with HIV. Further, we chose to retain the take-home activities, as practice outside of counseling sessions is a core part of the behavior change power of CBT. However, we ensured that the facilitators emphasized strongly and repeatedly the rationale for between-session practice, and functionally validated homework completion by devoting around one-third of each session to an in-depth review of the participants’ out-of-session activities. In this way, we addressed participant concerns and also maintained the key active ingredients of CBT.

METHODS: INTERVENTION PILOT

Intervention Structure and Content

As shown in Table 3, the manualized intervention had nine weekly group sessions (eight weekly sessions plus a “graduation” ceremony), conducted in Spanish, that used CBT techniques and assumptions from dialectical behavior therapy (DBT) to coping with discrimination—a novel use for these established techniques. Specifically, facilitators taught participants coping skills, such as mindfulness, cognitive restructuring, and relaxation,^30–34 and helped participants to understand responses to discrimination in terms of the events that led to the behavior, called a functional or chain analysis, and the behavior’s consequences.³⁵ Participants were guided through a step-by-step, microlevel recounting of thoughts, behaviors, and emotions related to a specific discrimination event chain that included distal vulnerability factors, proximal prompting events, and immediate and longer-term consequences of coping strategies, and learned how to identify problematic “links” in the chain.^30,35 Facilitators elicited in-session skills practice (e.g., via role-plays) and assigned take-home activities to encourage skills generalization, such as tracking cognitions, emotions, and behaviors in response to discrimination experiences that may have occurred in between sessions.^36,37 All sessions began and ended with relaxation exercises.

TABLE 3.

Siempre Seguiré Intervention Session Content

Session	Goals	Take-Home Activity
1. Orientation to the Group and Discussion about Discrimination and Group Members’ Intersecting Identities	• Orient group members to group/ground rules • Build group cohesion • Provide psychoeducation about systems of oppressions • Discuss how discrimination affects group members’ lives • Describe most important identities	Tracking Discrimination: Describe any discrimination experiences from ethnicity, immigration status, sexual orientation, and/or HIV-serostatus
2. Discussion of Multiple Identities and Coping with Discrimination	• Discuss men’s experiences living with multiple stigmatized identities • Evaluate specific instances of coping as effective or ineffective based on their own values/goals	Tracking Discrimination: Same as prior week and add tracking of coping responses
3. Introduction to Ways to Understand Discrimination and Coping with Discrimination I	• Introduce group members to the CBT model • Discuss how to apply CBT model (and chain analysis) to discrimination	Tracking Discrimination: Same as prior week
4. Ways to Understand Discrimination and Coping with Discrimination II	• Gain further knowledge and experience on understanding discrimination experiences • Define and identify critical links, and vulnerability and resilience factors	Tracking Discrimination: Same as prior week, and add identification of vulnerability and resilience factors
5. Ways to Understand Discrimination and Coping with Discrimination III	• Identify barriers to effectively coping with discrimination experiences (e.g., internalized stigma and power differentials with perpetrators, such as law enforcement) • Brainstorm and learn strategies for addressing those barriers	Tracking Discrimination: Same as prior week, with encouragement to use different coping strategies to broaden repertoire
6. Investigating Medical Mistrust	• Orient group members to mistrust as an expectable consequence of discrimination that can affect healthcare engagement and health outcomes	Tracking Discrimination: Same as prior week, focused specifically on the role of mistrust in experiences of and coping with discrimination
7. Getting the Social Support You Need	• Describe support that group members have • Strategize about how to get support for whole self, across identities	Tracking Discrimination: Same as Week 5
8. Addressing Structural Discrimination and Review	• Discuss ways to take action and advocate for change through changing societal structures • Review progress	Prepare for Graduation: same as Week 5 plus reflect on what was learned, what changes were made, and what will be remembered
9. Graduation	• Describe how to practice after group ends	N/A

Note. Sessions were conducted in Spanish. All sessions began and ended with a relaxation exercise, and except for Session 1, started with a review of the ground rules, a recap of the prior session, and a take-home activity review. Refreshments were served at the beginning of each session, and free-flowing discussions the communal meal helped to encourage group cohesion.

The standardized intervention content did not involve systematically teaching new coping skills; rather, facilitators guided participants on strengthening and generalizing their innate, effective coping skills—as well as learning new, effective, standard CBT skills from each other or the facilitators, based on the unique, expressed needs that emerged. In this way, facilitators were able to validate participants’ lived experiences. In addition, facilitators emphasized that different types of coping serve distinct functions according to a given situation and for some situations, such as discrimination from people in positions of power, such as law enforcement or immigration officials, there may be restricted coping options.³⁸ For example, speaking up directly to an immigration officer, rather than obtaining legal counsel, may be detrimental.

