Predictors of medication adherence in high risk youth of color living with HIV

Effectiveness of an intervention to improve ART adherence among men who have sex with men living with HIV: a randomized controlled trial in three public HIV clinics in Mexico

We conducted a parallel-group randomized controlled trial in three HIV clinics in Mexico to evaluate a user-centred habit-formation intervention to improve ART adherence among MSM living with HIV. We randomized 74 participants to the intervention group and 77 to the control group. We measured adherence at one, four, and ten months through medication possession ratio and self-reported adherence. Additionally, we measured viral load, CD4 cell count, major depression disorder symptoms, and alcohol and substance use disorder at baseline, fourth and tenth months. We found no statistically significant effect on adherence between groups. However, the intervention demonstrated positive results in major depression disorder symptoms (21% vs. 6%, p = 0.008) and substance use disorder (11% vs. 1%, p = 0.018) in the fourth month. The latter is relevant because, in addition to its direct benefit, it might also improve the chances of maintaining adequate adherence in the long term. This trial was retrospectively registered at ClinicalTrials.gov (trial number NCT03410680) on 8 January 2018.Trial registration: ClinicalTrials.gov identifier: NCT03410680.

Factors Associated With Antiretroviral Adherence Among Youth Living With HIV

BACKGROUND

Youth living with HIV (YLH) have an increased risk for psychosocial stressors that can affect their antiretroviral (ARV) adherence. We examined factors associated with self-reported ARV adherence among YLH ages 12-24 years old.

SETTING

YLH (N = 147) were recruited in Los Angeles, CA, and New Orleans, LA from 2017 to 2020.

METHODS

YLH whose self-reported recent (30 days) ARV adherence was "excellent" or "very good" were compared with nonadherent YLH on sociodemographic, clinical, and psychosocial factors using univariate and multivariate analyses.

RESULTS

Participants were predominantly male (88%), and 81% identified as gay, bisexual, transgender, queer, or other. The mean duration on ARV was 27 months (range 0-237 months). Most YLH (71.2%) self-reported being adherent, and 79% of those who self-reported adherence were also virally suppressed (<200 copies/mL). Multivariate analysis indicated being adherent was significantly associated with white race [aOR = 8.07, confidence intervals (CI): 1.45 to 74.0], Hispanic/Latinx ethnicity [aOR = 3.57, CI: 1.16 to 12.80], more social support [aOR = 1.11, CI: 1.05 to 1.18], and being on ARV for a shorter duration [aOR = 0.99, CI: 0.97 to 0.99]. Mental health symptoms, substance use, age, and history of homelessness or incarceration were unrelated to adherence.

CONCLUSIONS

Enhancing efforts to provide support for adherence to non-white youth, and those with limited social support and who have been on ARV treatment longer, may help increase viral suppression among YLH.

HIV symptom severity and associated factors among young people with HIV in Ghana

ABSTRACTAdolescents and young adults (young people) with HIV (YPWH) often struggle with treatment self-management. Many have symptoms due to HIV disease, medication side-effects, or comorbid conditions. Our study investigated the severity of HIV-related symptoms among YPWH aged 18-24 with detectable viral loads from an HIV clinic in Ghana (N = 60) and potential correlates of severity across a range of factors. Results indicated that YPWH currently experienced, on average, 13 symptoms (SD = 12.33). Six of the 10 most common symptoms were from two domains: fatigue and psychological. The most common symptoms were headaches (62%), weakness (53%), and fear/worries (52%). No differences were observed in number or severity of symptoms between youth based on HIV transmission status. Bivariate correlates of symptom severity were found with six that remained significant or approached significance in a multivariate model predicting severity: living with a parent/guardian, higher perceived access to HIV care, and higher treatment readiness were associated with lower severity while greater travel time to the HIV clinic, psychological distress, and more missed clinic appointments were associated with higher severity. Our findings suggest that interventions to address symptoms among YPWH should be multilevel and include strategies (e.g., telehealth, home care) to increase access to care.

Predictors of adherence to controller medication in urban African American emerging adults with uncontrolled persistent asthma

BACKGROUND

African American emerging adults tend to have low adherence to asthma controller medication, as well as a disproportionate burden of asthma morbidity and mortality. This study explored constructs from the Information-Motivation-Behavioral Skills model as predictors of controller medication adherence in urban African Americans ages 18-29 (N=152) with uncontrolled asthma using multiple measures of self-reported adherence.

METHODS

Structural equation modeling (SEM) was employed to test the hypothesized mediation model that specified the relationship among psychological distress, substance use, asthma knowledge, motivation, self-efficacy, and adherence.

RESULTS

Results suggested that motivation is an important predictor of adherence to medication; moreover, higher self-efficacy was associated with higher motivation. Results also highlighted psychological distress as an important intervention target to improve medication adherence in emerging adults.

CONCLUSIONS

The model tested in this study may offer a feasible framework for beginning to understand adherence to controller medication in this population.

Development and validation of a novel scale for antiretroviral therapy readiness among pregnant women in urban Zambia with newly diagnosed HIV infection

BACKGROUND

Women who are newly diagnosed with HIV infection during pregnancy may not be ready to immediately initiate lifelong antiretroviral therapy (ART; called Option B +) as is recommended. Lack of "readiness" drives early disengagement from care and undermines prevention of HIV transmission to infants. Several studies have shown high early attrition of women initiating ART in pregnancy. Although poor ART uptake and adherence have been attributed to various factors including stigma, disclosure issues and structural issues, there is no standard way of determining which pregnant woman will face challenges and therefore need additional support. We developed and validated a novel ART readiness tool in Lusaka, Zambia.

