AIDS and Behavior

BackgroundHeavy drinking among People Living With HIV (PLWH) reduces antiretroviral adherence and worsens health outcomes. Lengthy interventions to reduce drinking and improve adherence are not feasible in most HIV primary care settings, and patients seldom follow referrals to outside treatment. Utilizing visual and video features of smartphone technology, we developed and tested HealthCall as an electronic (smartphone) means of increasing patient involvement in brief intervention to reduce drinking and improve medication adherence without making unfeasible demands on providers. MethodsAlcohol-dependent patients at a large urban HIV clinic were randomized to one of three groups: (1) Motivational Interviewing (MI) plus HealthCall (n=39), (2) NIAAA Clinicians Guide (CG) plus HealthCall (n=38), or (3) CG-only (n=37). Baseline interventions targeting drinking reduction and medication adherence were [~]25 minutes, with brief (10-15 min) booster sessions at 30 and 60 days. HealthCall involved daily use of the smartphone for 3-5 min/day, covering drinking, medication adherence, and other aspects of the prior 24 hours. Our outcome, assessed at 30 and 60 days, and 3, 6 and 12 months, was ART adherence (using unannounced phone pill-count method; possible adherence scores: 0%-100%). Analysis: generalized linear mixed models with pre-planned contrasts. ResultsStudy retention was excellent (85%-94% across timepoints) and unrelated to treatment arm or patient characteristics. ART adherence was generally high throughout follow-up, with some decline by 12 months. Although both CG+HealthCall and MI+HealthCall evidenced benefits early in follow-up, by 6 months, ART adherence was 11% better among patients in CG+HealthCall than in CG-only (p=0.03) and 9% better than among patients in MI+HealthCall (p=0.07). Efficacy differed slightly by gender (p=.09). ConclusionHealthCall paired with CG resulted in better ART adherence than CG alone. MI+HealthCalls early benefits diminished over time. Given the importance of ART adherence and drinking reduction among PLWH, and the low costs and time required for HealthCall, pairing HealthCall with brief interventions within HIV clinics merits widespread consideration.

ObjectiveTo compare preferences, uptake, and cofactors for unassisted home-based oral self-testing (HB-HIVST) versus clinic-based rapid diagnostic blood tests (CB-RDT) for maternal HIV retesting. DesignProspective cohort MethodsBetween November 2017 and June 2019, HIV-negative pregnant Kenyan women receiving antenatal care were enrolled and given a choice to retest with HB-HIVST or CB-RDT. Women were asked to retest between 36 weeks gestation and 1 week post-delivery if the last HIV test was <24 weeks gestation or at 6 weeks postpartum if [&ge;]24 weeks gestation, and self-report on retesting at a 14 week postpartum. ResultsOverall, 994 women enrolled and 33% (n=330) selected HB-HIVST. HB-HIVST was selected because it was private (68%), convenient (63%), and offered flexibility in timing of retesting (63%), whereas CB-RDT was selected due to trust of providers to administer the test (77%) and convenience of clinic testing (64%). Among 905 women who reported retesting at follow-up, 135 (15%) used HB-HIVST. Most (94%) who selected CB-RDT retested with this strategy, compared to 39% who selected HB-HIVST retesting with HB-HIVST. HB-HIVST retesting was more common among women with higher household income and those who may have been unable to test during pregnancy (both retested postpartum and delivered <37 weeks gestation) and less common among women who were depressed. Most women said they would retest in the future using the test selected at enrollment (99% HB-HIVST; 93% CB-RDT-RDT). ConclusionsWhile most women preferred CB-RDT for maternal retesting, HB-HIVST was acceptable and feasible and may increase retesting coverage and partner testing.