Intervention Pilot Design and Procedures

The intervention was pilot-tested using a single-arm process evaluation (pre-post design without control). Thirty participants were recruited via flyers for two intervention groups, with the goal of enrolling 15 participants per group. Eligible individuals reported being 18 years old or older; Latino (or mixed-race/ethnicity, if their primary self-identification was Latino); HIV-positive; biologically male at birth; having had sex with men in their lifetime; and an immigrant. Participants completed audio computer-assisted self-interviews assessing sociodemographic and medical characteristics (see Table 4) and coping with discrimination (the Brief COPE,³⁹ 14 subscales, average α = .65; participants were asked to respond about how often they used each strategy “when faced with discrimination”), and emotional and behavioral coping (Perceived Racism Scale subscales,⁴⁰ average α = .93 and .95, respectively, adapted to assess coping with discrimination from HIV status, ethnicity, and sexual orientation). To document levels of discrimination at baseline, participants also completed the Multiple Discrimination Scale,⁴¹ to assess past-year levels of perceived discrimination from HIV status (α = .91), sexual minority orientation (α = .67), Latino ethnicity (α = .92), and undocumented immigration status (i.e., “because someone thought or knew that you are not a legal U.S. resident”) (α = .73).

TABLE 4.

Characteristics of Siempre Seguiré Pilot Intervention Study Sample (N = 30)

Variable	Mean (SD) or N (%)
Age (years)	48.5 (10.3)
Nationality
Mexican	19 (63)
Salvadoran	4 (13)
Honduran	2 (7)
Other Hispanic, Latino, or Latino (Argentinian, Ecuadorean, Panamanian, Venezuelan)	5 (17)
Mother born in the United States	2 (7)
English Speaking Frequency
Not at all	7 (23)
Very little or not very often	5 (17)
Moderately	10 (33)
Much or very often	6 (20)
Extremely often or almost always	2 (7)
Residency Status
U.S. citizen	8 (31)
Permanent resident	7 (27)
Undocumented status	7 (27)
Other	4 (15)
Years Lived in the United States
<1 year	0 (0)
1–5	1 (3)
6–10	2 (7)
11–15	4 (13)
16–20	8 (27)
>20	15 (50)
Highest Degree Earned
Less than high school	14 (47)
HS diploma or GED	11 (37)
Associate degree	2 (7)
Bachelor’s or four-year college degree	3 (10)
Graduate degree	0 (0)
Employment Status
Full time	0 (0)
Part time	9 (30)
On leave from a job (e.g., sick leave)	2 (7)
Not employed	11 (37)
Disabled and not working	7 (23)
Retired	1 (3)
Stable housing	22 (73)
Live alone	20 (67)
Total Household Income Past 12 Months
< $5,000	10 (38)
$5,000–$11,999	12 (46)
$12,000–$15,999	2 (8)
$16,000–$24,999	2 (8)
Sexual Orientation
Gay or same gender loving	26 (87)
Bisexual	1 (3)
Straight or heterosexual	1 (3)
Not sure or in transition	2 (7)
Length of time since HIV diagnosis (years)	14.6 (10.2)
Any Discrimination
Any HIV discrimination	19 (63)
Any sexual orientation discrimination	19 (63)
Any ethnic discrimination	15 (50)
Any immigration-related discrimination	19 (63)

Assessments were conducted at baseline and immediately post-intervention. Participants provided written informed consent and received gift-card incentives ($30/survey, $5/intervention session).

Statistical Analysis

We conducted descriptive statistics on all variables, and linear regressions predicting change in coping from baseline to post-intervention for each coping subscale on the 24 participants (80%) who had both baseline and follow-up data.

Feasibility

We measured feasibility as retention in the assessments and intervention sessions.¹⁷ Of the 30 participants, 24 (80%) completed follow-up interviews. In the first intervention group, three participants attended all sessions, two attended eight sessions, one attended seven sessions, one attended three sessions, two attended one session, and six did not attend any sessions (M = 3.7 sessions). The most common reasons for missing sessions included scheduling conflict (e.g., with work; n = 6) and illness of self or family member (n = 5). In the second group, five participants attended all sessions, three attended eight sessions, one attended seven sessions, one attended six sessions, two attended three sessions, and three did not attend any sessions (M = 5.9 sessions). The most common reasons for missing sessions included scheduling conflict (n = 3), illness of self or family member (n = 2), and chaotic lives due to active substance use (n = 2). Thus, there was less retention in the first group; 40% attended at least half of the sessions in the first group vs 66% in the second group.