METHODS

The aim of this study was to develop and validate a tool that could be used to assess how ready a newly diagnosed pregnant woman living with HIV would be to initiate ART on the day of diagnosis. Using a mixed method design, we conducted this study in three public-setting health facilities in Lusaka, Zambia. Informed by qualitative research and literature review, we identified 27 candidate items. We assessed content validity using expert and target population judgment approaches. We administered the 27-item questionnaire to 454 newly diagnosed pregnant women living with HIV, who were enrolled into a randomized trial (trials number NCT02459678). We performed item reduction analysis and used Cronbach's alpha coefficient of 0.70 as threshold for reliability.

RESULTS

A total of 454 pregnant women living with HIV enrolled in the study between March 2017 and December 2017; 452 had complete data for analysis. The correlation coefficient between the 27 items on the completed ART readiness scale ranged from 0.31 to 0.70 while item discrimination index ranged from -0.01 to 2.38. Sixteen items were selected for the final scale, representing three domains, which we classified as "internalized and anticipated HIV stigma", "partner support" and "anticipated structural barriers".

CONCLUSION

We developed and validated a tool that could be used to assess readiness of newly diagnosed women living with HIV to initiate ART. This ART readiness tool could allow clinics to tailor limited resources to pregnant women living with HIV needing additional support to initiate and remain on ART.

Feasibility, Acceptability and Preliminary Efficacy of Tikambisane ('Let's Talk to Each Other'): A Pilot Support Group Intervention for Adolescent Girls Living With HIV in Zambia

Background:

In Zambia, 84,959 adolescent girls and young women (AGYW) aged 15-24 are currently living with HIV. We explored the feasibility and acceptability of a 6-session, curriculum-based support group intervention designed to address key concerns of AGYW living with HIV.

Setting:

Urban Zambia

Methods:

Surveys and in-depth interviews were collected pre- and post-intervention from participants enrolled from 2 health facilities. Eight participant observations of sessions were conducted. Descriptive statistics at baseline were reported only for AGYW who participated in the intervention (N = 21), while analyses comparing baseline and endline outcome measures were restricted to participants who had data at both time points (N = 14).

Results:

Support groups were feasible to conduct and acceptable to participants. Co-facilitation by an adult counselor and peers living with HIV raised confidence about session content. Sessions on antiretroviral therapy (ART), disclosure and stigma, and grief and loss were most in demand. We did not observe significant differences in key outcome measures between baseline and follow-up. However, qualitative data supported the positive impact of the intervention on ART adherence and hope for the future following the intervention among our participants.

Conclusion:

A short-term, structured support group series holds promise for helping AGYW living with HIV safely navigate a complex time in their lives.

Factors associated with PrEP adherence among MSM living in Jackson, Mississippi

Understanding the determinants of pre-exposure prophylaxis (PrEP) adherence is integral to reducing HIV incidence in the United States, especially for those at highest risk. To this end, the present study explored demographic, psychosocial, and behavioral factors related to adherence among 43 Southern, predominately Black, men who have sex with men (MSM). During the study months, 46% of the sample reported being nonadherent to PrEP. Those with more sexual partners (p = .05), greater self-efficacy for taking PrEP (p = .03), and those who felt condoms were less important (p = .02), were more likely to be adherent to PrEP at six-month follow-up. Further interventions that consider perceived sexual risk, condom use, and adherence self-efficacy are needed to improve PrEP adherence among Southern MSM.

The Impact of a Mobile Gaming Intervention to Increase Adherence to Pre-exposure Prophylaxis

Pre-exposure prophylaxis is effective in preventing HIV, but data show that its effectiveness is compromised by suboptimal adherence. This randomized controlled trial (n = 69) tested the impact of an iPhone game, Viral Combat, on PrEP adherence over 24 weeks. Tenofovir-diphosphate in red blood cells was collected as a biological outcome of adherence. At 24-weeks, intervention participants were 3.75 (95% CI: 1.20-11.77; p = 0.02) times as likely to engage in optimal PrEP dosing compared to controls. Viral Combat showed preliminary efficacy in improving PrEP adherence for diverse young men who have sex with men.

ART Adherence Among Men Who Have Sex with Men Living with HIV: Key Challenges and Opportunities

PURPOSE OF REVIEW

In the USA, gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by HIV. High levels of adherence to antiretroviral therapy (ART) can dramatically improve outcomes for persons living with HIV and reduce the risk of HIV transmission to others. Yet, there are numerous individual, social, and structural barriers to optimal ART adherence. Many of these factors disproportionately impact Black MSM and may contribute to their poorer rates of ART adherence. This review synthesizes the key challenges and intervention opportunities to improve ART adherence among MSM in the USA.

RECENT FINDINGS

Key challenges to ART adherence include stigma, violence, depression, and substance use. Black MSM are significantly disadvantaged by several of these factors. There are several promising interventions to improve ART adherence among MSM, and there remains an opportunity to culturally tailor these to the needs of Black MSM populations to enhance adherence. Despite high rates of HIV among MSM, there continues to be a paucity of research on the various contributors to poor ART adherence among this population. Similarly, few interventions have been tested that lead to increased and sustained ART adherence among Black MSM.

Improving Diabetes Management in Emerging Adulthood: An Intervention Development Study Using the Multiphase Optimization Strategy

Background

Poor diabetes self-management in emerging adulthood (age 18-25 years) is associated with poorer diabetes health and diabetes complications. Emerging adults’ focus on individuation and independence underlies their poor diabetes outcomes, offering a lever for behavior change. Self-determination theory (SDT) suggests that interventions leveraging emerging adults’ innate developmental need for autonomy may offer a route to improving diabetes outcomes by increasing feelings of responsibility for and control over diabetes self-management activities.

