Willingness to participate in HIV vaccine trials among men who have sex with men in Chennai and Mumbai, India

INTRODUCTION

Men who have sex with men (MSM) are at disproportionately high risk for HIV in India and would benefit greatly from a safe and effective HIV vaccine. We assessed willingness to participate (WTP) in HIV vaccine trials and the impact of various trial characteristics on WTP among MSM in Mumbai and Chennai.

METHODS

We used venue-based time-space sampling to recruit MSM at cruising sites and drop-in centers at community-based organizations. Structured survey interviews assessed sociodemographics, WTP and the impact of 10 trial characteristics on WTP. We tested for differences in WTP by sociodemographics and trial characteristics, and sociodemographic differences in the impact of trial characteristics on WTP.

RESULTS

Among 400 participants (median age=25 years), 46.9% identified as kothi, 40.0% panthi/double-decker, 13.0% gay/bisexual; 29.0% had primary school education or less; and 40.0% had monthly income <=5000 INR (∼3USD/day). Overall, 48.1% reported being definitely willing to participate. Posttrial availability of an efficacious vaccine was the highest rated (90.98 on 100-point scale) trial characteristic, followed by availability of free medical treatment (90.79), life insurance (89.84) and side effects (79.81). Distance to the trial site, side effects, financial incentive, life insurance and free medical care had significant impacts on WTP, with differential importance of trial characteristics by sexual identity, education, income and living arrangement.

CONCLUSION

The prioritization of trial-related financial and healthcare provisions, including access to an efficacious vaccine posttrial, among MSM in India indicates the importance of trials providing such services, as well as the value of formative research in identifying key concerns among participating communities in resource-limited settings. The significant impact of trial characteristics on WTP suggests that providing trial benefits deemed fair and important, addressing logistical concerns, and supporting educational interventions to mitigate vaccine fears may support recruitment of MSM in India in fairly and ethically conducted HIV vaccine trials.

Development of an HIV vaccine attitudes scale to predict HIV vaccine acceptability among vulnerable populations: L.A. VOICES

BACKGROUND

Decade-long delays in successful implementation of Hepatitis B vaccines and ongoing obstacles in HPV vaccine roll-out suggest the importance of an implementation science approach to prepare for the effective translation of future HIV vaccines from clinical trials into routine practice. The objective of this study was to test HIV vaccine attitude items to develop reliable scales and to examine their association with HIV vaccine acceptability.

METHODS

HIV vaccine attitude items were assessed as part of the L.A. VOICES survey, a large-scale study conducted among underserved residents of Los Angeles, to identify factors that may influence HIV vaccine acceptability. Participants (n=1225) were randomly selected from public STD clinics, needle exchange sites and Latino community clinics using three-stage, venue-based time space sampling.

RESULTS

Exploratory factor analysis across 20 items revealed four distinct factors - mistrust, HIV vaccine social concerns, risk compensation, and altruistic vaccination - with acceptable reliability coefficients for each subscale (Cronbach's α range 0.61-0.84). We found no significant differences in reliability by gender or by vaccine acceptability. Risk compensation (odds ratio (OR)=1.49; 95% CI=[1.18, 1.89]; p=0.001) and altruistic vaccination (OR=1.40; 95% CI=[1.14, 1.71]; p=0.001) were significantly and positively associated with HIV vaccine acceptability.

CONCLUSIONS

We identified four HIV vaccine attitude scales with sound internal reliability parameters. In the aftermath of the first candidate vaccine to demonstrate efficacy against HIV infection, these scales may be helpful in bridging expectable research-to-practice gaps in future HIV vaccine dissemination among populations at risk. As HIV vaccine trials progress in the United States and globally, these measures also may be useful as a tool to assess and facilitate effective responses to community concerns about HIV vaccine trials and to target interventions to support recruitment and mitigate risk compensation.

A psycho-educational HIV/STI prevention intervention for internally displaced women in Leogane, Haiti: results from a non-randomized cohort pilot study

BACKGROUND

Little evidence exists regarding efficacious HIV and sexually transmitted infections (STI) prevention interventions with internally displaced populations. Internally displaced women are at elevated risk for HIV/STI due to limited access to health services, heightened poverty and social network breakdown. The FASY (Famn an Aksyon Pou Sante' Yo) (Women Taking Action For Their Health) study examined the effectiveness of a peer health worker (PHW) delivered psycho-educational HIV/STI pilot study with internally displaced women in Leogane, Haiti.

