Interventions to strengthen the HIV prevention cascade: a systematic review of reviews

Effectiveness of integrating HIV prevention within sexual reproductive health services with or without peer support among adolescents and young adults in rural KwaZulu-Natal, South Africa (Isisekelo Sempilo): 2 × 2 factorial, open-label, randomised controlled trial

BACKGROUND

Approximately 200 000 South Africans acquired HIV in 2021 despite the availability of universal HIV test and treat and pre-exposure prophylaxis (PrEP). The aim of this study was to test the effectiveness of sexual and reproductive health services or peer support, or both, on the uptake of serostatus neutral HIV services or reduction of sexually transmissible HIV.

METHODS

We did an open-label, 2 × 2 randomised factorial trial among young people in a mostly rural area of KwaZulu-Natal, South Africa. Inclusion criteria included being aged 16-29 years, living in the mapped geographical areas that were accessible to the area-based peer navigators, being willing and able to provide informed consent, and being willing to provide a dried blood spot for anonymous HIV testing and HIV viral load measurement at 12 months. Participants were randomly allocated by computer-generated algorithm to one of four groups: those in the standard-of-care group were referred to youth-friendly services for differentiated HIV prevention (condoms, universal HIV test and treat with antiretroviral therapy, and PrEP if eligible); those in the sexual and reproductive health services group received baseline self-collected specimens for sexually transmitted infection (STI) testing and referral to integrated sexual and reproductive health and HIV prevention services; those in the peer support group were referred to peer navigators for health promotion, condom provision, and facilitation of attendance for differentiated HIV prevention services; and those in the final group received a combination of sexual and reproductive health services and peer support. Coprimary outcomes were linkage to clinical services within 60 days of enrolment, proportion of participants who had sexually transmissible HIV at 12 months after enrolment, and proportion of sampled individuals who consented to participation and gave a dried blood spot for HIV testing at 12 months. Logistic regression was used for analyses, and adjusted for age, sex, and rural or peri-urban area of residence. This study is registered with ClinicalTrials.gov (NCT04532307) and is closed.

FINDINGS

Between March 2, 2020, and July 7, 2022, 1743 (75·7%) of 2301 eligible individuals were enrolled and followed up. 12-month dried blood spots were collected from 1168 participants (67·0%). The median age of the participants was 21 years (IQR 18-25), 51·4% were female, and 51·1% had secondary level education. Baseline characteristics and 12-month outcome ascertainment were similar between groups. 755 (43·3%) linked to services by 60 days. 430 (49·8%) of 863 who were in the sexual reproductive health services group were linked to care compared with 325 (36·9%) of 880 who were not in the sexual and reproductive health services group (adjusted odds ratio [aOR] 1·68; 95% CI 1·39-2·04); peer support had no effect: 385 (43·5%) of 858 compared with 370 (43·1%) of 885 (1·02, 0·84-1·23). At 12 months, 227 (19%) tested ELISA-positive for HIV, of whom 41 (18%) had viral loads of 400 copies per mL; overall prevalence of transmissible HIV was 3·5%. 22 (3·7%) of 578 participants in the sexual and reproductive health services group had transmissible HIV compared with 19 (3·3%) of 590 not in the sexual and reproductive health services group (aOR 1·12; 95% CI 0·60-2·11). The findings were also non-significant for peer support: 21 (3·3%) of 565 compared with 20 (3·3%) of 603 (aOR 1·03; 95% CI 0·55-1·94). There were no serious adverse events or deaths during the study.

INTERPRETATION

This study provides evidence that STI testing and sexual and reproductive health services create demand for serostatus neutral HIV prevention in adolescents and young adults in Africa. STI testing and integration of HIV and sexual health has the potential to reach those at risk and tackle unmet sexual health needs.

FUNDING

US National Institute of Health, Bill & Melinda Gates Foundation, and 3ie.

Randomized Clinical Trial of Stigma Counseling and HIV Testing Access Interventions to Increase HIV Testing Among Black Sexual Minority Men and Transwomen

Advances in HIV prevention tools have outpaced our ability to ensure equitable access to these tools. Novel approaches to reducing known barriers to accessing HIV prevention, such as stigma and logistical-related factors, are urgently needed. To evaluate the efficacy of a randomized controlled trial with four intervention arms to address barriers to HIV/STI testing uptake (primary outcome) and PrEP use, depression, and HIV test results (secondary outcomes). We tested a 2 × 2 research design: main effect 1-stigma-focused vs. health information evaluation-focused counseling, main effect 2-offering HIV/STI testing appointments in person vs. at home with a counselor via video chat, and the interaction of the main effects. Participants (N = 474) residing in the southeastern USA were screened and enrolled in a longitudinal trial. Intervention efficacy was established using generalized linear modeling with binomial or Poisson distributions. Intervention efficacy demonstrated an increase in HIV/STI testing uptake when testing was made available at home with a counselor via video chat vs. in person (83% vs. 75% uptake, p < .05), and participants were also more likely to test positive for HIV over the course of the study in the at-home condition (14.5% vs. 9.4%, p < .05). Stigma-focused counseling resulted in lower depression scores and greater uptake of PrEP among participants < 30 years of age when compared with health information counseling (15.4% vs. 9.6%, p < .05). In order to prevent further disparities between HIV prevention advances and access to HIV prevention tools, we must prioritize improvements in linking people to care. Novel interventions, such as those proposed here, offer a practical, evidence-based path to addressing long-standing barriers to HIV prevention strategies. Trial registration: NCT03107910.

Applying the HIV Prevention Cascade to an Evaluation of a Large-Scale Combination HIV Prevention Programme for Adolescent Girls and Young Women in South Africa

Adolescent girls and young women (AGYW) in South Africa are at a three times higher risk of acquiring HIV than their male counterparts. The HIV prevention cascade is a tool which can be used to measure coverage of HIV prevention services, although there is limited empirical evidence to demonstrate its application in low-resourced settings. The unifying framework is a conceptualisation of the HIV prevention cascade which theorises that both motivation and access are required for an individual to effectively use an HIV prevention method. We applied this framework to data from a random sample of 127,951 beneficiaries of a combination HIV prevention programme for AGYW aged 15-24 in South Africa to measure the steps to, and identify key barriers to, effective use of male condoms and oral pre-exposure prophylaxis (PrEP) among this vulnerable population. Barriers to each step were analysed using univariate and multivariable logistic regression. Among self-reported HIV-negative AGYW who had sex in the past 6 months, effective use of condoms (15.2%), access to PrEP (39.1%) and use of PrEP (3.8%) were low. AGYW were: less likely to be motivated to use condoms if they believed that they had a faithful partner (aOR 0.44, 95% CI 0.22-0.90) or disliked condoms (aOR 0.26, 95% CI 0.11-0.57), less likely to access condoms if the place where AGYW accessed them was far away (aOR 0.25, 95% CI 0.10-0.64), more likely to effectively use condoms if they received counselling on how to use them (aOR 2.24, 95% CI 1.05-4.76), less likely to be motivated to use PrEP if they did not believe PrEP was efficacious (aOR 0.35, 95% CI 0.17-0.72), more likely to be motivated if they felt confident that they could use PrEP, and more likely to have access to PrEP if they had ever been offered PrEP (aOR 2.94, 95% CI 1.19-7.22). This combination HIV prevention programme and similar programmes should focus on risk-reduction counselling interventions for AGYW and their male partners to improve effective use of condoms and ensure easy access to condoms and PrEP by making them available in youth-friendly spaces. Our findings demonstrate that the application of HIV prevention cascades can inform AGYW HIV prevention programming in low-resourced settings.

Alcohol, Sexual Arousal, and Partner Familiarity as Predictors of Condom Negotiation: An Experience Sampling Study

Numerous contextual factors contribute to risky sexual decision-making among men who have sex with men (MSM), with experimental laboratory-based studies suggesting that alcohol consumption, sexual arousal, and partner familiarity have the potential to impact condom negotiations during sexual encounters. The purpose of the current study was to extend this line of inquiry outside of the laboratory and into the everyday lives of MSM. We collected six weeks of daily data on alcohol consumption and sexual behaviors from 257 moderate- and heavy-drinking MSM to examine the within- and between-subjects effects of alcohol consumption, average daily sexual arousal, and partner familiarity on condom negotiation processes during sexual encounters. We hypothesized that alcohol consumption, higher levels of average daily sexual arousal, and greater partner familiarity would all contribute to a reduced likelihood of condom negotiation prior to sexual activity, and that they would also affect the difficulty of negotiations. Contrary to hypotheses, none of these three predictors had significant within-subjects effects on condom negotiation outcomes. However, partner familiarity and average daily sexual arousal did exert significant between-subjects effects on the incidence of negotiation and negotiation difficulty. These findings have important implications for risk-reduction strategies in this population. They also highlight the challenges of reconciling results from experimental laboratory research and experience sampling conducted outside of the laboratory on sexual risk behavior.

Analysis of HIV drug prophylaxis services cascade in healthcare workers: a cross-sectional study in China

BACKGROUND

Human immunodeficiency virus (HIV) drug prophylaxis, including post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), has not yet been generally recognized and accepted by the whole society in China, and the utilization coverage among high-risk populations is low. Healthcare workers (HCWs) are important to the promotion and implementation of HIV drug prophylaxis strategy. This study analyzed the HIV drug prophylaxis services cascade (knowledge, attitude, and service) in HCWs, and explored the correlations between PEP and PrEP.