Objective

This research project will use the multiphase optimization strategy to test the efficacy of three autonomy-supportive intervention components to elicit a clinically significant improvement in metabolic control, assessed by a 0.5% improvement in hemoglobin A_1c (HbA_1c), among older adolescents and emerging adults (16-25 years) with poorly controlled type 1 diabetes (T1D; HbA_1c≥9.0%).

Methods

A question prompt list (QPL) is a tool to empower patients to assume a more active role during medical visits by asking questions and stating concerns. The motivation enhancement system (MES) is a brief counseling intervention that uses motivational interviewing communication strategies to build intrinsic motivation and self-efficacy for self-management. Text message reminders to complete diabetes care tasks may increase self-efficacy for diabetes self-management. After refining these intervention components for emerging adults, we will conduct a component selection experiment using an eight-arm full factorial design: 2 (QPL yes or no)×2 (MES yes or no)×2 (Text yes or no). Participants will complete 3 study visits: baseline, treatment end at 2 months, and a follow-up at 6 months. The primary outcome is metabolic control, which will be measured via HbA_1c. Secondary outcomes include diabetes management and diabetes clinic attendance. SDT constructs of intrinsic motivation, self-efficacy, and the quality of the patient-provider relationship (ie, relatedness) are hypothesized mediators. Depression symptoms and emerging adults’ gender are hypothesized moderators. We will use the mixed-effects linear model for the analysis of variance of a factorial design to analyze continuous longitudinal experimental data; the generalized linear model will be used with categorical outcomes (eg, treatment attendance). The experiment was powered to detect the main effects of the intervention on the primary outcome.

Results

A total of 20 participants have enrolled and completed a qualitative interview after reviewing one or more intervention components. Analysis of interview data are underway, with a report of these results anticipated in the fall of 2020. The clinical trial will be launched in the fall 2020, with participants enrolled through May 2023 and data collection continuing through November 2023.

Conclusions

At the end of this experiment, we will have empirical evidence to support a large-scale, multisite effectiveness trial of an intervention package that has been optimized for older adolescents and emerging adults with poorly controlled T1D.

Trial Registration

ClinicalTrials.gov NCT04066959; https://clinicaltrials.gov/ct2/show/NCT04066959

International Registered Report Identifier (IRRID)

DERR1-10.2196/20191

A Multi-Site Study of Social Cognitive Factors Related to Adherence Among Youth Living With HIV in the New Era of Antiretroviral Medication

Objective

The goal of the current study was to determine how a set of social cognitive factors predict antiretroviral therapy (ART) medication adherence in youth living with HIV in an era of newer highly active ART medications using a conceptual model.

Methods

Behaviorally infected youth living with HIV ages 13-24 (N = 822) from 14 sites within the Adolescent Medicine Trials Unit (AMTU) were included in the study. Structural equation modeling was used to explore predictors of ART medication adherence.

Results

Results found that motivational readiness for ART was related to higher ART medication adherence, which was associated with lower viral load. Higher social support and higher self-efficacy had an indirect relationship with higher adherence through increased motivational readiness. Fewer psychological symptoms were associated with higher social support and higher self-efficacy. Lower substance use was directly associated with lower adherence.

Conclusions

The results provide insight into factors that may be related to adherence in youth living with HIV. Findings suggest focusing on motivational readiness to increase adherence. Improving the patients' ART self-efficacy and strengthening their social support networks during treatment can increase motivational readiness for ART treatment. Furthermore, programs maybe more effective with the inclusion of risk reduction components especially those related to substance use.

Predictors of viral suppression among youth living with HIV in the southern United States

Youth living with HIV (YLH) in the United States (U.S.) face significant problems with achieving viral suppression, especially in the South. To examine this issue, YLH with a detectable viral load (N = 61) were recruited from the southern U.S and assessed over 16 weeks for health and treatment factors. Participants were part of a smartphone-based intervention trial. Analyses focused on predictors of viral suppression controlling for intervention effects. Fifty-three percent achieved suppression. In univariate models, YLH who engaged in condomless sex four to 16 weeks into the study (odds ratio [OR] = 4.00; compared to those who did not) and self-reported ≥ 90% antiretroviral adherence in the first four weeks of the study (OR = 25.00; compared to youth with <90%) had a higher likelihood of suppression. Shifts in adherence-related social support (OR = 4.98) and appointments kept (OR = 2.72) were also associated with suppression. YLH endorsing illicit drug use had a lower likelihood of suppression (OR = 0.16; compared to those without use). Effects (except drug use) remained significant or approached significance in a multivariate model. Adherence promotion efforts should consider this population's adherence-related social support, drug use, and risk for sexually transmitted infections.

Psychological resilience among transfeminine adolescents and emerging adults living with HIV

OBJECTIVES

The current study sought to examine factors that promote psychological resilience related to engagement in the HIV continuum of care (CoC) among transfeminine adolescents and emerging adults (TF AEA) living with HIV in the U.S. using a qualitative approach.

DESIGN

The parent study from which these data came utilized a concurrent transformative mixed-methods research design grounded in Gender Affirmation and Gender Minority Stress Theory that focused on advancing our understanding of transgender youth's experiences with healthcare generally and their experiences across the HIV CoC.

METHODS

Semi-structured in-depth qualitative interviews with 66 TF AEA living with HIV were analysed using a two-stage interpretive phenomenological analytic approach that allowed for both inductive and deductive explorations of the data.

RESULTS

When discussing health-promoting psychological resilience factors, participants described both interpersonal resources (i.e. support or assistance via interactions with others) and intrapersonal assets (i.e. positive internal cognitive processes) that encouraged their engagement in the HIV CoC. The interpersonal resources described by participants included three main types of support: emotional support, gender support and instrumental-informational support. Three thematic categories describe the intrapersonal assets that participants discussed: health awareness and HIV acceptance; health motivation and health responsibility; and psychological well being and inner strength.

