Knowledge and Attitudes About Pre-Exposure Prophylaxis Among Young Adults Experiencing Homelessness in Seven U.S. Cities

The beliefs and practices used to promote physical and mental health in youth who identify as lesbian, gay, bisexual, transgender, intersex, or queer plus (LGBTIQ+) experiencing housing insecurity: An integrative review

PURPOSE

The purpose of this integrative review was to explore the beliefs and practices used to promote physical and mental health among youth ages 18-25 years, identifying as LGBTIQ+ experiencing housing insecurity.

METHOD

The approach used strategies described by Whittemore and Knafl. Peer-reviewed, published research articles in English were identified using eight electronic databases. Eighteen research reports using qualitative, quantitative, and mixed methods were identified. Articles were evaluated for quality using the American Association of Critical Care Nurses Evidenced-Level Hierarchy evaluation tool. Data were analyzed and synthesized using Braun and Clarke's method.

FINDINGS

Four themes related to the purpose were extracted: pervasive experiences of stigma and discrimination, constantly attuned to navigating risks, inconsistent engagement in health information and care, and inner strength developed through personal and community experiences.

DISCUSSION

There are strong implications for future research, public health nursing practice, and health policy. Public health nurses should incorporate social determinants of health (addressing harmful social processes such as homophobia and racism) as well as a strength-based upstream approach in research, education, and health care practices. More research must also be done to assess engagement in physical and mental health information and care.

Sociodemographic and Behavioral Risk Correlates of PrEP Interest and Use Among Young Adults Experiencing Homelessness in Los Angeles

Young adults experiencing homelessness (YAEH) are at elevated risk for HIV compared to their stably housed peers. Preexposure prophylaxis (PrEP) is highly effective at preventing HIV infection, yet YAEH have been largely overlooked in PrEP efforts to date despite YAEH reporting high overall interest in PrEP. We assessed individual, social, and structural variables associated with PrEP interest and use among a sample of 195 YAEH (ages 18-25) recruited from drop-in centers across Los Angeles County who met criteria for HIV risk. In the current sample, though most had heard of PrEP (81.0%), the majority were not interested in taking PrEP (68.2%) and only a minority had used/were using PrEP (11.8%). YAEH who identified as sexual and/or gender minority, reported knowing someone who had used PrEP, or recently accessed sexual health services were more likely to have used and/or reported interest in using PrEP. Those who reported more episodes of heavy drinking were less likely to report having used PrEP. Suggestions are provided for better integrating PrEP-related services into existing behavioral and health service programs for YAEH, as well as leveraging peers and fostering positive social norms to reduce PrEP-related stigma and increase interest and use of PrEP among YAEH.

Responding to the HIV Health Literacy Needs of Clients in Substance Use Treatment: The Role of Universal PrEP Education in HIV Health and Prevention

Health literacy, particularly HIV health literacy, is a key social determinant of health and can be significantly improved through targeted health education. This paper explores the often-overlooked potential of pre-exposure prophylaxis (PrEP) education as a powerful tool to enhance HIV health literacy among people with substance use disorders (PWSUD), a population notably susceptible to HIV. Given the syndemic interplay of substance use disorders (SUDs) and HIV, health professionals, especially substance use counselors, are uniquely positioned to bolster HIV health literacy and positively influence health outcomes. This article offers a brief introduction to PrEP, delineates potential barriers and facilitators to its use and education, and proposes strategies for effective PrEP education, implementation, and adherence. By equipping substance use counselors with essential knowledge and skills, we aim to encourage and promote the integration of PrEP education into substance use treatment. The overarching objective is to empower counselors to proactively engage in HIV prevention efforts, thereby fulfilling pressing health literacy needs and contributing to improved health outcomes among PWSUD.

Examining sources of Social Support and Depression Prevention Among Pregnant Youth Experiencing Homelessness: Outcomes of a Seven-City Study

Young adults experiencing homelessness (YAEH) with pregnancy history are at higher depression risk. Receiving social support is protective for depression in pregnancy. This study differentiates social support sources associated with depression by pregnancy history among YAEH.Using a subsample of data collected from YAEH in seven US cities that were collected through REALYST, we conducted stratified logistic regression models (by pregnancy history) to identify support sources associated with depression. Logistic regression analysis including the interaction term (i.e., pregnancy history x support sources) using the full sample was then conducted.A higher proportion with pregnancy history reported depression compared to those without. Support from home-based peers was significantly associated with reduced depression risks among YAEH with pregnancy history, but not among youth without. Home-based supports were less frequently indicated by homeless female youth with pregnancy experience.Home-based social support is protective against major depression for YAEH with pregnancy experience. Findings of this study suggest that interventions addressing depression among YAEH should take their pregnancy history and social support sources into consideration. Specifically, for YAEH with pregnancy history, facilitating supportive social ties with home-based peers may be promising in reducing their depression risks.