METHOD

This was a non-randomized cohort pilot study. Participants completed a computer-assisted pre-test programmed on Android tablet PCs followed by an HIV/STI educational video-based session and a 6-week psycho-educational group program of weekly meetings. Participants completed a post-test upon completion of group sessions. The primary outcome was HIV knowledge; our pre-specified index of clinically significant change was an effect size of 0.30. Secondary outcomes included: STI knowledge, condom use, social support, resilient coping, depression and relationship control. We used mixed-effects regression to calculate mean outcome pre-post score change. This study was registered (clinicaltrials.gov, NCT01492829).

RESULTS

Between January 1-April 30, 2012 we assigned 200 participants to the study. The majority of participants (n = 176, 88%) completed the study and were followed up at 8 weeks, finishing April 30, 2012. Adjusted for socio-demographic characteristics, HIV knowledge (β = 4.81; 95% CI 4.36-5.26), STI knowledge (β = 0.84; 95% CI 0.70-0.99), condom use (AOR = 4.05, 95% CI 1.86-8.83), and depression (β = -0.63, 95% CI -0.88--0.39) scores showed statistically significant change post-intervention (p<0.05).

CONCLUSIONS

This pilot study evaluated a PHW psycho-educational HIV/STI prevention intervention among internally displaced women in post-earthquake Haiti. Pilot studies are an important approach to understand feasibility and scientific impacts of HIV prevention strategies in disaster contexts. Study results may inform HIV prevention interventions among internally displaced women in Haiti and can be tested for applicability with internally displaced women globally. ClinicalTrials.gov: Identifier NCT01492829, URL: http://clinicaltrials.gov/ct2/show/NCT01492829?term=logie&rank=1.

Barriers to antiretroviral treatment access for injecting drug users living with HIV in Chennai, South India

India's National AIDS Control Organization provides free antiretroviral treatment (ART) to people living with HIV (PLHIV), including members of marginalized groups such as injecting drug users (IDUs). To help inform development of interventions to enhance ART access, we explored barriers to free ART access at government ART centers for IDUs living with HIV in Chennai by conducting three focus groups (n = 19 IDUs) and four key informant interviews. Data were explored using framework analysis to identify categories and derive themes. We found interrelated barriers at the family and social, health-care system, and individual levels. Family and social level barriers included lack of family support and fear of societal discrimination, as well as unmet basic needs, including food and shelter. Health-care system barriers included actual or perceived unfriendly hospital environment and procedures such as requiring proof of address and identity from PLHIV, including homeless IDUs; provider perception that IDUs will not adhere to ART, resulting in ART not being initiated; actual or perceived inadequate counseling services and lack of confidentiality; and lack of effective linkages between ART centers, needle/syringe programs, and drug dependence treatment centers. Individual-level barriers included active drug use, lack of self-efficacy in ART adherence, low motivation to initiate ART stemming from a fatalistic attitude, and inadequate knowledge about ART. These findings indicate that to facilitate IDUs gaining access to ART, systemic changes are needed, including steps to make the environment and procedures at government ART centers more IDU-friendly and steps to decrease HIV- and drug use-related stigma and discrimination faced by IDUs from the general public and health-care providers. Housing support for homeless IDUs and linkage of IDUs with drug dependence treatment are also essential.

"Sisters, Mothers, Daughters and Aunties": HIV vaccine acceptability among African, Caribbean and other Black women in Toronto

OBJECTIVES

Black women in Canada are at disproportionately high risk for HIV. We assessed HIV vaccine acceptability and correlates of acceptability among Black women from African and Caribbean communities in Toronto.

METHODS

"Sisters, Daughters, Mothers, and Aunties" was a community-based research project. Black women of African and Caribbean descent were recruited using venue-based sampling across diverse community organizations in Toronto. We used a structured questionnaire to collect data on socio-demographic characteristics and acceptability of 8 future HIV vaccines, each defined by a set of 7 dichotomous attributes. Conjoint analysis was used to quantify the relative impact of vaccine attributes on acceptability, with multiple regression to adjust for socio-demographic characteristics associated with overall acceptability.