METHODS

A cross-sectional study was conducted among 1066 HCWs in 20 designated hospitals for HIV antiretroviral therapy in 20 cities in China. We collected information on participants' essential characteristics, HIV drug prophylaxis services cascade (knowledge, attitude, and service) and so on. The Chi-square test was used to analyse whether the differences and correlations between categorical variables were statistically significant, and Pearson contingency coefficient was used to analyse the strength of correlations. Multivariable logistic regression was used to analyse associated factors.

RESULTS

Among three stages of HIV drug prophylaxis services cascade, a high percentage of 1066 participants had knowledge of HIV drug prophylaxis (PEP: 78.2%, PrEP: 80.0%). Of them, almost all had supportive attitudes towards HIV drug prophylaxis (PEP: 99.6%, PrEP: 98.6%). Only about half of them would provide HIV drug prophylaxis services (PEP: 53.5%, PrEP: 48.5%). There were positive correlations between knowledge of PEP and PrEP (r = 0.292), between attitudes toward PEP and PrEP (r = 0.325), and between provision of PEP services and PrEP services (r = 0.555) in HCWs.

CONCLUSIONS

There was a positive correlation between PEP and PrEP in HCWs. At the stage of providing HIV drug prophylaxis services, training, advocacy and education for HCWs, should be targeted and also combine PEP and PrEP to maximize the effects, so as to improve the enthusiasm of HCWs to provide HIV drug prophylaxis services.

Programme science: a route to effective coverage and population-level impact for HIV and sexually transmitted infection prevention

Improvements in context-specific programming are essential to address HIV and other sexually transmitted and blood-borne infection epidemics globally. A programme science approach emphasises the need for context-specific evidence and knowledge, generated on an ongoing basis, to inform timely and appropriate programmatic decisions. We aim to accelerate and improve the use of embedded research, inquiry, and learning to optimise population-level impact of public health programmes and to introduce an effective programme coverage framework as one tool to facilitate this goal. The framework was developed in partnership with public health experts in HIV and sexually transmitted and blood-borne infections through several workshops and meetings. The framework is a practice-based tool that centres on the use of data from iterative cycles of programme-embedded research and learning, as well as routine programme monitoring, to refine the strategy and implementation of a programme. This programme science approach aims to reduce programme coverage gaps, to optimise impact at the population level, and to achieve effective coverage. This framework should facilitate the generation of programme-embedded research and learning agendas to inform resource allocation, optimise population-level impact, and achieve equitable and effective programme coverage.

Factors Associated with COVID-19 Vaccine Uptake among Schoolgoing Adolescent Girls and Young Women in South Africa

(1) Background: By October 2022, vaccination rates with at least one dose of a COVID-19 vaccine were low among adolescent girls aged 12-17 (38%) and young women aged 18-34 (45%) in South Africa. This study aimed to measure and identify barriers to and facilitators of motivation to take up, access to, and uptake of COVID-19 vaccines among schoolgoing adolescent girls and young women in two districts in South Africa. (2) Methods: Using the theory of the HIV prevention cascade, we conceptualised the relationship between motivation, access, and uptake of COVID-19 vaccines, and associated barriers. Potential barriers and facilitators were identified using bivariate and multivariable Poisson regression. (3) Results: Among all 2375 participants, access was high (69%), but motivation (49%) and vaccination with at least one COVID-19 vaccine (45%) were lower. Fear of injections was a barrier to vaccine uptake (aRR 0.85 95% CI 0.82-0.88), while being tested for COVID-19 (aRR 2.10 95% CI 1.85-2.38) and believing that the COVID-19 vaccine was safe (aRR 1.31 95% CI 1.18-1.44) and would prevent you from getting very sick (aRR 1.11 95% CI 1.04-1.19) were facilitators. (4) Conclusions: The controversy about the value of vaccinating adolescents and the delay in vaccine rollout for adolescents and young adults may have contributed to fears about the safety and efficacy of COVID-19 vaccines, as well as a lack of motivation to get vaccinated.

Attitude and practice of secondary school students towards voluntary counselling and testing in Mwanza, North-West Tanzania

OBJECTIVES

Voluntary Counselling and Testing (VCT) has become popular in many parts of the world, especially in Africa, for people to learn about their HIV status and get motivation for positive sexual behaviour change. Our study explored the attitude and practice of secondary school students towards VCT.

METHODS

A cross-sectional descriptive study was conducted in Magu, Mwanza, North-West Tanzania. Recorded information included sex, factors promoting or hindering VCT attendance, reasons why attending VCT is necessary, awareness of VCT locations and source of information.

RESULTS

Of the 340 students interviewed, 93.2 % knew that VCT was necessary and had reasons such as getting Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) education, checking HIV status and getting advice if found to be HIV positive. The majority (74.4 %) knew the location of the VCT centres. However, only 20.3 % made use of the VCT services. Those who did not use VCT services had reasons such as time limitations, believing they were not infected and fear of being labelled HIV positive.

CONCLUSIONS

Our study shows that most secondary school students know that VCT is necessary and the locations of the VCT centres, but only a few use VCT services. More effort should be put into educating students and society on the importance of using VCT services.

Thetha Nami ngithethe nawe (Let's Talk): a stepped-wedge cluster randomised trial of social mobilisation by peer navigators into community-based sexual health and HIV care, including pre-exposure prophylaxis (PrEP), to reduce sexually transmissible HIV amongst young people in rural KwaZulu-Natal, South Africa

BACKGROUND

Antiretroviral therapy (ART) through universal test and treat (UTT) and HIV pre-exposure prophylaxis (PrEP) substantially reduces HIV-related mortality and incidence. Effective ART based prevention has not translated into population-level impact in southern Africa due to sub-optimal coverage among youth. We aim to investigate the effectiveness, implementation and cost effectiveness of peer-led social mobilisation into decentralised integrated HIV and sexual reproductive health (SRH) services amongst adolescents and young adults in KwaZulu-Natal (KZN).

METHODS

We are conducting a type 1a hybrid effectiveness/implementation study, with a cluster randomized stepped-wedge trial (SWT) to assess effectiveness and a realist process evaluation to assess implementation outcomes. The SWT will be conducted in 40 clusters in rural KZN over 45 months. Clusters will be randomly allocated to receive the intervention in period 1 (early) or period 2 (delayed). 1) Intervention arm: Resident peer navigators in each cluster will approach young men and women aged 15-30 years living in their cluster to conduct health, social and educational needs assessment and tailor psychosocial support and health promotion, peer mentorship, and facilitate referrals into nurse led mobile clinics that visit each cluster regularly to deliver integrated SRH and differentiated HIV prevention (HIV testing, UTT for those positive, and PrEP for those eligible and negative). Standard of Care is UTT and PrEP delivered to 15-30 year olds from control clusters through primary health clinics. There are 3 co-primary outcomes measured amongst cross sectional surveys of 15-30 year olds: 1) effectiveness of the intervention in reducing the prevalence of sexually transmissible HIV; 2) uptake of universal risk informed HIV prevention intervention; 3) cost of transmissible HIV infection averted. We will use a realist process evaluation to interrogate the extent to which the intervention components support demand, uptake, and retention in risk-differentiated biomedical HIV prevention.

DISCUSSION

The findings of this trial will be used by policy makers to optimize delivery of universal differentiated HIV prevention, including HIV pre-exposure prophylaxis through peer-led mobilisation into community-based integrated adolescent and youth friendly HIV and sexual and reproductive health care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier-NCT05405582. Registered: 6th June 2022.

Strengthening the HIV prevention cascade to maximise epidemiological impact in eastern Zimbabwe: a modelling study

BACKGROUND

HIV prevention cascades provide a systematic understanding of barriers to prevention. In this study we used mathematical modelling to understand the consequences of these barriers and how the cascade could be strengthened to maximise epidemiological impact, providing potentially important insights for programmes.

METHODS

We used an individual-based model of HIV transmission (PopART-IBM), calibrated to data from the Manicaland cohort from eastern Zimbabwe. HIV prevention cascade estimates from this cohort were used as probabilities for indicators in the model representing an individual's motivation, access, and capacity to effectively use pre-exposure prophylaxis, voluntary male medical circumcision, and condoms. We examined how current barriers affect the number and distribution of HIV infections compared with a no-barrier scenario. Using assumptions about how interventions could strengthen the HIV prevention cascade, we estimated the reduction in HIV infections over a 10-year period through addressing different elements of the cascade.

FINDINGS

21 200 new potentially avertable HIV infections will occur over the next 10 years due to existing HIV prevention cascade barriers, 74·2% of the 28 500 new infections that would occur with existing barriers in a population of approximately 1·2 million adults. Removing these barriers would reduce HIV incidence below the benchmarks for epidemic elimination. Addressing all cascade steps in one priority population is substantially more effective than addressing one step across all populations.

INTERPRETATION

Interventions exist in eastern Zimbabwe to reduce HIV towards elimination, but barriers of motivation, access, and effective use prevent their full effect being realised. Interventions need to be multilayered and address all steps along the HIV prevention cascade. Models incorporating the HIV prevention cascade can help to identify the main barriers to greater effectiveness.

FUNDING

National Institutes of Mental Health, Bill & Melinda Gates Foundation, and Medical Research Council Centre for Global Infectious Disease Analysis funding from the UK Medical Research Council and UK Foreign, Commonwealth & Development Office (FCDO).