BackgroundIn Uganda, fertility rates and adult HIV prevalence are high, and many women conceive with partners living with HIV. Oral pre-exposure prophylaxis (PrEP) reduces HIV acquisition risk for women and, therefore, infants. We conducted a longitudinal cohort study in Uganda to evaluate oral PrEP uptake and adherence as part of HIV prevention in the context of reproductive goals for women (i.e., safer conception care). MethodsWe enrolled HIV-negative women with personal or partner plans for pregnancy with a partner living, or thought to be living, with HIV (2017-2020) to evaluate the impact of the Healthy Families intervention on PrEP use. Quarterly study visits through 9 months included HIV and pregnancy testing, and safer conception counseling. PrEP was provided to women in electronic pillboxes as the primary adherence measure (categorized as "high" with pillbox openings on >80% of days). Enrollment questionnaires assessed factors associated with PrEP use. Plasma tenofovir (TFV) and intraerythrocytic TFV-diphosphate (TFV-DP) concentrations were determined at each visit for women who acquired HIV during follow-up and a randomly selected subset of those who did not. Women who became pregnant were initially exited from the cohort by design; from April 2019, women with incident pregnancy remained in the study with quarterly follow-up until pregnancy outcome. Primary outcomes included (1) PrEP uptake (proportion of enrolled women who initiated PrEP) and (2) PrEP adherence (proportion of days with electronic pillbox openings during the first 3 months following PrEP initiation). We used univariable and multivariable-adjusted linear regression to evaluate baseline predictors of mean adherence over 3 months. We also assessed mean monthly adherence over 9 months of follow-up and during pregnancy. ResultsWe enrolled 131 women with a mean age of 28.7 years (95% CI: 27.8-29.5). Ninety-seven (74%) reported a partner with HIV and 79 (60%) reported condomless sex at last encounter. Most women (N=118; 90%) initiated PrEP. Mean electronic adherence during the 3 months following initiation was 87% (95% CI: 83%, 90%); most (85%) had adherence >80%. No covariates were associated with 3-month pill-taking behavior. Plasma TFV concentrations were >40ng/mL among 66%, 56%, and 45% at months 3, 6, and 9, respectively. TFV-DP concentrations were >600 fmol/punch among 47%, 41%, and 45% of women at months 3, 6, and 9. We observed 53 pregnancies among 131 women with 848 person-months of follow-up (annualized incidence 75% [95% CI: 57%, 98%]) and one HIV-seroconversion in a non-pregnant woman accessing PrEP. Mean pillcap adherence for PrEP users with pregnancy follow-up (N=17) was 98% (95% CI: 97%, 99%). ConclusionsWomen in Uganda with PrEP indications and planning for pregnancy chose to use PrEP. By electronic pillcap, most were able to sustain high adherence to daily oral PrEP prior to and during pregnancy. Differences in adherence measures highlight challenges with adherence assessment and serial measures suggest 41-66% of women took sufficient periconception PrEP to prevent HIV. These data suggest that women planning for and with pregnancy should be prioritized for PrEP implementation, particularly in settings with high fertility rates and generalized HIV epidemics.

BackgroundDespite Pre-exposure prophylaxiss (PrEP) demonstrated effectiveness, Black cisgender women continue to be at an elevated risk for HIV acquisition and uptake of daily oral PrEP is low in this population in the US. As advancements in PrEP delivery options continue, it is important to understand womens acceptability of these additional options, specifically Black cisgender women, in order to inform uptake and adherence among this population at increased need of HIV prevention options. SettingA cross-sectional survey among Black cisgender women ages 13-45 (inclusive) attending womens health clinics in Chicago, IL, prior to the approval of CAB-LA. MethodsDescriptive statistics were used to describe the sample and bivariate analysis was used to detect differences between categorical and outcome variables using chi-square test. Responses to open-ended questions were thematically coded to explore Black cisgender womens attitudes and preferences between the three methods of PrEP delivery including: vaginal ring, long-acting injectable, and a combined method that would prevent both pregnancy and HIV. ResultsIn total, 211 cisgender women and adolescents responded to the survey. Both injections and combination pills were popular among participants, with 64.5% and 67.3% expressing interest in these forms of PrEP, respectively. The least popular method was the vaginal ring option, with 75.4% of respondents indicating that they would not consider using this modality. Overall, responses were not statistically different between the two surveys administered (Chi square p-values for injection PrEP method 0.66, combination PrEP method 0.93, and ring PrEP method 0.66) suggesting that the popularity of each method was not dependent on clinic location or age of participants. ConclusionThis research provides important insights into the preferences and attitudes of different PrEP modalities among Black cisgender women. As different modalities continue to be approved for use among cisgender women, more research is needed to investigate the acceptability and preferences of these different modalities in order to improve uptake and adherence among this population.