RESULTS

Mean vaccine acceptability was 58.8 (SD=17.2) on the 100-point scale. Efficacy had the greatest impact on acceptability, followed by side effects, cost, duration of protection, and number of doses. Acceptability of a high (99%) efficacy vaccine (70.1/100) was significantly greater than for a 50% efficacy vaccine (47.6/100). Vaccine acceptability was significantly higher among women of Caribbean versus African descent, ever married versus single women, and women with full-time versus part-time employment.

CONCLUSIONS

Black women in Toronto indicated a modest level of acceptability for future HIV vaccines. Educational interventions that address the benefits of partially efficacious vaccines and clearly explain potential side effects, as well as vaccine cost subsidies may promote HIV vaccine uptake. Differences in acceptability within Black communities suggest that tailored multi-level interventions may mitigate barriers to uptake.

"If It's Not Working, Why Would They Be Testing It?": mental models of HIV vaccine trials and preventive misconception among men who have sex with men in India

BACKGROUND

Informed consent based on comprehension of potential risks and benefits is fundamental to the ethical conduct of clinical research. We explored mental models of candidate HIV vaccines and clinical trials that may impact on the feasibility and ethics of biomedical HIV prevention trials among men who have sex with men (MSM) in India.

METHODS

A community-based research project was designed and implemented in partnership with community-based organizations serving MSM in Chennai and Mumbai. We conducted 12 focus groups (n=68) with diverse MSM and 14 key informant interviews with MSM community leaders/service providers using a semi-structured interview guide to explore knowledge and beliefs about HIV vaccines and clinical trials. Focus groups (60-90 minutes) and interviews (45-60 minutes) were conducted in participants' native language (Tamil in Chennai; Marathi or Hindi in Mumbai), audio-taped, transcribed and translated into English. We explored focus group and interview data using thematic analysis and a constant comparative method, with a focus on mental models of HIV vaccines and clinical trials.

RESULTS

A mental model of HIV vaccine-induced seropositivity as "having HIV" resulted in fears of vaccine-induced infection and HIV stigma. Some participants feared inactivated vaccines might "drink blood" and "come alive". Pervasive preventive misconception was based on a mental model of prevention trials as interventions, overestimation of likely efficacy of candidate vaccines and likelihood of being assigned to the experimental group, with expectations of protective benefits and decreased condom use. Widespread misunderstanding and lack of acceptance of placebo and random assignment supported perceptions of clinical trials as "cheating". Key informants expressed concerns that volunteers from vulnerable Indian communities were being used as "experimental rats" to benefit high-income countries.

CONCLUSIONS

Evidence-informed interventions that engage with shared mental models among potential trial volunteers, along with policies and funding mechanisms that ensure local access to products that demonstrate efficacy in trials, may support the safe and ethical implementation of HIV vaccine trials in India.

A social ecology of rectal microbicide acceptability among young men who have sex with men and transgender women in Thailand

INTRODUCTION

With HIV-incidence among men who have sex with men (MSM) in Bangkok among the highest in the world, a topical rectal microbicide would be a tremendous asset to prevention. Nevertheless, ubiquitous gaps between clinical trial efficacy and real-world effectiveness of existing HIV preventive interventions highlight the need to address multi-level factors that may impact on rectal microbicide implementation. We explored the social ecology of rectal microbicide acceptability among MSM and transgender women in Chiang Mai and Pattaya, Thailand.

METHODS

We used a qualitative approach guided by a social ecological model. Five focus groups were conducted in Thai using a semi-structured interview guide. All interviews were digitally recorded, transcribed verbatim in Thai and translated into English. We conducted thematic analysis using line-by-line and axial coding and a constant comparative method. Transcripts and codes were uploaded into a customized database programmed in Microsoft Access. We then used content analysis to calculate theme frequencies by group, and Chi-square tests and Fisher's exact test to compare themes by sexual orientation/gender expression and age.

RESULTS

Participant's (n=37) mean age was 24.8 years (SD=4.2). The majority (70.3%) self-identified as gay, 24.3% transgender women. Product-level themes (side effects, formulation, efficacy, scent, etc.) accounted for 42%, individual (increased sexual risk, packaging/portability, timing/duration of protection) 29%, interpersonal (trust/communication, power/negotiation, stealth) 8% and social-structural (cost, access, community influence, stigma) 21% of total codes, with significant differences by sexual orientation/gender identity. The intersections of multi-level influences included product formulation and timing of use preferences contingent on interpersonal communication and partner type, in the context of constraints posed by stigma, venues for access and cost.