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

BACKGROUND

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

OBJECTIVES

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

METHODS

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

SELECTION CRITERIA

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

RESULTS

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

CONCLUSION

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Initiation of HIV pre-exposure prophylaxis among youth in the United States, 2015-2018

Adolescents and young adults ("youth") account for one-fifth of new HIV diagnoses in the U.S. HIV pre-exposure prophylaxis (PrEP), which became FDA approved in adolescents in May 2018, is highly effective at preventing HIV infection though there are limited data for PrEP initiation in youth. We aimed to quantify PrEP initiation and identify factors associated with PrEP initiation among youth at risk for HIV. We conducted a retrospective cohort study of youth aged 13-26 years who had an indication for PrEP between 1 January 2015, and 31 December 2018. We used data on commercially insured US individuals from the IBM MarketScan Commercial Database. We compared factors among youth who did and did not receive PrEP. We developed a multivariable logistic regression model to identify the association of all study covariates with receipt of PrEP. Among potentially PrEP eligible youth, only 2171 (1.6%) received a PrEP prescription in the year following their PrEP eligible claim. In multivariable models, youth who received PrEP were more likely to be older (adjusted odd ratio [aOR] for 18-20 year olds = 5.11; 95% CI = 3.35-7.77; aOR for 21-26 year olds = 16.90; 95% CI = 11.0-24.7), male (aOR = 92.42; 95% CI = 68.24-125), have sexual activity with elevated risk (aOR = 7.47; 95% CI = 6.50-8.60), or be diagnosed with gonorrhea or syphilis than youth who did not receive PrEP. Our findings highlight an opportunity to improve HIV prevention early in the life course.

The effect of peer-to-peer education on health literacy, knowledge, and adherence to COVID-19 protocols in vulnerable adolescents

BACKGROUND

The study was done to examine the effectiveness of peer-to-peer education on increasing health literacy, knowledge s, and observance of coronavirus disease (COVID-19) health prevention protocols in vulnerable adolescents.

METHOD

The study was a one-group intervention (before and after the intervention) that was performed on 1200 vulnerable adolescents living in varamin. The educational intervention was presented to adolescents in a face-to-face session. In the next step, the adolescents were taught the information received by three members of their families. Data were evaluated using a self-designed questionnaire before, and three months after the intervention. The paired t-test was used to compare scores of health literacy, compliance, and knowledge before and after the intervention at a 0.05 confidence level. The Multiple linear regression model was used to determine the predictive factors of observance of COVID-19 preventive behaviors.

RESULTS

The most of adolescents were in the age group of 14 to 18 years (60%) and most of them were girls (61.5%). The most important source of information about COVID-19 disease was radio and television (59.6%). The results showed that the effectiveness of the intervention in increasing the adolescents' health literacy, knowledge, and adherence to preventive behaviors were 40%, 30%, and 23%, respectively. The effectiveness of the intervention in increasing their families' health literacy and adherence to the protocols were 11% and 20%, respectively (p = 0.001).

DISCUSSION

Involving volunteer adolescents as health ambassadors and transmitting messages and methods of promoting personal protection against COVID-19 epidemics to family members had a significant effect on increasing the knowledge and adherence to the health procedures.

Modelo multinível na identificação de fatores de risco comportamentais e estruturais ao HIV: revisão integrativa

RESUMO Objetivos: investigar estudos que adotaram o modelo de análise multinível na identificação de fatores de risco comportamentais e estruturais, que estão associados a infecção pelo HIV. Métodos: revisão integrativa da literatura com estudos disponíveis na íntegra, obtidos nas bases EMBASE, CINAHL, Pubmed e Scopus, cujos descritores selecionados foram os termos constantes: “HIV”, “multilevel analysis”, “behavior”. Resultados: a pesquisa resultou em 236 artigos. Destes, dez artigos compuseram a amostra. Desvantagem econômica, características de vizinhança, instabilidade habitacional, encarceramento, sexo transacional, múltiplos parceiros, abuso de substâncias e idade da primeira relação sexual foram classificados como fatores de risco estruturais e comportamentais ao HIV. Redução da desvantagem socioeconômica, fornecimento de estabilidade habitacional e uso de preservativos foram associados a fatores de proteção à exposição ao HIV. Conclusões: com a aplicabilidade do modelo multinível nos estudos de investigação de fatores de risco, foi possível identificar os elementos estruturais e comportamentais de risco ao HIV.

Multilevel model in the identification of behavioral and structural risk factors for HIV: integrative review

OBJECTIVES

to investigate studies that adopted the multilevel analysis model to identify behavioral and structural risk factors associated with HIV infection.

METHODS

an integrative review of the literature with studies available in full, obtained from EMBASE, CINAHL, Pubmed, and Scopus, whose selected descriptors were the indexed terms: "HIV", "multilevel analysis" and "behavior".

RESULTS

the search resulted in 236 studies. Out of these, ten studies comprised the sample. Economic disadvantage, neighborhood characteristics, housing instability, incarceration, transactional sex, multiple partners, substance abuse, and age at first intercourse were classified as structural and behavioral risk factors for HIV. Reduced socioeconomic disadvantage, provision of housing stability, and condom use were associated with protective factors for HIV exposure.

CONCLUSIONS

by applying the multilevel model in risk factor research studies, it was possible to identify the structural and behavioral elements of HIV risk.

Understanding the factors that impact effective uptake and maintenance of HIV care programs in South African primary health care clinics

BACKGROUND

There is an increasingly urgent gap in knowledge regarding the translation of effective HIV prevention and care programming into scaled clinical policy and practice. Challenges limiting the translation of efficacious programming into national policy include the paucity of proven efficacious programs that are reasonable for clinics to implement and the difficulty in moving a successful program from research trial to scaled programming. This study aims to bridge the divide between science and practice by exploring health care providers' views on what is needed to implement new HIV programs within existing HIV care.

METHODS

We conducted 20 in-depth interviews with clinic managers and clinic program implementing staff and five key informant interviews with district health managers overseeing programming in the uMgungundlovu District of KwaZulu-Natal Province, South Africa. Qualitative data were analyzed using a template approach. A priori themes were used to construct templates of relevance, including current care context for HIV and past predictors of successful implementation. Data were coded and analyzed by these templates.

RESULTS

Heath care providers identified three main factors that impact the integration of HIV programming into general clinical care: perceived benefits, resource availability, and clear communication. The perceived benefits of HIV programs hinged on the social validation of the program by early adopters. Wide program availability and improved convenience for providers and patients increased perceived benefit. Limited staffing capacity and a shortage of space were noted as resource constraints. Programs that specifically tackled these constraints through clinic decongestion were reported as being the most successful. Clear communication with all entities involved in clinic-based programs, some of which include external partners, was noted as central to maximizing program function and provider uptake.

CONCLUSIONS

Amid the COVID-19 pandemic, new programs are continuously being developed for implementation at the primary health care level. A better understanding of the factors that facilitate and prevent programmatic success will improve public health outcomes. Implementation is likely to be most successful when programs capitalize on endorsements from early adopters, tackle resource constraints, and foster greater communication among partners responsible for implementation.

Tackling structural stigma: a systems perspective

Introduction

Structural stigma in the global HIV response is a “moving target” that constantly evolves as the epidemic changes. Tackling structural stigma requires an understanding of the drivers and facilitators of stigma in complex community, policy and health systems. In this paper, we present findings from a study adopting a systems perspective to understand how to tackle structural stigma via the Meaningful Involvement of People with HIV/AIDS (MIPA), while highlighting the challenges in demonstrating peer leadership from people living with HIV (PLHIV).

Methods

Through a long‐term ongoing community‐research collaboration (2015–2023), the study applied systems thinking methods to draw together the insights of over 90 peer staff from 10 Australian community and peer organizations. We used hypothetical narratives, affinity methods and causal loop diagrams to co‐create system maps that visualize the factors that influence the extent to which peer leadership is expected, respected, sought‐out and funded in the Australian context. We then developed draft indicators of what we should see happening when PLHIV peer leadership and MIPA is enabled to challenge structural stigma.

Results

Participants in the collaboration identified the interactions at a system level, which can enable or constrain the quality and influence of PLHIV peer leadership. Participants identified that effective peer leadership is itself affected by structural stigma, and peer leaders and the programmes that support and enable peer leadership must navigate a complex network of causal pathways and strategic pitfalls. Participants identified that indicators for effective PLHIV peer leadership in terms of engagement, alignment, adaptation and influence also required indicators for policy and service organizations to recognize their own system role to value and enable PLHIV peer leadership. Failing to strengthen and incorporate PLHIV leadership within broader systems of policy making and health service provision was identified as an example of structural stigma.

Conclusions

Incorporating PLHIV leadership creates a virtuous cycle, because, as PLHIV voices are heard and trusted, the case for their inclusion only gets stronger. This paper argues that a systems perspective can help to guide the most productive leverage points for intervention to tackle structural stigma and promote effective PLHIV leadership.