CONCLUSION

Despite experiences of HIV-related stigma and transphobia, TF AEA living with HIV demonstrate psychological resilience, as they navigate engagement in the HIV CoC. Results highlight possibilities for implementing public health interventions at individual, community and systems levels to bolster resilience among TF AEA living with HIV.

Beyond HIV prevention: a qualitative study of patient-reported outcomes of PrEP among MSM patients in two public STD clinics in Baltimore

Pre-exposure prophylaxis (PrEP) could have a substantial impact on the HIV epidemic within the US. However, the implementation of PrEP interventions outside of clinical trials has been slow and faces considerable barriers. The aim of the current study was to qualitatively explore PrEP-related patient-reported outcomes (PRO) among MSM patients who enrolled in a PrEP program at two public STD clinics in Baltimore. We conducted in-depth interviews with 18 PrEP patients who self-identified as MSM at two Baltimore City Health Department STD clinics between March and November, 2017. A codebook was developed using an iterative process. During analysis, the study team identified various biomedical and psychosocial PrEP-related PRO among MSM PrEP patients. In addition to HIV prevention, PrEP-related PRO included greater peace of mind, better continuity in care and awareness about health and well-being, relationship solidarity with serodiscordant partners, and access to social services. These findings on PrEP-related PRO can potentially contribute to improving patient-provider communication, leading to increased engagement in care and uptake of PrEP by MSM.

eHealth to Enhance Treatment Adherence Among Youth Living with HIV

PURPOSE OF REVIEW

Multiple reviews have examined eHealth/mHealth interventions to address treatment adherence, including those focusing on youth living with HIV (YLWH). This review synthesizes results of prior reviews and recent studies (last 5 years) to provide a path forward for future research, acknowledging both lessons learned and gaps to be addressed.

RECENT FINDINGS

Recent studies provide further evidence for the feasibility and acceptability of technology-based HIV interventions. Formative research of more comprehensive smartphone applications and pilot studies of computer-delivered interventions provide additional guidance on YLWH's preferences for intervention components and show promising preliminary efficacy for impacting treatment adherence. Expanding access to technology among YLWH, in the United States (US) and globally, supports the continued focus on eHealth/mHealth interventions as a means to reduce disparities in clinical outcomes. Future research should lend greater focus to implementation and scale-up of interventions through the use of adaptive treatment strategies that include costing analyses, measuring and maximizing engagement, fostering information sharing between researchers, and building upon sustainable platforms.

Improving the Youth HIV Prevention and Care Continuums: The Adolescent Medicine Trials Network for HIV/AIDS Interventions

BACKGROUND

Epidemiologic and clinical information in the United States indicate that HIV transmission and acquisition among adolescents and young adults (youth) remain unchanged, without improvement. Interventions to prevent HIV transmission among youth are critically needed, as are interventions to improve adherence to all components of the continuum of care for youth living with HIV.

OBJECTIVE

The primary mission of the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) is to conduct both independent and collaborative research that explores promising behavioral, microbicidal, prophylactic, therapeutic, and vaccine modalities in HIV-infected and at-risk youth aged between 12 and 24.

METHODS

Through the ATN, the National Institutes of Health is supporting HIV interventional research for youth in the United States.

RESULTS

The ATN comprises 3 cooperative multiproject research programs and a coordinating center. Each program is led by a network hub and has well-defined research themes to assist, guide, and coordinate HIV research project activities.

CONCLUSIONS

ATN activities encompass the full spectrum of research needs for youth, from HIV primary prevention for at-risk youth in the community to secondary and tertiary prevention with clinical management of HIV infection among youth living with HIV experiencing adherence challenges.

Promoting resilience through neurocognitive functioning in youth living with HIV

Using a phased model of intervention development, we developed an intervention to promote resilience in youth living with HIV via improved neurocognitive resources. First, youth completed a naturalistic prospective memory (PM) task and were randomized into a visualization condition or control condition. Next, 47 of these participants completed another naturalistic PM task and were randomized into Calendaring condition, an Alarm condition, a Combined condition, or a Control condition. Youth with low PM demonstrated observable gains from the visualization technique. Youth in the Combined Calendaring and Alarm condition demonstrated significantly better performance than participants in the Control and Calendaring conditions. In a Proof-of-Concept study with 16 youth, the previous findings were translated into a single session in-person intervention followed by tailored text messaging to improve adherence and viral load via improved neurocognitive resources. The resulting intervention showed a signal of effect with viral load reductions in youth with available data. Targeting compensatory strategies to enhance neurocognitive functioning may promote resilience and health outcomes. A randomized pilot study with a control condition is the next step.

Adolescent Trials Network for HIV-AIDS Scale It Up Program: Protocol for a Rational and Overview

BACKGROUND

The past 30 years have witnessed such significant progress in the prevention and treatment of HIV/AIDS that an AIDS-free generation and the end to the global AIDS epidemic are ambitious, but achievable, national and global goals. Despite growing optimism, globally, youth living with HIV are markedly less likely to receive antiretroviral therapy than adults (23% vs 38%). Furthermore, marked health disparities exist regarding HIV infection risk, with young men of color who have sex with men disproportionately affected. A large body of research has identified highly impactful facilitators of and barriers to behavior change. Several efficacious interventions have been created that decrease the rate of new HIV infections among youth and reduce morbidity among youth living with HIV. However, full benefits that should be possible based on the tools and interventions currently available are yet to be realized in youth, in large part, because efficacious interventions have not been implemented in real-world settings. Scale It Up (SIU) primarily aims to assemble research teams that will ultimately bring to practice evidence-based interventions that positively impact the youth HIV prevention and care cascades, and in turn, advance the fields of implementation science and self-management science.

OBJECTIVE

This paper aims to describe the structure of the U19-SIU and the effectiveness-implementation hybrid trials, as well as other center-wide protocols and initiatives, implemented within SIU.