DISCUSSION

The intersecting influence of multi-level factors on rectal microbicide acceptability suggests that social-structural interventions to ensure widespread access, low cost and to mitigate stigma and discrimination against gay and other MSM and transgender women in the Thai health care system and broader society will support the effectiveness of rectal microbicides, in combination with other prevention technologies, in reducing HIV transmission. Education, outreach and small-group interventions that acknowledge differences between MSM and transgender women may support rectal microbicide implementation among most-at-risk populations in Thailand.

HPV vaccine acceptability among men: a systematic review and meta-analysis

OBJECTIVE

To understand rates of human papillomavirus (HPV) vaccine acceptability and factors correlated with HPV vaccine acceptability.

DESIGN

Meta-analyses of cross-sectional studies.

DATA SOURCES

We used a comprehensive search strategy across multiple electronic databases with no date or language restrictions to locate studies that examined rates and/or correlates of HPV vaccine acceptability. Search keywords included vaccine, acceptability and all terms for HPV.

REVIEW METHODS

We calculated mean HPV vaccine acceptability across studies. We conducted meta-analysis using a random effects model on studies reporting correlates of HPV vaccine acceptability. All studies were assessed for risk of bias.

RESULTS

Of 301 identified studies, 29 were included. Across 22 studies (n=8360), weighted mean HPV vaccine acceptability=50.4 (SD 21.5) (100-point scale). Among 16 studies (n=5048) included in meta-analyses, perceived HPV vaccine benefits, anticipatory regret, partner thinks one should get vaccine and healthcare provider recommendation had medium effect sizes, and the following factors had small effect sizes on HPV vaccine acceptability: perceived HPV vaccine effectiveness, need for multiple shots, fear of needles, fear of side effects, supportive/accepting social environment, perceived risk/susceptibility to HPV, perceived HPV severity, number of lifetime sexual partners, having a current sex partner, non-receipt of hepatitis B vaccine, smoking cigarettes, history of sexually transmitted infection, HPV awareness, HPV knowledge, cost, logistical barriers, being employed and non-white ethnicity.

CONCLUSIONS

Public health campaigns that promote positive HPV vaccine attitudes and awareness about HPV risk in men, and interventions to promote healthcare provider recommendation of HPV vaccination for boys and mitigate obstacles due to cost and logistical barriers may support HPV vaccine acceptability for men. Future investigations employing rigorous designs, including intervention studies, are needed to support effective HPV vaccine promotion among men.

Contextual influences on condom use among men who have sex with men in India: subjectivities, practices and risks

Quantitative studies among men who have sex with men in India have shown high levels of unprotected anal sex. However, there is little information about the contexts in which such men may not use condoms. Relevant information on these contexts can assist in designing HIV prevention programmes to remove barriers to consistent condom use. As part of a larger study on sexual and social networks, we explored the contexts in which men who have sex with men did not use condoms, with a focus on personal, interpersonal and structural levels of experience. Data indicate the importance of understanding the different contexts that lead to unprotected sex but also reveal that the concept 'context' itself as a complex variable to consider in research of this kind, as research subjects interpret their social worlds and sexual risks in subtle and varied ways. Based on this viewpoint we make recommendations regarding HIV prevention.

"Never reflected anywhere": body image among ethnoracialized gay and bisexual men

A growing body of literature has highlighted the increased prevalence of body image concerns and associations with health outcomes among gay and bisexual men (GBM). Little research, however, has examined the link between body image and social oppression for ethnoracialized GBM. Using an intersectionality lens and qualitative inductive analysis, data were collected through focus groups and interviews with GBM (n=61) who identify with one of four ethnoracial groups (Black, East/Southeast Asian, South Asian, Latino/Brazilian). Three main themes emerged: (1) body image idealization in gay/bisexual male culture, (2) negotiating a racialized body image, and (3) negotiating the impact of body image on relationship with self and others. The study results highlighted how multiple forms of oppression (e.g., racism, sexism) intersected with one another to impact the body image and overall well-being among ethnoracialized GBM.