Implementing pre-exposure prophylaxis for HIV prevention in women: the role of the obstetrician-gynecologist

Pre-exposure prophylaxis is a powerful HIV prevention tool that can reduce the risk of acquiring HIV by >90% from unprotected sex and >70% from injection drug use. The peripartum period is a time of heightened HIV risk, which underscores the need for HIV prevention counseling and the provision of biomedical interventions in all stages of a woman's reproductive life. It is important that women receive nonjudgmental care, have access to discussions of HIV risk, and are provided with pre-exposure prophylaxis counseling from their women's health practitioners. Obstetrician-gynecologists and other women's health providers are uniquely positioned to identify women who would benefit from pre-exposure prophylaxis and provide it in trusted clinical settings.

Spatial and Temporal Trends in HIV/AIDS Burden Among Worldwide Regions From 1990 to 2019: A Secondary Analysis of the Global Burden of Disease Study 2019

Purpose

HIV/AIDS is a critical public health concern worldwide. This article investigated the spatial and temporal trends in HIV/AIDS burden from 1990 to 2019.

Methods

Data were extracted from the Global Burden of Disease (GBD) Study 2019. The estimated annual percentage change (EAPC) and the age-standardized rate (ASR) were used to quantify the change in trends at the global, regional, and national levels.

Results

In terms of temporal trends, during the period 1990–2004, increasing trends in prevalence (EAPC = 7.47, 95% confidence interval [CI] 5.84, 9.12), death (EAPC = 10.85, 95% CI 8.90–12.84), and disability-adjusted life years (DALYs) (EAPC = 10.40, 95% CI 8.47–12.36) of HIV/AIDS were observed. During the period 2005–2019, the global trends in HIV/AIDS incidence, death, and DALYs of HIV/AIDS decreased, with the EAPCs of −2.68 (95% CI−2.82–−2.53), −6.73 (95% CI −6.98–−6.47), and −6.75 (95% CI −6.95–−6.54), respectively. However, the disease prevalence showed a slight increasing trend (EAPC = 0.71, 95% CI 0.54–0.87). In terms of spatial trends, over the past 15 years, trends in HIV/AIDS incidence of HIV/AIDS appeared upward in High-middle and High sociodemographic index (SDI) areas (EAPC = 6.51, 95% CI 5.50–7.53; EAPC = 2.31, 95% CI 2.02–2.60, respectively).

Conclusion

Decreasing trends in HIV/AIDS incidence, death, and DALYs have been observed worldwide over the past 15 years, especially in death and DALYs rates. However, the global population living with HIV/AIDS is still increasing. It is worth noting that an unfavorable trend emerged in High-middle and High SDI areas. Prevention and control of HIV/AIDS still need to be strengthened to counteract these concerning trends.

Monitoring socioeconomic inequalities across HIV knowledge, attitudes, behaviours and prevention in 18 sub-Saharan African countries

OBJECTIVES

Socioeconomic inequalities in HIV prevention services coverage constitute important barriers to global prevention targets, especially in sub-Saharan Africa (SSA). We aimed at monitoring these inequalities from population-based survey data in 18 SSA countries between 2010 and 2018.

METHODS

We defined eight HIV indicators aimed at capturing uptake of HIV prevention services among adult participants. Country-specific wealth-related inequalities were measured using the Relative and Slope Index of Inequalities (RII and SII, respectively) and then pooled using random-effects meta-analyses. We compared inequalities between African regions using the Wilcoxon rank-sum test.

RESULTS

The sample consisted of 358 591 participants (66% women). Despite variability between countries and indicators, the meta-analysis revealed significant levels of relative and absolute inequalities in six out of eight indicators: HIV-related knowledge, positive attitudes toward people with HIV (PWH), condom use at last sexual intercourse, participation to prevention of mother-to-child transmission programs, medical male circumcision and recent HIV testing. The largest inequalities were reported in condom use, with condom use reported five times more among the richest versus the poorest [RII = 5.02, 95% confidence interval (CI) 2.79-9.05] and in positive attitudes toward PWH, with a 32-percentage point difference between the richest and poorest (SII = 0.32, 95% CI 0.26-0.39). Conversely, no significant inequalities were observed in multipartnership and HIV seropositivity among youth. Overall, inequalities tended to be larger in West and Central vs. East and Southern African countries.

CONCLUSION

Despite efforts to scale-up HIV-prevention programs, socioeconomic inequalities remain substantial over the continuum of HIV primary and secondary prevention in several SSA countries.

Interest In and Uptake of HIV Pre-Exposure Prophylaxis (PrEP): A Cross-Sectional Study of High-Risk Patients in Western Canada

Rationale

Pre-exposure prophylaxis (PrEP) is a highly effective, evidence-based HIV prevention strategy. However, its use in the city of Saskatoon, Saskatchewan province of western Canada, is relatively new. Therefore, this study aimed to examine the interest and uptake of PrEP and investigate factors associated with HIV PrEP by high-risk patients.

Methods 

A cross-sectional, self-administered survey of patients attending Saskatoon’s Public Health Services Sexual Health Clinic was conducted from October until December 2018. The primary outcome was the interest in taking PrEP to reduce the risk of HIV infection. This outcome was evaluated for its association with potential correlates, which included: sociodemographic characteristics, HIV risk perception, prior PrEP awareness, and sexual behaviors/lifestyles. Descriptive, univariate, and multivariate analyses were used to pursue our research objectives.

Results

One hundred forty-one participants were recruited from a sexual health clinic in Saskatoon. The median age (interquartile range) was 26 (22-31) years. The median number of partners (interquartile range) was 3 (2-4) partners. A total of 66.0% of participants were unaware of PrEP, and almost half ( 49.6%) indicated an interest in taking PrEP. Among those disinterested in PrEP, 49.3% perceived minimal HIV risk, 35.2% expressed concern regarding side effects, 28.1% cited the added need for condom use, 23.9% indicated incomplete effectiveness, and 22.5% did not wish to undergo regular bloodwork. Multivariate analysis showed that interested patients were more likely to have been previously aware of PrEP (OR: 2.6, p-value = 0.03), perceived themselves to be vulnerable to HIV (OR: 15.7, p = <0.0001), or were unsure about their risk (OR: 3.9, p = 0.001).

Conclusion

This study suggests that a lack of knowledge regarding personal HIV risk and PrEP as a preventive option may influence PrEP interest. There lies a need for more health promotion campaigns around the health benefits of PrEP, including literacy efforts on HIV risk, concerns around side effects, and associated blood work with PrEP use.

Isisekelo Sempilo study protocol for the effectiveness of HIV prevention embedded in sexual health with or without peer navigator support (Thetha Nami) to reduce prevalence of transmissible HIV amongst adolescents and young adults in rural KwaZulu-Natal: a 2 × 2 factorial randomised controlled trial

Background

Antiretroviral therapy (ART) through universal test and treat (UTT) and HIV pre-exposure prophylaxis (PrEP) substantially reduces HIV-related mortality, morbidity and incidence. Effective individual-level prevention modalities have not translated into population-level impact in southern Africa due to sub-optimal coverage among adolescents and youth who are hard to engage. We aim to investigate the feasibility, acceptability, and preliminary population level effectiveness of HIV prevention services with or without peer support to reduce prevalence of transmissible HIV amongst adolescents and young adults in KwaZulu-Natal.

Methods

We are conducting a 2 × 2 factorial trial among young men and women aged 16–29 years, randomly selected from the Africa Health Research Institute demographic surveillance area. Participants are randomly allocated to one of four intervention combinations: 1) Standard of Care (SOC): nurse-led services for HIV testing plus ART if positive or PrEP for those eligible and negative; 2) Sexual and Reproductive Health (SRH): Baseline self-collected vaginal and urine samples with study-organized clinic appointments for results, treatment and delivery of HIV testing, ART and PrEP integrated with SRH services; 3) Peer-support: Study referral of participants to a peer navigator to assess their health, social and educational needs and provide risk-informed HIV prevention, including facilitating clinic attendance; or 4) SRH + peer-support.

The primary outcomes for effectiveness are: (1) the proportion of individuals with infectious HIV at 12 months and (2) uptake of risk-informed comprehensive HIV prevention services within 60 days of enrolment. At 12 months, all participants will be contacted at home and the study team will collect a dried blood spot for HIV ELISA and HIV viral load testing.

Discussion

This trial will enable us to understand the relative importance of SRH and peer support in creating demand for effective and risk informed biomedical HIV prevention and preliminary data on their effectiveness on reducing the prevalence of transmissible HIV amongst all adolescents and youth.

Trial registration

Trial Registry: clincialtrials.gov. ClinicalTrials.gov Identifier NCT04532307. Registered: March 2020.

How effects on health equity are assessed in systematic reviews of interventions

BACKGROUND

Enhancing health equity is endorsed in the Sustainable Development Goals. The failure of systematic reviews to consider potential differences in effects across equity factors is cited by decision-makers as a limitation to their ability to inform policy and program decisions.  OBJECTIVES: To explore what methods systematic reviewers use to consider health equity in systematic reviews of effectiveness.

SEARCH METHODS

We searched the following databases up to 26 February 2021: MEDLINE, PsycINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Hein Index to Foreign Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on 10 June 10 2021. We contacted authors and searched the reference lists of included studies to identify additional potentially relevant studies.