BackgroundWomen comprise 19% of new HIV infections in the U.S. Many women, particularly women of color, are unaware of pre-exposure prophylaxis (PrEP) as an HIV prevention option. We conducted a pilot randomized controlled trial (RCT) to assess feasibility and acceptability of a theory-based, contextually-relevant behavioral intervention, Just4Us, to promote PrEP initiation and adherence among women in New York City and Philadelphia. MethodsEligibility criteria included: cisgender women, aged 18-55, not living with HIV, not currently taking PrEP, and meeting PrEP eligibility guidelines. Participants were randomized 3:1 to the Just4Us Education and Activities (E&A) arm or to the Information arm (Info); all were provided with PrEP information and a referral list. E&A arm participants received an individually-delivered session with a counselor-navigator, who provided information, motivation enhancement, skills-building, problem-solving, and referrals. Between baseline and 3-month follow-up, E&A arm participants received phone calls to support linkage to care and text-messages to promote adherence. Feasibility and acceptability were assessed. ResultsEighty-three women were enrolled (61 intervention; 22 Info); 79% were Black, 26% Latina, exceeding diversity and enrollment targets. Attendance rate for the initial E&A and Info intervention session was 100%. Three-month retention rate was high at 90%. E&A arm participants reported feeling "very satisfied/satisfied with the following: overall session, 95%; discussion with counselor-navigator, 97%; tablet activities, 95%; text-messaging set-up, 93%.; and video, 90%. Among Info and E&A arms, 78% felt the session length was just right, and 95% stated that they would recommend/strongly recommend Just4Us to others. ConclusionsThe pilot RCT demonstrated feasibility and acceptability of the Just4Us E&A intervention, a promising intervention to increase uptake of PrEP among cisgender women. The team was able to recruit, implement the interventions with a high degree of fidelity, and retain the target number of PrEP-eligible socially disadvantaged women. Overall, participant feedback indicated they were generally very satisfied with their intervention.

ImportanceHIV transmission in Kazakhstan has increased among men who have sex with men (MSM) and transgender and nonbinary people who have sex with men (TSM), driven by low HIV testing rates. ObjectiveTo determine if the PRIDE in HIV Care intervention had a community effect of increasing HIV testing among MSM and TSM in Kazakhstan. DesignWe employed a stepped-wedge, cluster-randomized controlled trial with MSM and TSM community members recruited from three cities in Kazakhstan: Almaty, Astana, and Shymkent. We collected serial cross-sectional data where community members completed one assessment between 21 August 2018, and 30 March 2022. SettingWe collected data from 629 MSM and TSM among the study cities. Community respondents were recruited from real-world (e.g., NGOs, bars, clubs) or virtual sites (e.g., social media, apps) where MSM and TSM in each of the three cities were known to frequent. ParticipantsEligibility criteria for community respondents were: (1) [&ge;]18 years old; (2) identifying as male at any point in life or being assigned male at birth; (3) having consensual sex with another man in the past 12 months; (4) engaging in binge drinking (i.e., [&ge;]5 drinks in a 2 hour period), illicit use of drugs, or both in the past 90 days; and (5) residing in one of the three study cities. InterventionThe PRIDE in HIV Care intervention is a theory-driven "crowdsourcing and peer-actuated network intervention" designed to amplify community members successes and resilience via "influencers" who can strengthen and impart benefit to their networks and community. Main outcome measuresReceived an HIV test in the prior six months. ResultsThere was a statistically significant increase in odds of recent HIV testing for every additional month the intervention was implemented in a respondents city (AOR=1.08, 95% CI=1.05-1.12; p<.001). ConclusionsThe PRIDE in HIV Care intervention appears to be efficacious in enacting a community wide increase--i.e., promoted HIV testing among those who did not go through the intervention itself--in HIV testing among MSM and TSM. Trial RegistrationThis trial is registered with clinicaltrials.gov (NCT02786615). FundingNational Institute on Drug Abuse (NIDA), grant number R01DA040513. KEY POINTSO_ST_ABSQuestionC_ST_ABSDoes the PRIDE in HIV Care intervention exert a community effect of increasing HIV testing among men who have sex with men (MSM) and transgender and nonbinary people who have sex with men (TSM) in Kazakhstan? FindingsWe employed a stepped-wedge, cluster-randomized controlled trial among three cities in Kazakhstan. There was a statistically significant increase in odds of recent HIV testing for every additional month the intervention was implemented in a respondents city. MeaningThe intervention increased HIV testing among MSM and TSM in Kazakhstan who had not directly received the intervention, providing support for a community-wide impact.