METHODS

SIU will achieve its aims through 4 individual primary protocols, 2 center-wide protocols, and 3 cross-project initiatives.

RESULTS

SIU was funded by National Institute for Child Health and Human Development (U19HD089875) and began in October 2016. As of November 2018, 6 SIU protocols have launched at least the first phase of work (ATN 144 SMART: Sequential Multiple Assignment Randomized Trial; ATN 145 YMHP: Young Men's Health Project; ATN 146 TMI: Tailored Motivational Interviewing Intervention; ATN 153 EPIS: Exploration, Preparation, Implementation, Sustainment model; ATN 154 CM: Cascade Monitoring; ATN 156 We Test: Couples' Communication and HIV Testing). Further details can be found in the individual protocol papers.

CONCLUSIONS

To date, the youth HIV research portfolio has not adequately advanced the important care area of self-management. SIU protocols and initiatives address this broad issue by focusing on evaluating the effectiveness and implementation of self-management interventions. SIU is highly innovative for 5 primary reasons: (1) our research framework expands the application of "self-management"; (2) the 4 primary protocols utilize innovative hybrid designs; (3) our Analytic Core will conduct cost-effectiveness analyses of each intervention; (4) across all 4 primary protocols, our Implementation Science Core will apply implementation scales designed to assess inner and outer context factors; and (5) we shall advance understanding of the dynamics between provider and patient through analysis of recorded interactions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/11204.

Adaptive Antiretroviral Therapy Adherence Interventions for Youth Living With HIV Through Text Message and Cell Phone Support With and Without Incentives: Protocol for a Sequential Multiple Assignment Randomized Trial (SMART)

BACKGROUND

Youth living with HIV (YLH) aged 13 to 24 years made up over a fifth (21%) of new HIV diagnoses in 2016, yet only 27% of YLH are virally suppressed. YLH have been shown to be poorly adherent to antiretroviral therapy (ART); however, there has been limited research investigating how to increase adherence in YLH. Mobile health (mHealth) interventions may be one promising way to do this.

OBJECTIVE

This study (ATN [Adolescent Trials Network] 144 SMART) aimed to compare adaptive interventions that could increase ART adherence in YLH aged 15 to 24 years. This includes mHealth initiatives, the tapering of interventions, and the use of incentives. Cost-effectiveness of sequencing the interventions without incentives before providing incentives and the savings on societal costs due to suppressed viral loads will be determined. This protocol is part of the ATN Scale It Up program described in this issue by Naar et al.

METHODS

This study uses a Sequential Multiple Assignment Randomized Trial design. Approximately 190 participants are being recruited, enrolled, and randomized to either cell phone support or text message support. Both intervention groups receive 3 months of intervention, followed by a second randomization based on response to the intervention. Responders test tapering their intervention, and nonresponders test receiving incentives.

RESULTS

Data collection for this study is projected to begin in August 2018 and last until June 2020.

CONCLUSIONS

This is an innovative study, particularly in terms of population, intervention types, focus on cost-effectiveness, and recruitment. This study could be particularly effective in improving adherence in YLH while reducing long-term individual and societal costs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03535337; https://clinicaltrials.gov/ct2/show/NCT03535337 (Archived by WebCite at http://www.webcitation.org/74alXb92z).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/11183.

Critical Consciousness-Based HIV Prevention Interventions for Black Gay and Bisexual Male Youth

Black gay/bisexual male youth are one of the groups most affected by HIV in the U.S., but few behavioral interventions have been created specifically to address this health inequity. Oppression related to these youths' multiple social identities - including racism, heterosexism, and HIV stigma - contribute to increased health risks. Primary and secondary HIV prevention interventions created specifically for Black gay/bisexual male youth that address the negative impact of oppression are urgently needed. We present empowerment as a framework for understanding how oppression affects health, and critical consciousness as a tool to be utilized in behavioral interventions. This approach helps to move Black gay/bisexual male youth from a place of oppression and powerlessness that leads to elevated health risks to a position of empowerment that promotes feelings of control and participation in healthy behaviors. Finally, we present a case example of our own critical consciousness-based secondary HIV prevention intervention created specifically for Black gay/bisexual male youth.

A Gamified Smartphone App to Support Engagement in Care and Medication Adherence for HIV-Positive Young Men Who Have Sex With Men (AllyQuest): Development and Pilot Study

BACKGROUND

HIV disproportionately impacts young men who have sex with men (YMSM) who experience disparities across the HIV care continuum. Addressing antiretroviral therapy (ART) adherence among YMSM is an urgent public health priority. Technology-based interventions-particularly mobile health platforms-can provide tailored adherence interventions and allow YMSM to engage and connect with others.

OBJECTIVE

The objective of this study was to describe the development of AllyQuest, a novel, theoretically-based, smartphone app designed to improve engagement in care and ART adherence and social support among HIV-positive YMSM.

METHODS

AllyQuest was built on an established platform for patient engagement that embeds social networking and fundamental game mechanics, such as challenges, points, and rewards. A medication tracker provides reminders to promote ART adherence via personalized adherence strategies that are user and context specific; a calendar allows for reflection on adherence over time. After iterative development with input from two youth advisory boards, usability testing was conducted to assess app functionality, comprehension of the educational content, use of intervention features, and overall impressions of app relevance and appeal. A 28-day pilot trial was conducted with 20 HIV+ YMSM to evaluate intervention feasibility and acceptability.