SELECTION CRITERIA

We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities. We define health inequalities as unfair and avoidable differences across socially stratifying factors that limit opportunities for health. We operationalised this by assessing studies which evaluated differences in health across any component of the PROGRESS-Plus acronym, which stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender or sex, Religion, Education, Socioeconomic status, Social capital. "Plus" stands for other factors associated with discrimination, exclusion, marginalisation or vulnerability such as personal characteristics (e.g. age, disability), relationships that limit opportunities for health (e.g. children in a household with parents who smoke) or environmental situations which provide limited control of opportunities for health (e.g. school food environment).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data using a pre-tested form. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews.  MAIN RESULTS: In total, 48,814 studies were identified and the titles and abstracts were screened in duplicate. In this updated review, we identified an additional 124 methodological studies published in the 10 years since the first version of this review, which included 34 studies. Thus, 158 methodological studies met our criteria for inclusion. The methods used by these studies focused on evidence relevant to populations experiencing health inequity (108 out of 158 studies), assess subgroup analysis across PROGRESS-Plus (26 out of 158 studies), assess analysis of a gradient in effect across PROGRESS-Plus (2 out of 158 studies) or use a combination of subgroup analysis and focused approaches (20 out of 158 studies). The most common PROGRESS-Plus factors assessed were age (43 studies), socioeconomic status in 35 studies, low- and middle-income countries in 24 studies, gender or sex in 22 studies, race or ethnicity in 17 studies, and four studies assessed multiple factors across which health inequity may exist. Only 16 studies provided a definition of health inequity. Five methodological approaches to consider health equity in systematic reviews of effectiveness were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (140 of 158 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (50 studies); 3) analytic approaches which assessed differential effects across one or more PROGRESS-Plus factors (16 studies); 4) applicability assessment (25 studies) and 5) stakeholder engagement (28 studies), which is a new finding in this update and examines the appraisal of whether relevant stakeholders with lived experience of health inequity were included in the design of systematic reviews or design and delivery of interventions. Reporting for both approaches (analytic and applicability) lacked transparency and was insufficiently detailed to enable the assessment of credibility.

AUTHORS' CONCLUSIONS

There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to consider health equity in systematic reviews of effectiveness.

Feasibility of Indirect Secondary Distribution of HIV Self-test Kits via WeChat Among Men Who Have Sex With Men: National Cross-sectional Study in China

Background

HIV self-testing (HIVST) kits are common in key sexually active populations. Direct secondary distribution of HIVST kits (DSDHK) is effective in improving the uptake of HIVST. However, there are concerns about the various limitations of DSDHK, including limited geographic reach, payment problems, and need for face-to-face interactions.

Objective

In this study, we aim to evaluate the feasibility and characteristics of indirect secondary distribution of HIVST kits (ISDHK) via WeChat (distributing HIVST application links and follow-up HIVST kits to partners) among men who have sex with men (MSM).

Methods

From October 2017 to September 2019, an HIVST recruitment advertisement was disseminated on the WeChat social media platform to invite MSM to apply for the HIVST kits (referred to as index participants [IPs]). All MSM participants were encouraged to distribute the HIVST application link to their friends and sexual partners (referred to as alters) through their social networks. All the alters were further encouraged to continue distributing the HIVST application link. All participants paid a deposit (US $7), which was refundable upon completion of the questionnaire, and uploaded the test results via a web-based survey system.

Results

A total of 2263 MSM met the criteria and successfully applied for HIVST. Of these, 1816 participants returned their HIVST results, including 1422 (88.3%) IPs and 394 (21.7%) alters. More alters had condomless anal intercourse, a higher proportion of them had never previously tested for HIV, and they showed a greater willingness to distribute HIVST kits to their sexual partners (P=.002) than the IPs. After controlling for age, education, and income, the alters had a greater proportion of MSM who had never tested for HIV before (adjusted odds ratio [aOR] 1.29, 95% CI 1.00-1.68), were more willing to distribute the HIVST application link (aOR 1.71, 95% CI 1.21-2.40), had a lower number of sexual partners (aOR 0.71, 95% CI 0.57-0.90), and were less likely to search for sexual partners on the web (aOR 0.78, 95% CI 0.60-1.02) than IPs. In comparison, the rates of reactive HIVST results, conducting HIV confirmatory tests, HIV seropositivity, and initiation of HIV antiretroviral therapy were similar for IPs and alters.

Conclusions

The ISDHK model of distributing HIVST application links among the MSM population via social media is feasible. The ISDHK model should be used to supplement the DSDHK model to enable a greater proportion of the MSM population to know their HIV infection status.

Qualitative accounts of PrEP discontinuation from the general population in Eswatini

People in receipt of pre-exposure prophylaxis (PrEP) for the prevention of HIV in Sub-Saharan Africa often discontinue taking the medication. We conducted 27 semi-structured interviews with men and women who had started PrEP but did not return to the clinic for a refill after a 1, 2 or 3-month period. These 'discontinuation' clients were enrolled in a PrEP demonstration project for the general population in nurse-led, public-sector, primary-care clinics in Eswatini. Reasons for discontinuation included changes to self-perceived HIV risk such as the end of pregnancy and absent partners. Others described PrEP as inaccessible when working away from home and many described difficulties relating to a daily pill regimen and managing side effects. Female clients described being prohibited from using PrEP by their partners and co-wives. From these results, we recommend that client-centred counselling stresses the prevention-effective adherence paradigm, which promotes PrEP use in risk periods that are identifiable and PrEP discontinuation when the risk period has finished. A national scale up of PrEP may mitigate problems accessing PrEP. Extended counselling and support could assist with adherence and the management of side effects. Education and support for partners and families of PrEP clients may also contribute to better PrEP continuation.

Understanding the Factors that Impact Effective Uptake and Integration of Health Programs in South African Primary Health Care Clinics

Introduction : There is an increasingly urgent gap in knowledge regarding the translation of effective HIV prevention and care programming into scaled clinical policy and practice. Challenges limiting the translation of efficacious programming into national policy include both the paucity of proven efficacious programs that are reasonable for clinics to implement and the difficulty in moving a successful program from research trial to scaled programming. This study aims to bridge the divide between science and practice by exploring health care providers’ views on what is needed to integrate of HIV programming into clinic systems. Methods : We conducted 20 in-depth interviews with clinic managers and clinic program implementing staff and 5 key informant interviews with district health managers overseeing programming in the uMgungundlovu District of KwaZulu-Natal Province, South Africa. Qualitative data were analyzed using a template approach. A priori themes were used to construct templates of relevance including current care context for HIV and past predictors of successful implementation. Data were coded and analyzed in accordance with these templates. Results : Heath care providers identified three main factors that impact integration of HIV programming into general clinical care: perceived benefits, resource availability, and clear communication. The perceived benefits of HIV programs hinged on the social validation of the program by early adopters. Wide program availability and improved convenience for providers and patients increased perceived benefit. Limited staffing capacity and a shortage of space were noted as resource constraints. Programs that specifically tackled these constraints through, for example clinic decongestion, were reported as being the most successful. Clear communication with all entities involved in clinic-based programs, some of which include external partners, was noted as central to maximizing program function and provider uptake. Conclusions : Amid the COVID-19 pandemic, new programs are already being developed for implementation at the primary health care level. A better understanding of the factors which both facilitate and prevent programmatic success will improve public health outcomes. Implementation is likely to be most successful when programs capitalize on endorsements from early adopters, tackle resource constraints, and foster greater communication among partners responsible for implementation.

Refugee Health During COVID-19 and Future Pandemics

Purpose of Review

This commentary summarizes recent literature pertaining to healthcare challenges and needs during the current pandemic among refugees and asylum seekers residing in a host country. We conducted a literature review to identify barriers to shielding these structurally marginalized populations from the impact of the COVID-19 pandemic.

Recent Findings

Many populations, including refugees, migrants, and asylum seekers, endure structural vulnerabilities in refugee camps and during their resettlement. These structural vulnerabilities include fear of contacting the healthcare system, cultural differences, housing insecurity, food insecurity, discrimination, lack of health insurance, health illiteracy and lack of readily available, and culturally appropriate educational materials. During pandemics, displaced persons suffer disproportionately from poorly managed chronic diseases, economic hardships isolation, and mental illnesses, in addition to the threats posed by the infectious agent.

Summary

Underserved groups, including refugee populations, shoulder a disproportionate burden of disease during pandemics. In order to mitigate the impact of preventable chronic illnesses and also reduce the spread of COVID-19 and other easily-transmissible and deadly viruses during pandemics, governments and public health authorities need to implement policies that allow refugees, asylum seekers, and displaced persons to be fully incorporated into their respective healthcare systems, so that they can be supported and protected and to reduce the amplifying networks of transmission.

Does community-based distribution of HIV self-tests increase uptake of HIV testing? Results of pair-matched cluster randomised trial in Zambia

OBJECTIVES

Ending HIV by 2030 is a global priority. Achieving this requires alternative HIV testing strategies, such as HIV self-testing (HIVST) to reach all individuals with HIV testing services (HTS). We present the results of a trial evaluating the impact of community-based distribution of HIVST in community and facility settings on the uptake of HTS in rural and urban Zambia.

DESIGN

Pair-matched cluster randomised trial.

METHODS

In catchment areas of government health facilities, OraQuick HIVST kits were distributed by community-based distributors (CBDs) over 12 months in 2016-2017. Within matched pairs, clusters were randomised to receive the HIVST intervention or standard of care (SOC). Individuals aged ≥16 years were eligible for HIVST. Within communities, CBDs offered HIVST in high traffic areas, door to door and at healthcare facilities. The primary outcome was self-reported recent testing within the previous 12 months measured using a population-based survey.