BackgroundPrEP uptake among Black and Latino gay, bisexual, and other men who have sex with men (GBM) remains low in the United States. The design and implementation of PrEP delivery programs that incorporate the preferences of Black and Latino GBM may overcome barriers to uptake. We aimed to identify preferences for PrEP care among high-priority GBM in the U.S. with a large discrete choice experiment. MethodsWe conducted two discreet choice experiments (DCE) to elicit care preferences for (1) Starting PrEP and (2) Continuing PrEP care among GBM clinically indicated for PrEP. The DCE web-based survey was nested in a longitudinal cohort study of GBM in the U.S., implemented with video and audio directions among 16-49 year-old participants, not using PrEP, and verified to be HIV-negative. All participants were presented with 16 choice sets, with choices determined by BLGBM and PrEP implementation stakeholders. We calculated overall utility scores and relative importance and used latent class analyses (LCA) to identify classes within the Starting and Continuing PrEP DCE. Multivariable analysis was performed to identify factors associated with class membership. FindingsAmong 1514 participants, mean age was 32 years; 46{middle dot}5% identified as Latino, 21{middle dot}4% Black, and 25{middle dot}2 White; 37{middle dot}5% had an income less than USD $20,000. Two latent classes were identified for Starting PrEP: Class 1 (n=431 [28{middle dot}5%]) was driven by preference for more traditional in-person care, and Class 2 (n=1083 [71{middle dot}5%]) preferred flexible care options and on-demand PrEP. In a multivariable model, having a sexual health doctor (adjusted OR 0{middle dot}7, CI 0{middle dot}5, 0{middle dot}9), having a primary care provider (OR 0{middle dot}7,CI 0{middle dot}5, 0{middle dot}9, p= 0{middle dot}023), and concerns over PrEP side effects (OR 1{middle dot}1, CI 1{middle dot}0,1{middle dot}2, p= 0{middle dot}003) were all associated with class membership. InterpretationThe different preferences identified for PrEP care indicate the need for diverse care and formulation choices to improve PrEP uptake and persistence. Addressing these preferences and understanding the factors that shape them can inform the implementation of programs that increase PrEP uptake.

BackgroundStigma remains a pervasive barrier to curbing the spread of human immunodeficiency virus (HIV) among adolescents and young adults in Lima, Peru. Social media offers a promising avenue for scalable, youth-centered stigma reduction, but few interventions have been rigorously evaluated in this context. ObjectiveWe evaluated the potential of a social media campaign to reduce perceived HIV-related stigma among young adults living with HIV. This involved a sequential explanatory mixed-methods study, including a randomized evaluation, followed by focus groups to understand the findings. Methods150 young adults (aged 18-29 years) living with HIV (YLWH) were randomized to receive information on social media from one of the following: (1) the control account; (2) the control account and the social media campaign accounts (Instagram and TikTok); or (3) the control account, the campaign accounts, and the accounts of participating influencers. Perceived stigma was measured via pre- and post-campaign surveys using Spanish versions of the abridged Berger HIV Stigma Scale and the Stigma Stress Scale. Focus groups and interviews were conducted with a purposive sample of participants to contextualize quantitative results. Qualitative data were analyzed using Framework Analysis. ResultsMean changes in HIV Stigma and Stigma Stress scores were small and not statistically significant. Post-hoc as-treated analyses supported these findings. Fidelity to intervention allocation was low to moderate, depending on the metric considered. Qualitative data suggested that the campaign positively impacted participants perceived stigma and that personal circumstances, crossover, frequency of exposure to content, and issues related to completing study questionnaires contributed to the lack of meaningful change in stigma scores. ConclusionsWhile quantitative data did not support that exposure to a social media campaign led to meaningful reductions in HIV-related stigma, qualitative data suggested that the campaign had a positive impact and that limitations in the study design, together with external factors, may have obscured benefits in quantitative analyses.

Lack of adherence to antiretroviral therapy (ART) and poor retention in care are significant barriers to ending HIV epidemics. Treatment adherence support (TAS) effectiveness may be constrained by limited awareness and understanding of the benefits of ART, particularly the concepts of treatment as prevention and Undetectable=Untransmittable (U=U), for which substantial knowledge gaps persist. We used mixed methods to evaluate a straightforward visual and tactile tool, the B-OK Bottles ("B-OK"), that incorporates human-centered design and behavioral economics principles and is designed to change and strengthen mental models about HIV disease progression and transmission. We enrolled 118 consenting adults living with HIV who were clients of medical case managers at one of four case management agencies in Philadelphia. All participants completed a pre-intervention survey, a B-OK intervention, and a post-intervention survey. A subset (N=52) also completed qualitative interviews before (N=20) or after (N=32) B-OK. Participants had a median age of 55 years (IQR 47-60), about two-thirds were male sex (N=77, 65%), nearly three-quarters identified as non-Hispanic Black (N=85, 72%), and almost all reported receiving ART (N=116, 98%). Exposure to B-OK was associated with improved awareness and understanding of HIV terminology, changes in attitudes about HIV treatment, and increased intention to rely on HIV treatment for transmission prevention. Insights from qualitative interviews aligned with the quantitative findings as respondents expressed a better understanding of U=U and felt that B-OK clearly explained concepts of HIV treatment and prevention. These findings provide a strong rationale to further evaluate the potential for B-OK to improve TAS for PLWH.