RESULTS

Mean age of participants was 21.8 years (range 19-24), and 95% (19/20) of the participants were nonwhite. The mean time of app use was 158.4 min (SD 114.1), with a range of 13 to 441 min. There was a mean of 21.2 days of use (out of a total possible 28 days). There were 222 posts to the daily discussion social wall. Feasibility and acceptability ratings were high. Overall, participants found the app easy to use and navigate, not intrusive, and had few reported technical issues. Higher levels of app usage were positively correlated with HIV self-management outcomes, and there was a statistically significant (P<.05) positive association between the number of days logged into the app and knowledge and confidence in ability to reliably take HIV medications.

CONCLUSIONS

AllyQuest represents a new, highly scalable solution that is well-suited to meet the specific prevention and care needs of HIV+ YMSM. The development of this intervention is both timely and vital, given the urgency of the ongoing HIV epidemic among YMSM.

Correlates of missed clinic visits among youth living with HIV

Youth living with HIV (YLH) have significant problems with attending their medical appointments. Poor attendance, consequently, predicts viral non-suppression and other negative health outcomes. To identity targets of intervention, this cross-sectional study examined correlates of past-year missed clinic visits among YLH (N = 2125) attending HIV clinics in the United States and Puerto Rico. Thirty-six percent of YLH missed two or more visits in the past year. Several factors were associated with missed visits in our regression model. Among sociodemographic characteristics and HIV disclosure status, females (adjusted odds ratio [OR] = 1.63, compared to males), Black YLH or YLH of mixed racial heritage (AORs = 1.76, 1.71, respectively, compared to White YLH), YLH with an unknown route of infection (AOR = 1.86, compared to YLH with perinatal infection), and YLH endorsing HIV disclosure (AOR = 1.37, compared to YLH not endorsing disclosure) were at greater risk for missed visits. Among behavioral health risks, YLH who endorsed marijuana use (AOR = 1.42), frequent other drug use (AOR = 1.60), or a history of incarceration (AOR = 1.27) had greater odds of missed visits than youth not endorsing these risks. Finally, two social-cognitive resources emerged as protective factors: adherence self-efficacy (AOR = .28) and social support (AOR = .88). We discuss how providers working with YLH can improve this population's retention outcomes.

Uptake of HIV Pre-Exposure Prophylaxis (PrEP) in a National Cohort of Gay and Bisexual Men in the United States

OBJECTIVES

The HIV care cascade provides milestones to track the progress of HIV-positive people from seroconversion through viral suppression. We propose a Motivational pre-exposure prophylaxis (PrEP) Cascade involving 5 stages based on the Transtheoretical Model of Change.

METHODS

We analyzed data from 995 men in One Thousand Strong, a longitudinal study of a national panel of HIV-negative gay and bisexual men in the United States.

RESULTS

Nearly all (89%) participants were sexually active in the past 3 months and 65% met Centers for Disease Control criteria for PrEP candidacy. Of those identified as appropriate candidates, 53% were Precontemplative (stage 1; unwilling to take or believing they were inappropriate candidates for PrEP) and 23% were in Contemplation (stage 2; willing and self-identified as appropriate candidates). Only 11% were in PrEParation (stage 3; seeing PrEP as accessible and planning to initiate PrEP) and 4% were in PrEP Action (stage 4; prescribed PrEP). Although few of those who were identified as appropriate candidates were on PrEP, nearly all PrEP users (98%) reported adhering to 4 or more doses per week and most (72%) were returning for recommended quarterly medical visits, resulting in 9% of PrEP candidates reaching Maintenance and Adherence (stage 5).

CONCLUSIONS

The large majority of participants were appropriate candidates for PrEP, yet fewer than 1 in 10 were using and adherent to PrEP. These findings highlight the need for interventions tailored to address the unique barriers men face at each stage of the cascade, particularly at the earliest stages where the most dramatic losses were identified.

Using Syndemics Theory to Investigate Risk and Protective Factors Associated with Condomless Sex Among Youth Living with HIV in 17 U.S. Cities

Identifying risk and protective factors associated with condomless sex among youth living with HIV is imperative for developing effective HIV prevention strategies. A cross-sectional sample of 1728 participants, 12-26 years of age, recruited from adolescent medicine clinics in 17 U.S. cities completed an audio-computer assisted self-interview with questions about their substance use, psychosocial factors, and attitudinal and behavioral factors. Guided by syndemics theory, a path analysis was used to assess the interrelations of these factors. Analyses of model fit statistics indicated statistically significant direct pathways between substance use, psychosocial factors, self-efficacy for risk-reduction, alternative risk-reduction attitudes and behaviors and condomless sex. The total indirect effect of self-efficacy for risk-reduction on condomless sex through alternative risk-reduction attitudes and behaviors was also significant. Multi-faceted, tailored interventions that address individual risk and protective factors and their combined synergistic effects are urgently needed to prevent condomless sex among this population.

Brief Computer-Delivered Intervention to Increase Parental Monitoring in Families of African American Adolescents with Type 1 Diabetes: A Randomized Controlled Trial

BACKGROUND

African American adolescents with type 1 diabetes (T1D) are at elevated risk for poor diabetes management and metabolic control. Parental supervision and monitoring of adolescent diabetes management have been shown to promote better diabetes management among adolescents, but parents typically decrease their oversight during the transition to independent diabetes care.

INTRODUCTION

The purpose of the study was to conduct a randomized clinical trial to test the feasibility and efficacy of a three-session, computer-delivered motivational intervention (The 3Ms) to promote increased parental monitoring among primary caregivers of young African American adolescents with T1D. The intervention was brief and optimized for delivery during routine diabetes clinic visits.

MATERIALS AND METHODS

Sixty-seven adolescents with T1D aged 11-14 and their primary caregiver were randomly assigned to one of three arms: adolescent and parent motivational intervention (Arm 1), adolescent control and parent motivational intervention (Arm 2), or adolescent and parent control (Arm 3). Intervention effects were assessed 1 month after intervention completion.