PreexposureProphylaxis at School-Based Health Centers: Awareness and Interest in Starting Preexposure Prophylaxis While Attending a School-Based Health Center in New York City

INTRODUCTION

Youth aged 13-29 years represent 23% of the population but account for 40% of new HIV diagnoses, with risk peaking at ages 22-23 years. We assessed sexual behaviors, PrEP knowledge and attitudes among patients of 6 School-Based-Health-Centers (SBHCs) located in Northern Manhattan and the Bronx.

METHOD

667 patients, aged 13-19 years, completed a survey in the SBHCs waiting rooms between 10/2018 - 4/2019 RESULTS: Of the survey respondents attending SBHCs, 32% reported ever having heard of PrEP and, upon learning of PrEP, 67% stated that would be very likely (35%) or somewhat likely (32%) to take PrEP if it was offered to them free of charge.

DISCUSSION

Youth of color are disproportionately infected by HIV throughout the US. Efforts are needed to educate adolescents on the benefits of PrEP, SBHCs are well situated to reduce barriers in providing PrEP directly to those who would benefit from its protection..

Characterizing the PrEP Continuum for Black and Latinx Sexual and Gender Minority Youth

Pre-exposure prophylaxis (PrEP) rollout efforts thus far have inadequately reached young people from underrepresented backgrounds. This study explores PrEP engagement among young Black and Latinx men who have sex with men, transgender women, and gender diverse individuals in three U.S. cities using an adapted PrEP continuum measure. We analyze data from the recruitment phase of an ongoing PrEP engagement intervention (n = 319) using partial proportional odds logistic regression. Participants reported high willingness and intention to use PrEP, yet most (82%) were not currently taking PrEP. Being insured (aOR = 2.95, 95%-CI = 1.60-5.49), having one or more PrEP users in one's sexual network (aOR = 4.19, 95%-CI = 2.61-6.79), and higher individual HIV risk scores (aOR = 1.62, 95%-CI = 1.34-1.97) were each associated with being further along the PrEP continuum. Strategies are needed to address barriers to healthcare access and leverage connections within social and sexual networks in order to bolster PrEP engagement among marginalized young people from diverse backgrounds.

Adolescents and Young Adults: The Pediatrician's Role in HIV Testing and Pre- and Postexposure HIV Prophylaxis

Most sexually active youth in the United States do not believe that they are at risk for contracting HIV and have never been tested. Creating safe environments that promote confidentiality and respect, obtaining an accurate sexual and reproductive health assessment, and providing nonstigmatizing risk counseling are key components of any youth encounters. Pediatricians can play a key role in preventing and controlling HIV infection by promoting risk-reduction counseling and offering routine HIV testing and prophylaxis to adolescent and young adult (youth) patients. In light of persistently high numbers of people living with HIV in the United States and documented missed opportunities for HIV testing, the Centers for Disease Control and Prevention and the US Preventive Services Task Force recommend universal and routine HIV screening among US populations, including youth. Recent advances in HIV diagnostics, treatment, and prevention help support this recommendation. This clinical report reviews epidemiological data and recommends that routine HIV screening be offered to all youth 15 years or older, at least once, in health care settings. After initial screening, youth at increased risk, including those who are sexually active, should be rescreened at least annually, and potentially as frequently as every 3 to 6 months if at high risk (male youth reporting male sexual contact, active injection drug users, transgender youth; youth having sexual partners who are HIV-infected, of both genders, or injection drug users; youth exchanging sex for drugs or money; or youth who have had a diagnosis of or have requested testing for other sexually transmitted infections). Youth at substantial risk for HIV acquisition should be routinely offered HIV preexposure prophylaxis, and HIV postexposure prophylaxis is also indicated after high-risk exposures. This clinical report also addresses consent, confidentiality, and coverage issues that pediatricians face in promoting routine HIV testing and HIV prophylaxis for their patients.