Belief in AIDS-related conspiracy theories and mistrust in the government: relationship with HIV testing among at-risk older adults

PURPOSE

One in 4 persons living with HIV/AIDS is an older adult (age 50 or older); unfortunately, older adults are disproportionately diagnosed in late stages of HIV disease. Psychological barriers, including belief in AIDS-related conspiracy theories (e.g., HIV was created to eliminate certain groups) and mistrust in the government, may influence whether adults undergo HIV testing. We examined relationships between these factors and recent HIV testing among at-risk, older adults.

DESIGN AND METHODS

This was a cross-sectional study among older adults enrolled in a large venue-based study. None had a previous diagnosis of HIV/AIDS; all were seeking care at venues with high HIV prevalence. We used multiple logistic regression to estimate the associations between self-reported belief in AIDS-related conspiracy theories, mistrust in the government, and HIV testing performed within the past 12 months.

RESULTS

Among the 226 participants, 30% reported belief in AIDS conspiracy theories, 72% reported government mistrust, and 45% reported not undergoing HIV testing within the past 12 months. Belief in conspiracy theories was positively associated with recent HIV testing (adjusted odds ratio [OR] = 1.94, 95% confidence interval [CI] = 1.05-3.60), whereas mistrust in the government was negatively associated with testing (OR = 0.43, 95% CI = 0.26-0.73).

IMPLICATIONS

Psychological barriers are prevalent among at-risk older adults seeking services at venues with high HIV prevalences and may influence HIV testing. Identifying particular sources of misinformation and mistrust would appear useful for appropriate targeting of HIV testing strategies.

Demographic and behavioral correlates of HIV risk among men and transgender women recruited from gay entertainment venues and community-based organizations in Thailand: implications for HIV prevention

High HIV prevalence among men who have sex with men (MSM) and transgender women in Thailand suggest a vital need for targeted interventions. We conducted a cross-sectional survey to examine and compare sexual risk behaviors, and demographic and behavioral correlates of risk, among MSM and transgender women recruited from gay entertainment venue staff and community-based organization (CBO) participants. We used venue-based sampling across nine sites in Bangkok and Chiang Mai. Among 260 participants (57.3% gay-identified, 26.9% heterosexual/bisexual-identified, 15.8% transgender; mean age = 26.7 years), nearly one-fifth (18.5%) reported unprotected anal sex (UAS), half (50.4%) sex in exchange for money, and one-fifth (20.0%) STI diagnosis (past year). Nearly one-fourth (23.1%) reported oral erectile dysfunction medication use and nearly one-fifth (19.2%) illicit drug use (past 3 months). Overall, 43.1% indicated that healthcare providers exhibited hostility towards them. Gay entertainment venue staff were significantly more likely to self-identify as heterosexual/bisexual (versus gay or transgender female), and to have less than high school degree education, higher monthly income, to have engaged in sex in exchange for money, sex with women and unprotected vaginal sex, but were significantly less likely to have engaged in UAS than CBO participants. Targeted interventions for younger MSM and transgender women, for non gay-identified men, and strategies to address structural determinants of risk, including low education and discrimination from healthcare providers, may support HIV prevention among MSM and transgender women, and serve broader national HIV prevention efforts in Thailand.

Willingness to participate in HIV vaccine trials among men who have sex with men in Chennai and Mumbai, India: a social ecological approach

BACKGROUND

Recruitment of low- and middle-income country volunteers from most-at-risk populations in HIV vaccine trials is essential to vaccine development. In India, men who have sex with men (MSM) are at disproportionately high risk for HIV infection and an important population for trial recruitment. Investigations of willingness to participate (WTP) in HIV vaccine trials have focused predominantly on individual-level determinants. We explored multi-level factors associated with WTP among MSM in India.

METHODS

We conducted 12 focus groups (n = 68) with low socioeconomic MSM in Chennai and Mumbai, and 14 key informant interviews with MSM community leaders and service providers. Focus groups/interviews were recorded, transcribed and translated into English. Two bilingual investigators conducted thematic analysis using line-by-line coding and a constant comparative method, with member-checking by community representatives.

RESULTS

Factors associated with WTP were evidenced across the social ecology of MSM-social-structural: poverty, HIV-, sexual- and gender non-conformity stigma, institutionalized discrimination and government sponsorship of trials; community-level: endorsement by MSM community leaders and organizations, and fear of within-group discrimination; interpersonal: anticipated family discord, partner rejection, having financially-dependent family members and disclosure of same-sex sexuality; and individual-level: HIV vaccine trial knowledge and misconceptions, safety concerns, altruism and preventive misconception.