RESULTS

In six intervention clusters (population 148 541), 60 CBDs distributed 65 585 HIVST kits. A recent test was reported by 66% (1622/2465) in the intervention arm compared with 60% (1456/2429) in SOC arm (adjusted risk ratio 1.08, 95% CI 0.94 to 1.24; p=0.15). Uptake of the HIVST intervention was low: 24% of respondents in the intervention arm (585/2493) used an HIVST kit in the previous 12 months. No social harms were identified during implementation.

CONCLUSION

Despite distributing a large number of HIVST kits, we found no evidence that this community-based HIVST distribution intervention increased HTS uptake. Other models of HIVST distribution, including secondary distribution and community-designed distribution models, provide alternative strategies to reach target populations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02793804).

Thetha Nami: participatory development of a peer-navigator intervention to deliver biosocial HIV prevention for adolescents and youth in rural South Africa

BACKGROUND

Despite effective biomedical tools, HIV remains the largest cause of morbidity/mortality in South Africa - especially among adolescents and young people. We used community-based participatory research (CBPR), informed by principles of social justice, to develop a peer-led biosocial intervention for HIV prevention in KwaZulu-Natal (KZN).

METHODS

Between March 2018 and September 2019 we used CBPR to iteratively co-create and contextually adapt a biosocial peer-led intervention to support HIV prevention. Men and women aged 18-30 years were selected by community leaders of 21 intervention implementation areas (izigodi) and underwent 20 weeks of training as peer-navigators. We synthesised quantitative and qualitative data collected during a 2016-2018 study into 17 vignettes illustrating the local drivers of HIV. During three participatory intervention development workshops and community mapping sessions, the peer-navigators critically engaged with vignettes, brainstormed solutions and mapped the components to their own izigodi. The intervention components were plotted to a Theory of Change which, following a six-month pilot and process evaluation, the peer-navigators refined. The intervention will be evaluated in a randomised controlled trial ( NCT04532307 ).

RESULTS

Following written and oral assessments, 57 of the 108 initially selected participated in two workshops to discuss the vignettes and co-create the Thetha Nami (`talk to me'). The intervention included peer-led health promotion to improve self-efficacy and demand for HIV prevention, referrals to social and educational resources, and aaccessible youth-friendly clinical services to improve uptake of HIV prevention. During the pilot the peer-navigators approached 6871 young people, of whom 6141 (89%) accepted health promotion and 438 were linked to care. During semi-structured interviews peer-navigators described the appeal of providing sexual health information to peers of a similar age and background but wanted to provide more than just "onward referral". In the third participatory workshop 54 peer-navigators refined the Thetha Nami intervention to add three components: structured assessment tool to tailor health promotion and referrals, safe spaces and community advocacy to create an enabling environment, and peer-mentorship and navigation of resources to improve retention in HIV prevention.

CONCLUSION

Local youth were able to use evidence to develop a contextually adapted peer-led intervention to deliver biosocial HIV prevention.

Effect of peer-distributed HIV self-test kits on demand for biomedical HIV prevention in rural KwaZulu-Natal, South Africa: a three-armed cluster-randomised trial comparing social networks versus direct delivery

STUDY OBJECTIVE

We investigated two peer distribution models of HIV self-testing (HIVST) in HIV prevention demand creation compared with trained young community members (peer navigators).

METHODS

We used restricted randomisation to allocate 24 peer navigator pairs (clusters) in KwaZulu-Natal 1:1:1: (1) standard of care (SOC): peer navigators distributed clinic referrals, pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) information to 18-30 year olds. (2) peer navigator direct distribution (PND): Peer navigators distributed HIVST packs (SOC plus two OraQuick HIVST kits) (3) incentivised peer networks (IPN): peer navigators recruited young community members (seeds) to distribute up to five HIVST packs to 18-30 year olds within their social networks. Seeds received 20 Rand (US$1.5) for each recipient who distributed further packs. The primary outcome was PrEP/ART linkage, defined as screening for PrEP/ART eligibility within 90 days of pack distribution per peer navigator month (pnm) of outreach, in women aged 18-24 (a priority for HIV prevention). Investigators and statisticians were blinded to allocation. Analysis was intention to treat. Total and unit costs were collected prospectively.

RESULTS

Between March and December 2019, 4163 packs (1098 SOC, 1480 PND, 1585 IPN) were distributed across 24 clusters. During 144 pnm, 272 18-30 year olds linked to PrEP/ART (1.9/pnm). Linkage rates for 18-24-year-old women were lower for IPN (n=26, 0.54/pnm) than PND (n=45, 0.80/pnm; SOC n=49, 0.85/pnm). Rate ratios were 0.68 (95% CI 0.28 to 1.66) for IPN versus PND, 0.64 (95% CI 0.26 to 1.62) for IPN versus SOC and 0.95 (95% CI 0.38 to 2.36) for PND versus SOC. In 18-30 year olds, PND had significantly more linkages than IPN (2.11 vs 0.88/pnm, RR 0.42, 95% CI 0.18 to 0.98). Cost per pack distributed was cheapest for IPN (US$36) c.f. SOC (US$64). Cost per person linked to PrEP/ART was cheaper in both peer navigator arms compared with IPN.

DISCUSSION

HIVST did not increase demand for PrEP/ART. Incentivised social network distribution reached large numbers with HIVST but resulted in fewer linkages compared with PrEP/ART promotion by peer navigators.

TRIAL REGISTRATION NUMBER

NCT03751826.

ART initiations following community-based distribution of HIV self-tests: meta-analysis and meta-regression of STAR Initiative data

INTRODUCTION

Measuring linkage after community-based testing, particularly HIV self-testing (HIVST), is challenging. Here, we use data from studies of community-based HIVST distribution, conducted within the STAR Initiative, to assess initiation of antiretroviral therapy (ART) and factors driving differences in linkage rates.

METHODS

Five STAR studies evaluated HIVST implementation in Malawi, Zambia and Zimbabwe. New ART initiations during the months of intervention at clinics in HIVST and comparison areas were presented graphically, and study effects combined using meta-analysis. Meta-regression was used to estimate associations between the impact of community-based HIVST distribution and indicators of implementation context, intensity and reach. Effect size estimates used (1) prespecified trial definitions of ART timing and comparator facilities and (2) exploratory definitions accounting for unexpected diffusion of HIVST into comparison areas and periods with less distribution of HIVST than was expected.

RESULTS

Compared with arms with standard testing only, ART initiations were higher in clinics in HIVST distribution areas in 4/5 studies. The prespecified meta-analysis found positive but variable effects of HIVST on facility ART initiations (RR: 1.14, 95% CI 0.93 to 1.40; p=0.21). The exploratory meta-analysis found a stronger impact of HIVST distribution on ART initiations (RR: 1.29, 95% CI 1.08 to 1.55, p=0.02).ART initiations were higher in studies with greater self-reported population-level intensity of HIVST use (RR: 1.12; 95% CI 1.04 to 1.21; p=0.02.), but did not differ by national-level indicators of ART use among people living with HIV, number of HIVST kits distributed per 1000 population, or self-reported knowledge of how to link to care after a reactive HIVST.

CONCLUSION

Community-based HIVST distribution has variable effect on ART initiations compared with standard testing service alone. Optimising both support for and approach to measurement of effective and timely linkage or relinkage to HIV care and prevention following HIVST is needed to maximise impact and guide implementation strategies.

Effect of Biomedical Materials in the Implementation of a Long and Healthy Life Policy

This paper is divided into seven main parts. Its purpose is to review the literature to demonstrate the importance of developing bioengineering and global production of biomaterials to care for the level of healthcare in the world. First, the general description of health as a universal human value and assumptions of a long and healthy life policy is presented. The ethical aspects of the mission of medical doctors and dentists were emphasized. The coronavirus, COVID-19, pandemic has had a significant impact on health issues, determining the world’s health situation. The scope of the diseases is given, and specific methods of their prevention are discussed. The next part focuses on bioengineering issues, mainly medical engineering and dental engineering, and the need for doctors to use technical solutions supporting medicine and dentistry, taking into account the current stage Industry 4.0 of the industrial revolution. The concept of Dentistry 4.0 was generally presented, and a general Bioengineering 4.0 approach was suggested. The basics of production management and the quality loop of the product life cycle were analyzed. The general classification of medical devices and biomedical materials necessary for their production was presented. The paper contains an analysis of the synthesis and characterization of biomedical materials supporting medicine and dentistry, emphasizing additive manufacturing methods. Numerous examples of clinical applications supported considerations regarding biomedical materials. The economic conditions for implementing various biomedical materials groups were supported by forecasts for developing global markets for biomaterials, regenerative medicine, and tissue engineering. In the seventh part, recapitulation and final remarks against the background of historical retrospection, it was emphasized that the technological processes of production and processing of biomedical materials and the systematic increase in their global production are a determinant of the implementation of a long and healthy policy.

Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: Coverage, barriers and facilitators

The provision of comprehensive prevention services is vital for reducing the high burden of HIV amongst Ukrainian female sex workers (FSWs). To identify barriers and facilitators that influence access to HIV prevention amongst this population between 2009 and 2017, we developed a literature-informed conceptual framework and conducted a document analysis to identify the components of the Ukrainian prevention package (PP). Using the Integrated Bio Behavioural Surveillance Surveys, we then conducted descriptive analyses to explore PP coverage from 2009 to 2017 and the influence of factors, identified by our conceptual framework. After increasing over four years, a drop in PP coverage was observed from 2013 onwards. Being a client of a non-governmental organisation, street and highway solicitation, non-condom use, and knowledge of HIV may influence access to HIV prevention in the Ukrainian context. Future interventions should consider barriers and facilitators to HIV prevention and the multiple structural levels on which they operate.