Efficacy of a Just-in-Time Adaptive Intervention to Promote HIV Risk Reduction Behaviors Among Young Adults Experiencing Homelessness: Pilot Randomized Controlled Trial

BACKGROUND

People experiencing homelessness have higher rates of HIV than those who are stably housed. Mental health needs, substance use problems, and issues unique to homelessness such as lack of shelter and transiency need to be considered with regard to HIV prevention. To date, HIV prevention interventions for young adults experiencing homelessness have not specifically addressed modifiable real-time factors such as stress, sexual or drug use urge, or substance use, or been delivered at the time of heightened risk. Real-time, personalized HIV prevention messages may reduce HIV risk behaviors.

OBJECTIVE

This pilot study tested the initial efficacy of an innovative, smartphone-based, just-in-time adaptive intervention that assessed predictors of HIV risk behaviors in real time and automatically provided behavioral feedback and goal attainment information.

METHODS

A randomized attention control design was used among young adults experiencing homelessness, aged 18-25 years, recruited from shelters and drop-in centers in May 2019. Participants were randomized to either a control or an intervention group. The intervention (called MY-RID [Motivating Youth to Reduce Infection and Disconnection]) consisted of brief messages delivered via smartphone over 6 weeks in response to preidentified predictors that were assessed using ecological momentary assessments. Bayesian hierarchical regression models were used to assess intervention effects on sexual activity, drug use, alcohol use, and their corresponding urges.

RESULTS

Participants (N=97) were predominantly youth (mean age 21.2, SD 2.1 years) who identified as heterosexual (n=51, 52%), male (n=56, 57%), and African American (n=56, 57%). Reports of sexual activity, drug use, alcohol use, stress, and all urges (ie, sexual, drug, alcohol) reduced over time in both groups. Daily drug use reduced by a factor of 13.8 times over 6 weeks in the intervention group relative to the control group (Multimedia Appendix 4). Lower urges for sex were found in the intervention group relative to the control group over the duration of the study. Finally, there was a statistically significant reduction in reports of feeling stressed the day before between the intervention and control conditions (P=.03).

CONCLUSIONS

Findings indicate promising intervention effects on drug use, stress, and urges for sex in a hard-to-reach, high-risk population. The MY-RID intervention should be further tested in a larger randomized controlled trial to further investigate its efficacy and impact on sexual risk behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03911024; https://clinicaltrials.gov/ct2/show/NCT03911024.

A Digital Gaming Intervention to Improve HIV Testing for Adolescents and Young Adults: Protocol for Development and a Pilot Randomized Controlled Trial

Background

Two strategies of the US Ending the HIV Epidemic initiative are early diagnosis of infections via widespread testing and prevention of new infections using pre-exposure prophylaxis (PrEP). These strategies are particularly important for adolescents and young adults (AYAs) who are disproportionately affected by HIV, particularly if they identify as Black and/or lesbian, gay, bisexual, transgender, queer or questioning, and others (LGBTQ+). This study will develop and test an interactive life-simulation game in which players can enact real-life behaviors and receive their HIV risk profile to improve HIV testing and PrEP access among AYAs aged 13-24 years in Washington, DC.

Objective

This mixed methods study aims to determine the acceptability of an interactive, enhanced life-simulation game prototype among AYAs, conduct a pilot test of the gaming intervention among a small cohort of AYAs to ensure game usability and acceptability, and evaluate the efficacy of the game in a randomized controlled study with AYAs at risk for HIV in Washington, DC.

Methods

This research protocol will be conducted in 3 phases. A formative phase will involve surveys and focus groups (n=64) with AYAs living in the DC area. These focus groups will allow researchers to understand youth preferences for game enhancement. The second phase will consist of a pilot test (n=10) of the gaming intervention. This pilot test will allow researchers to modify the game based on formative results and test the planned recruitment and data collection strategy with intended end users. The third phase will consist of a randomized controlled study among 300 AYAs to examine the efficacy of the life-simulation game compared with app-based HIV educational materials on HIV and PrEP in changing HIV testing, knowledge, risk behaviors, and PrEP access. Participants will have unlimited access to either the life-simulation game or the educational app for 3 months from the time of enrollment. Study assessments will occur at enrollment and at 1, 3, and 6 months post enrollment via e-surveys. At 6 months, a subset of intervention participants (n=25) will participate in in-depth exit interviews regarding their experience being in the study.

Results

Institutional review board approval was received on February 5, 2020. This project is currently recruiting participants for the formative phase.