ObjectiveThe current study sought to assess womens understanding of pre-exposure prophylaxis interest and initiation in heterosexually-active relationships with and without histories of intimate partner violence. Design2017-18 prospective cohort study with an embedded, story completion exercise in the 90-day follow-up such that participants were randomized to receive one of two versions of a story stem based on whether they experienced intimate partner violence. SettingConnecticut. Participants132 heterosexually-active, cisgender adult women residing in the state of Connecticut. Primary outcomes measuresOur primary outcome included identifying principal narratives that describes womens conceptualizations of pre-exposure prophylaxis interest and initiation in heterosexually-active relationships. ResultsUsing both story mapping and thematic analysis techniques, four principal narratives were identified across the stories: 1) the Informed and Empowered PrEP User, 2) the Clandestine PrEP User, 3) the Hesitant PrEP Contemplator, and 4) the Disenfranchised PrEP Non-User. These novel narratives provide insights on how social, clinical, and interpersonal factors are underpinning heterosexually-active, cisgender adult womens ability to display interest and initiate pre-exposure prophylaxis in their relationships. ConclusionsIf our findings are replicated in studies in different settings, it will provide substantial support for future prevention interventions adopting empowerment-centered approaches to refocus womens needs in the context of PrEP initiation and healthy relationships.

Female sex workers (FSW) and men who have sex with men (MSM) are disproportionately affected by HIV. Oral pre-exposure prophylaxis (PrEP) has become increasingly available in African countries including the Democratic Republic of Congo (DRC). However, limited data exist on PrEP uptake and retention or on factors that affect PrEP use among FSW and MSM. This mixed-method study, conducted at KP-friendly centers in Kinshasa, DRC, aimed to identify patterns of PrEP retention and to understand underlying factors of PrEP engagement. Collected data included programmatic data, extraction of routine clinical records, and qualitative interviews with FSW and MSM. Logistic regression was used to identify factors associated with PrEP retention. Qualitative data were analyzed thematically. Findings were then synthesized. Low rates of PrEP initiation and retention were of concern. Only 25% of eligible FSW and MSM initiated PrEP in 2019-2022. Among FSW, 79% returned to the clinic for PrEP refills at 1 month, with only 15% returning for a 3-month visit. Similarly, 74% of MSM were retained at 1 month, with 10% retained at 3 months. Previous experience using PrEP was significantly associated with retention at 3 months. Qualitative analyses identified stigma, side effects, dislike of daily medication regimen, and a shortage of KP-friendly facilities as major barriers to PrEP engagement. This warrants the need for interventions to strengthen messaging about PrEP and side effects wading over time. Raising awareness among the Congolese general population may help to avoid stigmatization of PrEP users and improve PrEP acceptance among key populations at risk.

This paper aims to summarize conference proceedings and testimonies from the "Empowering Women to Take Control of Their Sexual Health Summit" convened in South Florida. In the present study, the phrase "women of color" refers to 279 cisgender and transgender African American, Latina, and Haitian women. Data were collected through three 90-minute group discussions conducted at the conference Individual-, social-, and structural-level PrEP barriers and facilitators were identified. Individual level barriers included: medical distrust, limited knowledge about PrEP, and economic dependence on sexual partners. Participants discussed cultural gender norms and roles as overarching social barriers, with religiosity reinforcing these norms. Structural barriers included: health literacy, health insurance coverage, immigration status, and structural racism. Community attributes that acted as facilitators of PrEP use were resilience and adaptability. Increasing PrEP utilization among women of color requires a multi-tiered approach to comprehensively address structural and community level barriers.