RESULTS

Parents in Arm 1 and Arm 2 had significant increases in knowledge of the importance of monitoring adolescents' diabetes care. Parents in Arm 2 also had trend to significant increases in direct observation and monitoring of adolescent diabetes care, and adolescents in Arm 2 had significant improvements in glycemic control.

DISCUSSION AND CONCLUSIONS

Findings from the present study provide preliminary support for the efficacy of a brief, computer-delivered parenting intervention for improving family management practices and adolescent health outcomes among African American adolescents with T1D and their caregivers.

Multiple Dimensions of Stigma and Health Related Factors Among Young Black Men Who Have Sex with Men

This study is among the first to examine the association between multiple domains of HIV-related stigma and health-related correlates including viral load and medication adherence among young Black men who have sex with men (N = 92). Individual logistic regressions were done to examine the hypothesized relationships between HIV-related stigma and various health and psychosocial outcomes. In addition to examining total stigma, we also examined four domains of HIV stigma. Findings revealed the various domains of stigma had differential effects on health-related outcomes. Individuals who reported higher levels of total stigma and personalized stigma were less likely to be virally suppressed (OR 0.96, 95 % CI 0.91-1.00 and OR 0.50, 95 % CI 0.25-1.02, respectively). Concerns about public attitudes toward HIV were positively related to medication adherence (OR 2.18, 95 % CI 1.20-3.94) and psychological distress (OR 5.02, 95 % CI 1.54-16.34). The various domains of HIV stigma differentially affected health and psychosocial outcomes, and our findings suggest that some forms of HIV stigma may significantly affect viral load and medication adherence among this population. Stigma-informed approaches to care and treatment are needed, along with incorporated psychological and social supports.

Medication Adherence in 13- to 24-Year-Old Youth Living With HIV

Despite advances in HIV medicine, adherence presents as a barrier to effective treatment for youth. We designed this study to assess medication knowledge, adherence, and factors affecting adherence in youth with HIV. Participants were 72 youth ages 13 to 24 years with perinatally or behaviorally acquired HIV. Demographic data were collected and a self-report adherence interview was administered. Interviews were audio-recorded to allow for qualitative data analysis. Self-reported adherence varied depending on the framing of questions, with participants reporting greater adherence when asked how many doses they had missed within the past 7 days compared to results from a 7-day recall interview. At least 74% of the sample said they sometimes forgot to take their medication. A taxonomic approach to the qualitative analysis revealed internal and external facilitators and barriers to adherence. Findings suggest a need for education and provider support to include strategies to improve adherence.

The Experience of Antiretroviral Treatment for Black West African Women who are HIV Positive and Living in London: An Interpretative Phenomenological Analysis

Antiretroviral therapy (ART) offers a powerful intervention in HIV but effectiveness can be compromised by inadequate adherence. This paper is a detailed examination of the experience of medication in a purposively selected group of people living with HIV. In-depth interviews were conducted with 10 HIV positive, West African women of black heritage living in London, UK. This group was of interest since it is the second largest group affected by HIV in the UK. Interviews were subjected to interpretative phenomenological analysis, an idiographic, experiential, qualitative approach. The paper details the women's negative experience of treatment. ART can be considered difficult and unrelenting and may be disconnected from the women's sense of health or illness. Participants' social context often exacerbated the difficulties. Some reported an improvement in their feelings about the medication over time. These findings point to some intrinsic and social motivators which could act as spurs to adherence.

Predictors and Profiles of Antiretroviral Therapy Adherence Among African American Adolescents and Young Adult Males Living with HIV

Adherence to antiretroviral therapy (ART) is crucial for thwarting HIV disease progression and reducing secondary HIV transmission, yet youth living with HIV (YLH) struggle with adherence. The highest rates of new HIV infections in the United States occur in young African American men. A sample of 387 HIV-positive young African American males on ART was selected from a cross-sectional assessment of (YLH) receiving medical care within the Adolescent Trials Network for HIV/AIDS Interventions (ATN) from 2010 to 2012 (12-24 years old, median 22.00, SD 2.08). Participants completed self-reported adherence, demographic, health, and psychosocial measures. Sixty-two percent self-reported 100% ART adherence. Optimal data analysis identified frequency of cannabis use during the past 3 months as the strongest independent predictor of adherence, yielding moderate effect strength sensitivity (ESS) = 27.1, p < 0.001. Among participants with infrequent cannabis use, 72% reported full adherence; in contrast, only 45% of participants who used cannabis frequently reported full adherence. Classification tree analysis (CTA) was utilized to improve classification accuracy and to identify the pathways of ART adherence and nonadherence. The CTA model evidenced a 38% improvement above chance for correctly classifying participants as ART adherent or nonadherent. Participants most likely to be adherent were those with low psychological distress and minimal alcohol use (82% were adherent). Participants least likely to be adherent were those with higher psychological distress and engaged in weekly cannabis use (69% were nonadherent). Findings suggest multiple profiles of ART adherence for young African American males living with HIV and argue for targeted psychosocial interventions.