Conclusions

This interactive life-simulation intervention aims to increase HIV testing and PrEP access among AYAs in the DC area. In this intervention, players can enact real-life behaviors and receive their HIV risk profile to promote HIV testing and PrEP seeking. Such an intervention has great potential to improve knowledge of HIV and PrEP among AYAs, increase motivation and self-efficacy related to HIV testing and PrEP use, and decrease individual and structural barriers that often preclude engagement in HIV prevention services.

Trial Registration

ClinicalTrials.gov NCT04917575; https://clinicaltrials.gov/ct2/show/NCT04917575

International Registered Report Identifier (IRRID)

PRR1-10.2196/29792

A Nurse Case Management HIV Prevention Intervention (Come As You Are) for Youth Experiencing Homelessness: Protocol for a Randomized Wait-list Controlled Trial

Background

Youth experiencing homelessness are more likely than housed youth to experience premature death, suicide, drug overdose, pregnancy, substance use, and mental illness. Yet while youth experiencing homelessness are 6 to 12 times more likely to become infected with HIV than housed youth, with HIV prevalence as high as 16%, many do not access the prevention services they need. Despite adversities, youth experiencing homelessness are interested in health promotion programs, can be recruited and retained in interventions and research studies, and demonstrate improved outcomes when programs are tailored and relevant to them.

Objective

The study aims to compare the efficacy of a nurse case management HIV prevention and care intervention, titled Come As You Are, with that of usual care among youth experiencing homelessness aged 16 to 25 years.

Methods

The study is designed as a 2-armed randomized wait-list controlled trial. Participants (n=450) will be recruited and followed up for 9 months after the intervention for a total study period of 12 months. Come As You Are combines nurse case management with a smartphone-based daily ecological momentary assessment to develop participant-driven HIV prevention behavioral goals that can be monitored in real-time. Youth in the city of Houston, Texas will be recruited from drop-in centers, shelters, street outreach programs, youth-serving organizations, and clinics.

Results

Institutional review board approval (Committee for the Protection of Human Subjects, University of Texas Health Science Center at Houston) was obtained in November 2018. The first participant was enrolled in November 2019. Data collection is ongoing. To date, 123 participants have consented to participate in the study, 89 have been enrolled, and 15 have completed their final follow-up.

Conclusions

There is a paucity of HIV prevention research regarding youth experiencing homelessness. Novel and scalable interventions that address the full continuum of behavioral and biomedical HIV prevention are needed. This study will determine whether a personalized and mobile HIV prevention approach can reduce HIV risk among a hard-to-reach, transient population of youth at high risk.

International Registered Report Identifier (IRRID)

DERR1-10.2196/26716

Learning to endure: A qualitative examination of the protective factors of homeless transgender and gender expansive youth engaged in survival sex

Background: Transgender and gender expansive (TGE) youth face a number of adversities that are associated with deleterious consequences, including mental health problems, substance misuse, suicide, and homelessness. However, there is evidence that TGE youth still demonstrate resilience under extraordinary conditions. Aims: Therefore, this study examined how TGE youth who are homeless and engaging in survival sex describe and understand the protective factors present in their lives. Methods: In-depth qualitative interviews were conducted with 57 TGE youth living in a large U.S. city. Participants were 17-26 years old (M = 19.88, SD = 1.55), and identified as transgender woman (53%), transgender man (16%), and other (32%; gender-queer, gender-fluid, androgynous, or non-binary). Youth identified as Black (40%), multiracial (35%), Latinx (16%), White (5%), and as another race (3%). Researchers conducted a secondary analysis of qualitative data using thematic analysis. Results: We identified three themes to capture youth's understanding of their protective factors: relying on oneself and others to avoid violence, accessing gender-affirming health and mental health care, and proactively maintaining sexual health. Participants described strategies for mitigating risk of harm while attempting to meet their basic needs. Additionally, they discussed the importance of having gender-affirming health and mental health services. Participants also expressed keen awareness of their sexual health risks and making calculated, often proactive decisions about their sexual health. Conclusion: The protective factors described by TGE youth reflect the unique ways in which hyper-marginalized youth must navigate their own survival and well-being, and align with literature suggesting resilience is not mutually exclusive from risk. By focusing on TGE youth, this research privileges the experiences of individuals historically underrepresented in research and encourages future research to incorporate these perspectives into policies and programs.