Women comprise 20% of new HIV diagnoses in the U.S. with 86% attributed to heterosexual contact, but HIV pre-exposure prophylaxis (PrEP) uptake is low. OB/GYN clinics are ideal settings to increase HIV prevention counseling for cisgender women, as patients are more likely to discuss their sexual behavior, undergo sexually transmitted infection screening, and receive risk reduction counseling. Our study will assess the feasibility, acceptability, and effectiveness of a registered nurse (RN)-led PrEP project in OB/GYN clinics. Microlearning and Plan-Do-Study-Act cycles will be performed, followed by a randomized controlled trial (RCT). A total of cisgender women determined to be at-risk for HIV will be randomized to standard of care with electronic medical record enhancements (e-SOC) or e-SOC with contact and PrEP counselling by an RN, who will be able to prescribe PrEP under protocol guidance. By shifting HIV PrEP counselling to a nurse, clinics may be able to increase PrEP awareness and uptake. Registered with clinicaltrials.gov: NCT05095818

Substance use remains a robust predictor of HIV infection, as well as a serious impediment to progress across the HIV care continuum for people living with HIV. As such, the careful design and implementation of interventions uniquely tailored to target substance use and HIV care behaviors remain paramount. A necessary step in these efforts is to understand the extent to which HIV care interventions have been efficacious in helping people who use substances progress across the HIV care continuum. Using PubMed and ProQuest databases, we performed a systematic review of randomized trials of HIV care continuum interventions among people who use substances published between 2011 and 2021, the treatment-as-prevention era. Existing systematic reviews and studies in which less than half of those sampled reported substance use were excluded. We identified ten studies (total N=5410; range: 210-1308), nine of which intentionally targeted substance-using populations. Four of these studies involved use of at least one of several substances, including alcohol, opioids, stimulants, and/or marijuana, among others; three involved injection drug use only; one involved methamphetamine use only; and one involved alcohol use only. One study targeted a population with incidental substance use, which involved use of alcohol, injection drug use, and non-injection drug use. Viral suppression was targeted in 8/10 studies, followed by uptake/initiation of antiretroviral therapy (ART; 6/10), ART adherence (6/10), retention to care (4/10), and linkage to care (3/10). For each outcome, intervention effects were found in roughly half of the studies in which a given outcome was assessed. Mediated (2/10) and moderated (2/10) effects were minimally examined. The diversity of substances used in and across studies, as well as other characteristics that varied across studies, prevented broad deductions or conclusions about the amenability of specific substances to intervention. Moreover, study quality was mixed due to varying attrition and assessment measures (self-report vs biological/clinical). More coordinated, comprehensive, and targeted efforts are needed to disentangle intervention effects on HIV care continuum outcomes among populations using diverse substances.

BackgroundLimited research exists on pre-exposure prophylaxis (PrEP) interest or use among female university students in high HIV-prevalence African settings. This study sought to establish the relationship between epidemiologic and perceived HIV risk and PrEP intention among Zambian female university students. MethodsWe recruited female students at an urban university to complete a survey on intention to use PrEP in the next year (primary outcome); other PrEP knowledge, attitudes, and behaviors; demographics; epidemiologic HIV risk and risk perception. Descriptive statistics, regression and mediation analyses were used. ResultsOf the 454 sexually active participants, 118 (26%) reported PrEP intention. Actual PrEP use was rare (< 5%). The odds of PrEP intention increased for those with perceived high HIV risk (aOR 3.08; 95% CI 1.71-5.55) and with each year at university (aOR 1.47; 95% CI 1.21-1.80) but decreased with higher PrEP stigma (aOR 0.91; 95% CI 0.86-0.96) and more negative PrEP perceptions (aOR 0.91; 95% CI 0.85-0.97). More epidemiologic risk factors were originally associated with PrEP intention (OR 1.24; 95% CI 1.01-1.53 for each risk factor), though this relationship weakened after adjustment for perceived HIV risk, which mediated 69% of the relationship between epidemiologic HIV risk and PrEP intention. Only 29% of high-risk participants recognized their high epidemiological HIV risk (3+ risk factors). ConclusionsAlong with PrEP education and stigma reduction, there is a need for approaches that help female university students in Zambia accurately identify their HIV risk to make informed PrEP decisions.