Use of HIV pre-exposure prophylaxis among urban Canadian gay, bisexual and other men who have sex with men: a cross-sectional analysis of the Engage cohort study

BACKGROUND

In Canada, gay, bisexual and other men who have sex with men (GBM) are disproportionately affected by HIV. Our objective was to describe access to HIV pre-exposure prophylaxis (PrEP) and identify factors associated with not using PrEP among self-reported HIV-negative or HIV-unknown GBM.

METHODS

This was a cross-sectional analysis of the Engage study cohort. Between 2017 and 2019, sexually active GBM aged 16 years or more in Montréal, Toronto and Vancouver were recruited via respondent-driven sampling (RDS). Participation included testing for HIV and sexually transmitted and blood-borne infections, and completion of a questionnaire. We examined PrEP access using a health care services model and fit RDS-adjusted logistic regressions to determine correlates of not using PrEP among those for whom PrEP was clinically recommended and who were aware of the intervention.

RESULTS

A total of 2449 GBM were recruited, of whom 2008 were HIV-negative or HIV-unknown; 1159 (511 in Montréal, 247 in Toronto and 401 in Vancouver) met clinical recommendations for PrEP. Of the 1159, 1100 were aware of PrEP (RDS-adjusted proportion: Montréal 84.6%, Toronto 94.2%, Vancouver 92.7%), 678 had felt the need for PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 39.2%, Toronto 56.1%, Vancouver 49.0%), 406 had tried to access PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 20.6%, Toronto 33.2%, Vancouver 29.6%) and 319 had used PrEP in the previous 6 months (RDS-adjusted proportion: Montréal 14.5%, Toronto 21.6%, Vancouver 21.8%). Not using PrEP was associated with several factors, including not feeling at high enough risk, viewing PrEP as not completely effective, not having a primary care provider and lacking medication insurance.

INTERPRETATION

Although half of GBM met clinical recommendations for PrEP, less than a quarter of them reported use. Despite high levels of awareness, a programmatic response that addresses PrEP-related perceptions and health care system barriers is needed to scale up PrEP access among GBM in Canada.

Challenges to quality assurance of surgical interventions in clinical oncology trials: A systematic review

Where surgery forms the primary curative modality in surgical oncology trials the quality of this intervention has the potential to directly influence outcomes. Many trials however lack a robust framework to ensure surgical quality. We aim to report existing published challenges to quality assurance of surgical interventions within oncological trials. A systematic on-line literature search of Embase and Medline identified 34 relevant studies, including 19 RCTs, 11 further analyses of the primary RCTs, and 4 trial protocols. Inclusion criteria: oncological RCTs with a surgical intervention and/or associated publications relevant to the research question; 'Challenges to quality assurance of surgery in clinical oncology trials'. Selected articles were assessed by two reviewers to identify reported challenges to quality assurance of surgical intervention within these trials. Reported challenges to surgical quality could be classified as those affecting credentialing, standardisation and monitoring of surgical interventions. Constraints of using case volume for credentialing surgeons; inter-centre variation in the definition and execution of interventions; insufficient training, and monitoring of surgical quality, were the most commonly encountered challenges within each of these three domains. Findings confirmed an inadequacy in the implementation and reporting of effective surgical quality assurance measures. The surgical community should enable implementation of agreed upon mitigating strategies to overcome challenges to surgical quality in oncology trials.

Interactive digital interventions for prevention of sexually transmitted HIV

BACKGROUND

Digital technology offers good opportunities for HIV prevention. This systematic review assesses the effectiveness of interactive digital interventions (IDIs) for prevention of sexually transmitted HIV.

METHODS

We conducted a systematic search for randomized controlled trials (RCTs) of IDIs for HIV prevention, defining 'interactive' as producing personally tailored material. We searched databases including the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, grey literature, reference lists, and contacted authors if needed.Two authors screened abstracts, applied eligibility and quality criteria and extracted data. Meta-analyses used random-effects models with standardized mean differences (SMD) for continuous outcomes and odds ratios (OR) for binary outcomes, assessing heterogeneity using the I2 statistic.

RESULTS

We included 31 RCTs of IDIs for HIV prevention. Meta-analyses of 29 RCTs comparing IDIs with minimal interventions (e.g. leaflet, waiting list) showed a moderate increase in knowledge (SMD 0.56, 95% CI 0.33 to 0.80), no effect on self-efficacy (SMD 0.13, 95% CI 0.00 to 0.27), a small improvement in intention (SMD 0.16, 95% CI 0.06 to 0.26), improvement in HIV prevention behaviours (OR 1.28, 95% CI 1.04 to 1.57) and a possible increase in viral load, but this finding is unreliable.We found no evidence of difference between IDIs and face-to-face interventions for knowledge, self-efficacy, intention, or HIV-related behaviours in meta-analyses of five small RCTs. We found no health economic studies.

CONCLUSION

There is good evidence that IDIs have positive effects on knowledge, intention and HIV prevention behaviours. IDIs are appropriate for HIV prevention in a variety of settings.Supplementary Video Abstract, http://links.lww.com/QAD/B934.

Shifting Coronavirus Disease 2019 Testing Policy and Research to Include the Full Translation Pipeline

The current severe acute respiratory syndrome coronavirus 2 testing policy and practice limits testing as a prevention tool. Radical shifts are required to increase the scale of rapid testing strategies and improve dissemination and implementation of venue-based and self-testing approaches. Attention to the full translation pipeline is required to reach high-risk segments of the population.

Sexual health literacy among gay, bisexual and other men who have sex with men: a conceptual framework for future research

Good sexual health requires navigating intimate relationships within diverse power dynamics and sexual cultures, coupled with the complexities of increasing biomedicalisation of sexual health. Understanding this is important for the implementation of biomedical HIV prevention. We propose a socially nuanced conceptual framework for sexual health literacy developed through a consensus building workshop with experts in the field. We use rigorous qualitative data analysis to illustrate the functionality of the framework by reference to two complementary studies. The first collected data from five focus groups (FGs) in 2012 (n = 22), with gay, bisexual and other men who have sex with men aged 18-75 years and 20 in-depth interviews in 2013 with men aged 19-60 years. The second included 12 FGs in 2014/15 with 55 patients/service providers involved in the use/implementation of HIV self-testing or HIV prevention/care. Sexual health literacy goes well beyond individual health literacy and is enabled through complex community practices and multi-sectoral services. It is affected by emerging (and older) technologies and demands tailored approaches for specific groups and needs. The framework serves as a starting point for how sexual health literacy should be understood in the evaluation of sustainable and equitable implementation of biomedical sexual healthcare and prevention internationally.

Facilitators and barriers to condom use among Filipinos: A systematic review of literature

Background: Between 2010 and 2018, the Philippines had a 203% increase in new human immunodeficiency virus (HIV) infections. The use of condoms is an effective and practical means to prevent HIV transmission. The purpose of this study was to identify facilitators and barriers to condom use among Filipinos guided by the Ecological Model of Health Promotion.

Methods: A systematic review of literature using electronic databases was performed using the following keywords: "condom," "Filipinos," and "Philippines." To be included in this review, papers should be (1) research studies, (2) studies that examined condom use, and (3) studies that sampled Filipinos residing in the Philippines. The final sample comprised of 27 articles.

Results: Multiple and interrelated factors at the individual and social environment levels influence condom use among different groups of Filipinos. Majority of these factors originated at the intrapersonal level. Some of the facilitators to condom use were knowledge on HIV, higher perceived HIV risk, peer support, positive manager attitude, health provider engagement, and city ordinances. In contrast, some of the barriers to condom use were discomfort and displeasure on condom use, low parental communication, lack of sex education, social stigma, and the high price of condoms.

Conclusion: A collaborative, culturally-sensitive, and population-specific approach is essential to develop and implement acceptable, sustainable, and successful condom use interventions.

Interprofessional collaboration associated with frequency of life-saving links to HIV continuum of care services in the urban environment of Newark, New Jersey

BACKGROUND

HIV continuum of care has been used as a strategy to reduce HIV transmission rates, with timely engagement in HIV testing being the first and most critical step. This study examines interprofessional-collaboration (IPC) after controlling for agency/ provider demographics, provider training and self-efficacy as a significant predictor of how frequently HIV service providers link their clients to HIV testing.

METHODS

Multilevel binary logistic regression analysis was conducted to examine the effects of IPC on links to HIV testing while controlling for demographic and agency information, provider training, and standardized measures of providers' feelings, attitudes, and opinions about IPC. Cross-sectional data from 142 providers in 13 agencies offering treatment and prevention services for HIV and substance-use disorders were collected via a survey.

RESULTS

Those who scored higher on the IPC scale reported significantly higher rates of linkages to HIV testing. Compared to the null model (i.e., no predictor model), the final multilevel binary logistic regression model showed a significantly improved likelihood of linkage to HIV testing by 11.4%, p. < .05. The final model correctly classified 90.2% of links to HIV testing. Providers in agencies with smaller budgets and in agencies offering substance use disorder services were more likely to link clients to HIV testing. Younger providers who received HIV training were also more likely to link clients to HIV testing.