Because we used an iterative process—in which we incorporated participant feedback during the pilot test—we were able to improve retention in the second intervention group compared to the first group. A key reason for the low retention in the first group was scheduling issues, because the group was held on a weekday evening. Thus, we held the second group on a Saturday midday, when more participants were available. In addition, we held the first group in a church and the second at a community organization more familiar to participants. We trained a new facilitator and co-facilitator for the second group. The first group was led by a Latina woman who counseled clients at the community-based organization, but who did not have experience with group facilitation. The second group was led by a Latino gay man with a long history of facilitating well-attended support groups at the organization.

Preliminary Effectiveness

Bivariate linear regressions showed decreased negative emotional responses to discrimination events (due to HIV, ethnicity, and sexual orientation) pre-to-post intervention. Specifically, participants reported feeling less anger and frustration on one emotional coping subscale (baseline: M [SD] = 0.84 [0.57]; follow-up: M [SD] = 0.60 [0.41]; b [SE] = −0.23 (0.10), p = .03). They also reported lower levels of sadness, powerlessness, helplessness, and shame on another subscale (baseline: M [SD] = 0.84 [0.53]; follow-up: M [SD] = 0.59 [0.39]; b [SE] = −0.25 [0.11], p = .03). Other types of coping (i.e., 14 subscales from the Brief COPE) did not show significant effects (all p values > .05).

DISCUSSION

The present study showed promising acceptability, feasibility, and preliminary effects of Siempre Seguiré, a novel intervention to address coping with discrimination from intersectional identities among Latino SMM. Although prior research has shown the effectiveness of CBT in improving coping with stress among people with HIV,^14,15 our work is the first to apply the CBT model to address coping with discrimination from intersectional identities.

Results indicated that intervention participants showed higher emotion-focused coping at follow-up compared to baseline, in that they were less likely to react negatively, such as with anger or anxiety, to discrimination. The intervention’s focus on mindfulness, including in-session education and activities about attentiveness to reactions to stressful situations, could have contributed in part to these changes. However, other coping effects were nonsignificant—for example, problem-focused coping, such as finding social support or pro-active avoidance of situations in which discrimination is likely—which may have been due to the small sample size and reduced statistical power or, alternately, it may be a sign that we need to strengthen the intervention to emphasize these other forms of coping more directly. Due to the main purpose of the present study to evaluate intervention acceptability and feasibility, and because the study was not adequately statistically powered to detect effects across multiple outcomes, interpretation of the quantitative effects should be done with caution.

In addition to the small sample size, primary limitations of the study include the lack of a control group, and difficulties with participant retention, especially for the first pilot group. In practice, the intervention would be conducted in communities as an ongoing, open support group, similar to other current programs in the community-based organization in which we conducted the study. Thus, material would be repeated, such that clients who miss sessions would still receive the complete intervention over a longer period of time. Such an ongoing format would be more tailored to clients’ lives, as we found that attending weekly sessions regularly proved challenging for some participants, due to life circumstances not related to the intervention (e.g., illness, work schedule changes). In terms of generalizability, the intervention was tailored specifically for immigrant Latino SMM in Los Angeles, most of whom were from Mexico, and the sample was close to 50 years old on average. Different content may be needed for other Latino subgroups—although intervention content did address potential ethnic/national variability. However, through our efforts, the core structure and components of the intervention have now been shown to be acceptable to both Black and Latino SMM, and, thus, we expect that other SMM would show similar positive attitudes about the intervention.

CONCLUSIONS

Structural-level interventions are essential for reducing societal discrimination as a long-term strategy. However, individual-level interventions such as Siempre Seguiré are necessary in tandem, to mitigate negative physical and mental health effects of discrimination in the shortterm.⁴² Such individual-level interventions need to be conducted in a sensitive manner that does not explicitly or implicitly blame individuals who are the target of discrimination but, rather, empowers them to leverage their innate resilience resources to improve their health in the face of real and persistent discrimination.⁴³

Public Health Significance Statement:

Discrimination likely contributes to racial/ethnic and LGBT health disparities. Our pilot of a community-based cognitive behavior therapy group intervention to address coping with discrimination among HIV-positive Latino immigrant sexual minority men found high intervention acceptability and preliminary effects on improved coping, which ultimately can lead to better long-term health outcomes.