Although 22% of new HIV diagnoses in the United States are attributed to heterosexual contact, uptake of pre-exposure prophylaxis (PrEP) remains low among heterosexually active women and men, and information about PrEP considerations in this population is scarce. We report on a cross-sectional qualitative study that explored attitudes towards PrEP among a diverse sample of 50 heterosexually active cisgender adults (31 women, 19 men) in New York City. We categorized factors influencing PrEP attitudes along social-ecological levels: societal (e.g., social marketing), community (e.g., health care organizations and providers), interpersonal (e.g., friends and sexual partners), and individual (e.g., personal beliefs and preferences). About two-thirds had previously heard of PrEP, but a few had inaccurate or lacking knowledge of it, and none had ever used it. Many participants had learned about PrEP through marketing and social interactions, from which many perceived that PrEP was mainly indicated for gay or bisexual men and transgender individuals. Most participants had never discussed PrEP or received information about it in health-care settings, even though the majority had recently been screened for HIV or sexually transmitted infections. Participants generally felt PrEP was not relevant to them because they perceived themselves at low risk for HIV, thinking PrEP would be indicated for people who have high numbers of sex partners or partners with HIV. Some participants said they would view a potential partner using PrEP positively (e.g., as responsible), while others raised concerns (e.g., about their presumed behaviors). Concerns with side effects and long-term drug toxicity were common, and a few participants expressed anti-medication beliefs. Although awareness seems high, PrEP appears to not have yet entered the repertoire of HIV prevention options for heterosexually active New Yorkers. PrEP promotion among this population could benefit from: messaging targeted to heterosexual adults; ensuring health-care providers inform all sexually active patients about PrEP; and clarifying for practitioners and the public that PrEP is an option for any sexually active person, even those who do not report substantial HIV risk.

In the US, there is a need for interventions that address gaps in awareness, interest, and uptake of HIV testing and biomedical HIV prevention strategies, such as pre-exposure prophylaxis and non-occupational post-exposure prophylaxis. The Test-to-PrEP intervention; an HIV self-test bundled with prevention information that was distributed via a social network strategy, was found to be effective at bridging said gaps. This manuscript presents the development and design of Test-to-PrEP, in which a community-based participatory research approach was used. The intervention combines peer-to-peer distribution of HIV self-testing kits with tailored HIV prevention education. Key features include culturally sensitive educational materials, a strategic emphasis on the connection between intervention distributors and recipients, and rigorous training protocols. Our process led to the creation of materials that were neutral to sexual identity, highlighting the importance of inclusivity and cultural relevance. It also led to a mechanism that allows enhanced network member selection. Stakeholder guidance ensured the initiative was well-aligned with community needs, enhancing its potential acceptability and effectiveness. By centering community needs and cultural nuances, interventions like Test-to-PrEP can potentially increase their reach and efficacy. Our development process underscores the importance of community engagement, cultural relevance, and well-defined reporting.

HIV treatment can suppress viral load and prevent transmission between sex partners, a strategy known as treatment as prevention (TasP). TasP is key for ending the HIV epidemic, and it is important to understand its adoption among priority populations. We examined the TasP adoption cascade using cross-sectional survey data from 1443 U.S. men and transgender, gender-nonconforming, and nonbinary individuals who reported having sex with men. Most participants (82.4%; n = 1189/1443) reported prior awareness of TasP, but only 52.6% of them (n = 625/1189) perceived it as effective at preventing HIV transmission. Of those, 83.8% (n = 524/625) indicated being willing to rely on TasP, among whom 30.2% (n = 158/524) reported having recently done so. Among participants aware of TasP, we compared those who perceived it as effective to those who did not. Participants who did not have HIV and never used PrEP were less likely to agree with TasPs effectiveness than those who had used PrEP or had HIV. Those who had learned about TasP from a sex partner or who had a partner of different HIV status were more likely to perceive it as effective. TasP promotion appears to have achieved broad awareness, but future efforts should aim at increasing the understanding of its effectiveness, especially among those not connected to HIV-related services, organizations, or communities. Public Health SignificanceTasP is an important tool to end the HIV epidemic. Examining stages of its adoption can inform tailored promotion among priority populations. In our study, many participants were aware of TasP, but fewer perceived it as effective. Monitoring uptake over time will allow for responsive promotion strategies as attitudes continue to evolve.