Predicting Daily Sheltering Arrangements among Youth Experiencing Homelessness Using Diary Measurements Collected by Ecological Momentary Assessment

Youths experiencing homelessness (YEH) often cycle between various sheltering locations including spending nights on the streets, in shelters and with others. Few studies have explored the patterns of daily sheltering over time. A total of 66 participants completed 724 ecological momentary assessments that assessed daily sleeping arrangements. Analyses applied a hypothesis-generating machine learning algorithm (component-wise gradient boosting) to build interpretable models that would select only the best predictors of daily sheltering from a large set of 92 variables while accounting for the correlated nature of the data. Sheltering was examined as a three-category outcome comparing nights spent literally homeless, unstably housed or at a shelter. The final model retained 15 predictors. These predictors included (among others) specific stressors (e.g., not having a place to stay, parenting and hunger), discrimination (by a friend or nonspecified other; due to race or homelessness), being arrested and synthetic cannabinoids use (a.k.a., “kush”). The final model demonstrated success in classifying the categorical outcome. These results have implications for developing just-in-time adaptive interventions for improving the lives of YEH.

Factors Associated With HIV Testing Among Atlanta's Homeless Youth

Homeless youth experience increased risk of contracting HIV, making HIV testing imperative in this population. We analyzed factors associated with HIV testing among homeless youth in Atlanta, Georgia using data from the 2015 Atlanta Youth Count and Needs Assessment. The analysis included 693 homeless youth aged 14-25 years, of whom 88.4% reported ever being tested for HIV, and 74.6% reported being tested within the previous year. Prevalence of ever testing for HIV was significantly higher among youth who reported risk factors for HIV (sexually active, transactional sex, or ever having an STI). Higher prevalence of testing within the last year was significantly associated with experiencing physical abuse or transactional sex. However, reporting ≥ 4 sexual partners or not using condoms were not associated with higher testing. Although testing prevalence among homeless youth was high, homeless youth engaging in certain high risk behaviors could benefit from further promotion of HIV testing.

Human Papillomavirus Vaccination Initiation and Completion among Youth Experiencing Homelessness in Seven U.S. Cities

Little is known about human papillomavirus (HPV) vaccination uptake among youth experiencing homelessness (YEH), who may be at higher risk for HPV than their housed counterparts. We examined the prevalence and associations of HPV vaccination initiation and completion among YEH. Guided by the Behavioral Model for Vulnerable Populations, we analyzed cross-sectional data collected from YEH (N = 1074; ages 18-26) in seven U.S. cities to assess HPV vaccination prevalence and to identify predisposing, enabling, and need factors associated with HPV vaccination status. Due to timing differences in the release of HPV vaccine recommendations, we conducted separate logistic regression analyses for men (n = 673) and women (n = 401). Approximately 19% of men and 37% of women had initiated and completed HPV vaccination. Several factors among men (i.e., older age, Latinx ethnicity, San Jose or St. Louis residence compared with New York City, never having had sex, and not previously being tested for STIs) and women (i.e., lower education level, San Jose or Houston residence compared with New York City, and never having had sex) were associated with lower odds of HPV vaccination initiation, completion, or both. Gay men had higher odds of initiating and completing the vaccination series than their heterosexual counterparts. Our findings reveal that HPV vaccination uptake is low among YEH and that there are vaccination disparities among subgroups of YEH. HPV vaccination strategies and resources that are easy-to-understand, facilitate point-of-care services, and address societal and system-level vaccination barriers encountered by YEH are needed.

Sexual risk classes among youth experiencing homelessness: Relation to childhood adversities, current mental symptoms, substance use, and HIV testing

The aim of this study was to determine whether there are meaningful subgroups with different types of sexual risk behaviors among youth experiencing homelessness and examine the associations between potential classes and other risk variables. A latent class analysis was used to identify classes of youth according to sexual risk behaviors and sexual assault. A two-class solution was found to be the best fit for the data-Lower and Higher Risk groups. The Higher Risk class had significantly higher levels of synthetic marijuana and alcohol use, mental health diagnoses, and were more likely to have been tested for HIV than the Lower Risk group. Youth were more likely to be in the Higher Risk group if they were cisgender female or lesbian, gay, bisexual, or questioning (LGBQ). Nearly all youth (10/11) who reported having HIV infection were in the Higher Risk group. The Lower Risk group were sexually active but had lower rates of risk behaviors and sexual assault. Youth who were not sexually active had the lowest rates of marijuana and alcohol use as well as HIV testing. Health and social service providers should be aware of the added risks for stress, mental distress, mental health diagnoses, and substance use among youth who also report higher risk sexual behaviors and treat as needed.