CONCLUSION

Pervasive familial, community and social-structural factors characteristic of the Indian sociocultural context may complicate individual-focused approaches to WTP and thereby constrain the effectiveness of interventions to support recruitment and retention in HIV vaccine trials. Interventions to reduce stigma and discrimination against MSM and people living with HIV, capacity-building of MSM community organizations and transparent communications tailored to the knowledge and educational level of local communities may support meaningful engagement of MSM in HIV vaccine trials. Vigilance in providing fair but not excessive compensation and healthcare benefits and in mitigating preventive misconception are warranted to support ethical conduct of trials among MSM in India.

'It looks like you just want them when things get rough': civil society perspectives on negative trial results and stakeholder engagement in HIV prevention trials

Civil society organizations (CSOs) have significantly impacted on the politics of health research and the field of bioethics. In the global HIV epidemic, CSOs have served a pivotal stakeholder role. The dire need for development of new prevention technologies has raised critical challenges for the ethical engagement of community stakeholders in HIV research. This study explored the perspectives of CSO representatives involved in HIV prevention trials (HPTs) on the impact of premature trial closures on stakeholder engagement. Fourteen respondents from South African and international CSOs representing activist and advocacy groups, community mobilisation initiatives, and human and legal rights groups were purposively sampled based on involvement in HPTs. Interviews were conducted from February-May 2010. Descriptive analysis was undertaken across interviews and key themes were developed inductively. CSO representatives largely described positive outcomes of recent microbicide and HIV vaccine trial terminations, particularly in South Africa, which they attributed to improvements in stakeholder engagement. Ongoing challenges to community engagement included the need for principled justifications for selective stakeholder engagement at strategic time-points, as well as the need for legitimate alternatives to CABs as mechanisms for engagement. Key issues for CSOs in relation to research were also raised.

Use of conjoint analysis to assess HIV vaccine acceptability: feasibility of an innovation in the assessment of consumer health-care preferences

Engaging consumers in prospectively shaping strategies for dissemination of health-care innovations may help to ensure acceptability. We examined the feasibility of using conjoint analysis to assess future HIV vaccine acceptability among three diverse communities: a multiethnic sample in Los Angeles, CA, USA (n = 143); a Thai resident sample in Los Angeles (three groups; n = 27) and an Aboriginal peoples sample in Toronto (n = 13). Efficacy had the greatest impact on acceptability for all three groups, followed by cross-clade protection, side-effects and duration of protection in the Los Angeles sample; side-effects and duration of protection in the Thai-Los Angeles sample; and number of doses and duration of protection in the Aboriginal peoples-Toronto sample. Conjoint analysis provided insights into universal and population-specific preferences among diverse end users of future HIV vaccines, with implications for evidence-informed targeting of dissemination efforts to optimize vaccine uptake.

A social vaccine? Social and structural contexts of HIV vaccine acceptability among most-at-risk populations in Thailand

A safe and efficacious preventive HIV vaccine would be a tremendous asset for low- and middle-income country (LMIC) settings, which bear the greatest global impact of AIDS. Nevertheless, substantial gaps between clinical trial efficacy and real-world effectiveness of already licensed vaccines demonstrate that availability does not guarantee uptake. In order to advance an implementation science of HIV vaccines centred on LMIC settings, we explored sociocultural and structural contexts of HIV vaccine acceptability among most-at-risk populations in Thailand, the site of the largest HIV vaccine trial ever conducted. Cross-cutting challenges for HIV vaccine uptake - social stigma, discrimination in healthcare settings and out-of-pocket vaccine cost - emerged in addition to population-specific barriers and opportunities. A 'social vaccine' describes broad sociocultural and structural interventions - culturally relevant vaccine promotion galvanised by communitarian norms, mitigating anti-gay, anti-injecting drug user and HIV-related stigma, combating discrimination in healthcare, decriminalising adult sex work and injecting drug use and providing vaccine cost subsidies - that create an enabling environment for HIV vaccine uptake among most-at-risk populations. By approaching culturally relevant social and structural interventions as integral mechanisms to the success of new HIV prevention technologies, biomedical advances may be leveraged in renewed opportunities to promote and optimise combination prevention.