BackgroundRates of intimate partner violence (IPV) and HIV in South Africa are among the highest globally. IPV is associated with a range of adverse mental health and HIV outcomes. The Common Elements Treatment Approach (CETA) is a transdiagnostic, evidence-based intervention delivered by lay providers. ObjectiveTo compare the effectiveness of CETA to active attention control in reducing IPV, depression, Post-Traumatic Stress Disorder (PTSD), and substance use among women at risk of poor HIV outcomes who have experienced IPV. MethodsWomen living with HIV with an unsuppressed viral load or at risk for poor adherence and experienced past 12-month IPV were recruited from Johannesburg-area clinics and randomised 1:1 to CETA or control (SMS HIV appointment reminders plus safety checks and planning). The primary trial outcome was HIV retention and viral suppression, reported elsewhere. This paper reports secondary outcomes, evaluated at three and 12 months: IPV, depression, PTSD, and substance use. FindingsParticipants were enrolled between November 11, 2021 to July 19, 2023 and randomised to CETA (N=202) or control (N=197). In the intent to treat analysis, the Cohens d treatment effect for depression at three months was 0.24 (difference in mean change -3.1; 95% CI: -6.1, 0.1) and 0.48 at 12 months (-6.2; 95% CI: -9.5, -2.8). The PTSD treatment effect was 0.39 at three (-0.3; 95% CI: -0.5, -0.1) and 0.47 at 12 months (-0.3; 95% CI: -0.5, -0.2). Effect sizes were larger in a subgroup of participants with the top 50% of baseline symptom scores (depression: d=0.50, d=0.74; PTSD: d=0.58, d=0.94, at three and 12 months, respectively). There were no statistically significant differences in change for substance use or IPV. At baseline, only 12% of participants had past 3-month substance use and 32% had past 3-month or ongoing experiences of IPV, which made these outcomes challenging to evaluate. ConclusionsCETA was effective for reducing depression and PTSD including among high severity participants and at an extended follow-up. Future studies with increased power for substance use and IPV outcomes are warranted. Clinical implicationsCETA is a recommended treatment for depression and PTSD among this population. Trial registration numberClinicaltrials.gov NCT04242992, registered January 27, 2020 Key MessagesO_ST_ABSWhat is already known about this topic?C_ST_ABSIntimate partner violence (IPV) and related mental health problems are common in South Africa and can lead to poor HIV outcomes, such as low retention in care and viral non-suppression. There is a lack of evidence-based mental healthcare options for women living with HIV who have experienced IPV. What this study addsAmong women living with HIV and past-year IPV experiences, we found that Common Elements Treatment Approach (CETA) was an effective treatment for depression and PTSD compared to a control condition. How this study might affect research, practice, or policyCETA is recommended to treat common mental health problems among women with HIV and experiences of IPV.

Background Adolescents and young adults (AYAs) from key and priority populations face persistent challenges with sustained engagement in HIV pre-exposure prophylaxis (PrEP) care. While PrEP initiation has expanded across sub-Saharan Africa, evidence on long-term retention and determinants of disengagement among AYAs remains limited. We examined time to PrEP disengagement and associated factors among AYAs initiating PrEP in eastern Uganda. Methods We conducted a retrospective longitudinal analysis of routinely collected program data for AYAs aged 15-29 years from key and priority populations who initiated PrEP between 2019 and 2025 at Mbale Regional Referral Hospital. Time to PrEP disengagement was assessed using Kaplan-Meier survival analysis and Cox proportional hazards regression. Multivariable models adjusted for sociodemographic, relational, behavioral, and service delivery factors. Sensitivity analyses redefined the time origin to day 91 following PrEP initiation to reflect the programmatic 90-day grace period. Results Among 3,553 AYAs initiating PrEP, the median time to disengagement was 284 days (95% CI: 273-295). The median age was 24 years (interquartile range [IQR]: 20-26). The probability of remaining engaged in PrEP care declined from 60.1% at 90 days to 20.2% at 365 days. Survival patterns differed significantly by population category and sex at birth but not by age group. In adjusted analyses (N = 3,391), knowledge of a partners HIV status (aHR = 2.04; 95% CI: 1.82-2.29) and initiation through community-based services (aHR = 1.42; 95% CI: 1.17-1.72) were associated with faster disengagement. Married participants had lower hazards of disengagement compared with single participants (aHR = 0.69; 95% CI: 0.64-0.76). Reporting an STI syndrome (aHR = 0.42; 95% CI: 0.32-0.55) or recent gender-based violence (aHR = 0.76; 95% CI: 0.60-0.96) was associated with reduced disengagement. Findings were highly consistent in sensitivity analyses using an alternative risk-period definition. Conclusions PrEP disengagement among AYAs occurs rapidly following initiation, with substantial attrition within the first year. Relational factors, service delivery modality, and population-specific vulnerabilities strongly shape retention trajectories. These findings underscore the need for risk-responsive, differentiated PrEP delivery strategies that strengthen partner-based services, integrate STI and GBV screening, and adapt retention support for AYAs in community and facility settings.