CONCLUSIONS

Findings suggest IPC training as a potential strategy to improve linkages to HIV testing for clients at risk for HIV infection. Future research is recommended to identify specific areas of IPC that might have differential effects on links to HIV testing.

PrEP Use Awareness and Interest Cascade among MSM and Transgender Women Living in Bali, Indonesia

Indonesia has not implemented HIV pre-exposure prophylaxis (PrEP) despite global calls for its scale-up, and there is limited information about attitudes towards PrEP among its potential users. We aim to present a PrEP cascade among men who have sex with men (MSM) and transgender women (known locally as “waria”) in Denpasar, Bali, from a cross-sectional survey with 220 HIV-negative MSM/waria recruited from one clinic in Denpasar. Only 16.4% of participants had heard of PrEP before. From first-to-last steps included in the cascade, we found 77.3% (170/220) of participants were classified with HIV high risk, 75.9% (129/170) perceived themselves as being at high risk, 81.4% (105/129) expressed interest in using PrEP, 78.1% (82/105) were willing to do PrEP procedures, 48.8% (40/82) were willing to pay 500,000–600,000 IDR, and only two participants had ever been on PrEP before (5.0% of those willing to pay and 0.9% of the total sample). Multivariate logistic regression analysis showed that self-perception of high HIV risk was lower among older age groups (p < 0.001 among 30–39; p = 0.002 among > 40) and higher among participants with multiple sex partners (p = 0.016). Interest in using PrEP was lower among participants with high social engagement as MSM/waria (p = 0.002) and was higher among participants with multiple sex partners (p = 0.020) and inconsistent condom use (p = 0.011). This study has shown a significantly low level of PrEP awareness among its participants and decreases in interest in PrEP use due to procedure and cost. It suggested that an appropriate PrEP campaign is needed if PrEP is going to be introduced in Indonesia.

HIV prevention cascades for injection and sexual risk behaviors among HIV-negative people who inject drug in Iran

BACKGROUND

The HIV prevention cascade complements the HIV treatment cascade and helps evaluate the access to and use of harm reduction programs among HIV-negative individuals at risk for HIV, including people who inject drugs (PWID). This study aimed to estimate the HIV prevention cascades among PWID in Iran.

METHODS

Using data from the 2014 national bio-behavioral surveillance survey, 2,391 PWID were recruited from 31 harm reduction facilities and through outreach efforts across 10 major cities. PWID aged ≥18 years who reported drug injection in the past year were interviewed, and information regarding their demographic characteristics, sexual and drug injection practices, and access to services were gathered. PWID were also tested for HIV infection. We examined the prevention cascade framework among HIV-negative PWID.

RESULTS

The majority of PWID were male (97.6%) and more than half aged ≥ 35 years old (55.5%). Overall, 2,092 (92.5% [95% CI: 90.8, 93.9]) were HIV-negative; 93% of whom knew illicit drug injection could increase the risk of HIV transmission, 54% had access to free-of-charge sterile needles and syringes, 51% used sterile needles and syringes in their last injection practice, and 33% used sterile needles and syringes in all injection practices in the past month. Also, 87.8% (95% CI: 85.1, 90.0) of HIV-negative PWID had sex with any partner in the past year; 88% of whom knew using condoms could reduce the risk of HIV transmission, 35% had access to free-of-charge condoms, 32% used condoms in their last sexual practice, and 18% used condoms in all of their sexual practices in the past month.

CONCLUSION

The majority of HIV-negative PWID in Iran were at risk for HIV acquisition through unsafe drug injection or sexual practices. Harm reduction programs should improve access to free sterile needles, syringes, and condoms for PWID.

Better Service by Doing Less: Introducing De-implementation Research in HIV

The course of HIV research has led to a multitude of interventions to prevent and treat HIV. With the arrival of more effective interventions comes the need to end, or de-implement, less effective interventions. PURPOSE OF REVIEW: To describe the state of de-implementation research in HIV and provide a rationale for expanded research in this area. RECENT FINDINGS: Existing studies have identified a set of HIV-specific interventions appropriate for de-implementing and described the persistence of interventions that should be ended. However, to our knowledge, strategies to successfully promote appropriate de-implementation of HIV-specific interventions have not been examined. De-implementing interventions that are no longer needed is an opportunity to improve the quality and effectiveness of HIV services. Opportunities to expand this field of research abound.

HIV-prevention measures on a university campus in South Africa - perceptions, practices and needs of undergraduate medical students

Background: Young adults such as university students are considered to be a key population for HIV-prevention efforts. This study aimed to determine the perceptions, practices and needs of undergraduate medical students regarding HIV-prevention measures available on campus. Methods: The research design was descriptive cross-sectional. Data were collected using an anonymous, self-administered questionnaire distributed to all 745 undergraduate medical students in the School of Clinical Medicine, University of the Free State, South Africa, of whom 470 responded (63.1%). Results: Almost half (45.5%) of all respondents across the five academic years had received information about available HIV-prevention measures on campus. Most reported that information had been received during lectures (59.7%) and only 24.2% from the local health clinic on campus. The findings also revealed that 14.2% of students had used at least one prevention measure in the past, while the majority of students (70.2%) used abstinence as an HIV-prevention measure. A large percentage of all the students (47.6%) had been tested for HIV before the start of the study. Two-thirds (67%) of students indicated that the current HIV-prevention services on campus were not sufficient. Conclusion: Medical students received HIV-prevention information as part of their curriculum but this was deemed not to be sufficient. This study suggests that tertiary education institutions should evaluate the effectiveness of strategies currently in place for the distribution and awareness of HIV-prevention measures and sexual health issues affecting students, using a student-centred approach.

Proyecto Promover: Attempts to Roll Out an HIV Prevention and Testing Initiative Within a Mexican Immigrant Community

Latinx immigrants and men, in particular, living in the US are disproportionally impacted by HIV. Despite these concerns, there is limited research on the development, implementation, and evaluation of community-based HIV education and HIV testing interventions. The current study describes such efforts within a historic Mexican immigrant enclave in Chicago. A mixed-methods case study was used to describe intervention development, as well as preliminary evaluation data. Community intervention components were refined through early focus groups, asset mapping, community networking and consultation with cultural advisors. We exceeded our activity goals. We were successful in reaching a segment of the population that is often overlooked and remains unaware of HIV and its risks. Incorporating social network approaches could facilitate reaching at-risk community groups. Demonstration projects require more time and resources (fiscal and technical) to develop, refine, evaluate and sustain community-level intervention components.

Exploring the equity impact of mobile health-based human immunodeficiency virus interventions: A systematic review of reviews and evidence synthesis

Objective

While mobile health-based human immunodeficiency virus (HIV) interventions are often designed to promote health equity, systematic differences in the use of and access to mobile technologies may counteract that and widen treatment gaps. This systematic review applies an equity lens to investigate whether existing research provides adequate evidence on the ethical implications of mHealth technologies in HIV treatment and prevention.

Methods

This study included a two-stage methodology, consisting of (a) a systematic review of systematic reviews and (b) an evidence synthesis of primary studies. For the review of reviews we searched eight electronic databases, eight electronic journals and Google Scholar. We also screened reference lists and consulted authors of included studies. Primary studies were extracted from eligible reviews. We based our data extraction and analysis on the Place of residence, Race, Occupation, Gender/Sex, Religion, Education, Socioeconomic status, Social capital and other disadvantage related characteristics (PROGRESS-Plus) framework and the use of harvest plots, focusing on the socio-demographic distribution of mHealth effects.

Results

A total of 8786 citations resulted in 19 eligible reviews and 39 eligible primary studies. Existing reviews did not provide any analyses of the equity impacts of mobile health-based HIV initiatives. Information availability was higher in primary studies, predominantly suggesting no social gradient of mobile health-based HIV interventions. Overall, evidence remains weak and not sufficient to allow for confident equity statements.

Conclusions

Despite the negative force of socio-demographic inequities and the emerging nature of mobile health technologies, evidence on the equity implications of mobile health interventions for HIV care remains scarce. Not knowing how the effects of mobile health technologies differ across population subgroups inevitably limits our capacities to equitably adopt, adjust and integrate mobile health interventions towards reaching those disproportionally affected by the epidemic.

"No good man will ever want me". How structural social inequality increases women's vulnerability to HIV transmission: a qualitative study from Bandung, Indonesia

Understanding the pathways that expose women to HIV transmission are vital in improving HIV prevention, especially among a "hidden" group of women without pre-established known risk for HIV. We investigated the pathways which place certain women at greater risk for HIV in a qualitative exploratory study with theoretical sampling using an emergent theory study design in an urban setting in Indonesia. We conducted semi-structured interviews with 47 HIV-infected women, one focus group discussion with five young women who occassionally engage in sex work, participant observation at six sex work venues and two midwife clinics, and 11 informal interviews with midwives, nurses, and obstetricians. Our research found that many women not characterized as belonging to a "high-risk group" or "key population" were nevertheless at increased risk for HIV. A history of sexual abuse, premarital sex, divorce, or involvement in sex work, often precipitated by poverty coupled with discriminatory public health policies further heightened women's exposure to HIV. While reaching at-risk populations is a key strategy in HIV prevention, a novel and more tailored approach is needed to reach more hidden categories of women with less apparent risk behavior yet considerable risk for HIV infection.