Perceptions of sexual risk compensation following posttrial HIV vaccine uptake among young South Africans

Concerns about the impact of risk compensation on advances in biomedical human immunodeficiency virus (HIV) prevention technologies have been documented. We conducted an exploratory qualitative study using focus group discussions with young South African men and women (aged 18 to 24 years) to explore perceptions of risk compensation with regard to a hypothetical posttrial HIV vaccine. During the discussions, participants expressed their disquiet about the potential for risk compensation and the manner in which this might manifest among young people. Discussions specifically focused on reductions in condom use, an increase in multiple partners, and increased frequency of sex. The discussions also revealed contradictory feelings about HIV vaccines: appreciation for their development tempered by concerns about loss of control and undermining morality. Women were particularly concerned with the possibility of increased partner concurrency and infidelity. We suggest that concerns in HIV vaccine target populations about the impact of possible risk compensation be incorporated into strategies for vaccine introduction once vaccines move from the hypothetical to reality.

An HIV/STI prevention intervention for internally displaced women in Leogane, Haiti: study protocol for an N-of-1 pilot study

INTRODUCTION

Haiti has the highest HIV infection rate in the Western hemisphere, with approximately one in 50 people infected. The January 2010 earthquake led to the collapse of Haiti's social, economic and health infrastructure, exacerbating social and structural HIV risk factors. Internally displaced (ID) women are particularly at high risk for HIV infection due to breakdown of community networks, increased poverty and sexual violence. The authors present the rationale and study protocol for pilot-testing FASY (Famn an Aksyon Pou Santé Yo) (Women Taking Action For Their Health), a psychoeducational HIV/STI prevention intervention with ID women in Haiti.

METHODS AND ANALYSIS

This is a single-centre pragmatic N-of-1 pilot study. The target population is ID women in Leogane, Haiti. The authors aim to recruit 200 participants using purposive peer-driven recruitment methods. ID women will be trained as community health workers to deliver the FASY intervention in Kreyol. Participants will conduct a pretest that involves an individual HIV/STI educational video-based component followed by a 6-week group programme of 2 h women's health meetings. The primary outcome is HIV knowledge; our prespecified index of clinically significant change is an effect size of 0.30. Secondary outcomes include: sexually transmitted infections knowledge, condom use, social support, resilient coping, depression and relationship control. Multivariate analysis of variance will be used to compare pretest and post-test differences across variables to assess if the intervention influenced primary or secondary outcomes. Significant multivariate analysis of variance will be followed up with both univariate tests and discriminant function analyses to understand significant effects.

ETHICS AND DISSEMINATION

Research Ethics Board approval (2011-0033-E) was attained from the Women's College Hospital, University of Toronto, Toronto, Ontario, Canada. Trial results will be published according to the CONSORT statement, modified for the N-of-1 pilot study design, regardless of the outcomes.

TRIAL REGISTRATION NUMBER

This study is registered at http://clinicaltrials.gov, registration number NCT01492829.

Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India

The Indian government provides free antiretroviral treatment (ART) for people living with HIV. To assist in developing policies and programs to advance equity in ART access, we explored barriers to ART access among kothis (men who have sex with men [MSM] whose gender expression is feminine) and aravanis (transgender women, also known as hijras) living with HIV in Chennai. In the last quarter of 2007, we conducted six focus groups and four key-informant interviews. Data were explored using framework analysis to identify categories and derive themes. We identified barriers to ART access at the family/social-level, health care system-level, and individual-level; however, we found these barriers to be highly interrelated. The primary individual-level barrier was integrally linked to the family/social and health care levels: many kothis and aravanis feared serious adverse consequences if their HIV-positive status were revealed to others. Strong motivations to keep one's HIV-positive status and same-sex attraction secret were interconnected with sexual prejudice against MSM and transgenders, and HIV stigma prevalent in families, the health care system, and the larger society. HIV stigma was present within kothi and aravani communities as well. Consequences of disclosure, including rejection by family, eviction from home, social isolation, loss of subsistence income, and maltreatment (although improving) within the health care system, presented powerful disincentives to accessing ART. Given the multi-level barriers to ART access related to stigma and discrimination, interventions to facilitate ART uptake should address multiple constituencies: the general public, health care providers, and the kothi and aravani communities. India needs a national policy and action plan to address barriers to ART access at family/social, health care system, and individual levels for aravanis, kothis, other subgroups of MSM and other marginalized groups.