Enhancing HIV Prevention Among Young Men Who Have Sex With Men: A Systematic Review of HIV Behavioral Interventions for Young Gay and Bisexual Men

Men who have sex with men (MSM) represent 64.0% of people living with HIV (PLWH) over the age of 13 years. Young men who have sex with men (YMSM) are particularly affected by HIV/AIDS; the rate of HIV infection for YMSM between the ages of 13 and 24 represents 72.0% of new infections among youth. To understand the current state of the science meant to prevent HIV for YMSM, we reviewed studies of HIV behavioral prevention interventions for YMSM. Five literature databases were searched, from their inception through October 2015, using key words associated with HIV prevention intervention evaluation studies for YMSM. The review criteria included behavioral HIV/AIDS prevention interventions, articles published in English-language peer-reviewed journals, YMSM between 13 and 24 years of age, and longitudinal repeated measures design. A total of 15 YMSM behavioral HIV prevention intervention studies were identified that met inclusion criteria and reported statistically significant findings. Common outcomes included unprotected sexual intercourse, HIV/AIDS risk behavior, condom use, HIV testing, safer sex attitude, and HIV prevention communication. Participant age, representation of Black/African American YMSM, application of theoretical and model underpinnings, congruence of assessment measures used, follow-up assessment times, and application of process evaluation were inconsistent across studies. To advance HIV prevention intervention research for YMSM, future studies should be theory-based, identify common constructs, utilize standard measures, include process evaluation, and evaluate sustained change over standard periods of time. HIV prevention interventions should incorporate the needs of the diverse, well-educated, web-connected millennial generation and differentiate between adolescent YMSM (13 to 18 years of age) and young adulthood YMSM (19 to 24 years of age). Because Black/African American YMSM represent more than 50% of new HIV infections, future HIV prevention intervention studies should prioritize these young men.

A Randomized Controlled Trial of Personalized Text Message Reminders to Promote Medication Adherence Among HIV-Positive Adolescents and Young Adults

HIV-positive adolescents and young adults often experience suboptimal medication adherence, yet few interventions to improve adherence in this group have shown evidence of efficacy. We conducted a randomized trial of a two-way, personalized daily text messaging intervention to improve adherence to antiretroviral therapy (ART) among N = 105 poorly adherent HIV-positive adolescents and young adults, ages 16-29. Adherence to ART was assessed via self-reported visual analogue scale (VAS; 0-100 %) at 3 and 6-months for mean adherence level and proportion ≥90 % adherent. The average effect estimate over the 6-month intervention period was significant for ≥90 % adherence (OR = 2.12, 95 % CI 1.01-4.45, p < .05) and maintained at 12-months (6 months post-intervention). Satisfaction scores for the intervention were very high. These results suggest both feasibility and initial efficacy of this approach. Given study limitations, additional testing of this intervention as part of a larger clinical trial with objective and/or clinical outcome measures of adherence is warranted.

Predictors of Self-Reported Adherence to Antiretroviral Medication in a Multisite Study of Ethnic and Racial Minority HIV-Positive Youth

OBJECTIVE

To test social cognitive predictors of medication adherence in racial/ethnic minority youth living with HIV using a conceptual model.

METHODS

Youth were participants in two descriptive studies by the Adolescent Trials Network for HIV/AIDS Interventions. Minority youth ages 16-24 years who were prescribed antiretroviral medication were included (N = 956). Data were collected through chart extraction and/or laboratory testing and by Audio Computer-Assisted Self-Interview.

RESULTS

39% of youth reported suboptimal adherence. Path analysis was used to explore predictors of medication adherence. Higher self-efficacy predicted higher readiness and adherence. Greater social support predicted higher self-efficacy. Psychological symptoms and substance use were associated with several predictors and lower adherence.

CONCLUSIONS

The model provided a plausible framework for understanding adherence in this population. Culturally competent, but individually tailored, interventions focused on increasing self-efficacy to take medication and reducing risk behaviors (e.g., substance use) may be helpful for racial or ethnic minority youth with HIV.

Juvenile Justice, Mental Health, and the Transition to Adulthood: A Review of Service System Involvement and Unmet Needs in the U.S

Although adolescents are the primary focus of juvenile justice, a significant number of young people involved with this system are considered transition age youth (i.e., 16-25 years of age). The aim of this review is to summarize the specific needs of transition age youth with mental health conditions involved with the juvenile justice system, identify the multiple service systems relevant to this group, and offer recommendations for policies and practice. A comprehensive search strategy was used to identify and synthesize the literature. Findings highlight the paucity of research specific to transition age youth. Thus, we also summarized relevant research on justice-involved adolescents, with a focus evaluating its potential relevance in the context of the unique milestones of the transition age, including finishing one's education, setting and working towards vocational goals, and transitioning from ones' family of origin to more independent living situations. Existing programs and initiatives relevant to transition age youth with mental health conditions are highlighted, and nine specific recommendations for policy and practice are offered.

Social Support and Human Immunodeficiency Virus-Status Disclosure to Friends and Family: Implications for Human Immunodeficiency Virus-Positive Youth

PURPOSE

The fear of negative reactions from friends and family members affects many human immunodeficiency virus (HIV)-positive adolescents' decisions regarding disclosure of their HIV status. The complex relationships and interplay among social support, fear of stigma, and disclosure of HIV status need to be better understood among youth living with HIV (YLHIV).

METHODS

Social support from friends and family members and HIV status disclosure were examined among 402 youth, aged 12-24 years, living with HIV.

RESULTS

In separate analyses, (1) HIV-positive youth who reported more than one close friend and (2) HIV-positive youth who reported that friends and family members continued to socialize with them after disclosure of their HIV diagnosis, had higher levels of perceived social support overall (both p < .05). Furthermore, perceived social support did not differ significantly between those participants for whom no family member knew their HIV status and those for whom at least one family member knew their status (p = .13). Race/ethnicity, sexual orientation, education level, and current living situation were not associated with family's knowledge of the participants' HIV infection status (p > .07).

CONCLUSION

This investigation adds important information concerning YLHIV, whose early disclosure experiences may influence their resilience and future coping mechanisms regarding experienced stigma, and thus influence the length of time they conceal their HIV status, their decision to disclose their status, and potentially their decisions regarding treatment. Interventions and support systems to assist YLHIV with disclosure, as well as medical care, may improve their overall quality of life.

Acceptability and Feasibility of a Cell Phone Support Intervention for Youth Living with HIV with Nonadherence to Antiretroviral Therapy

A pilot randomized clinical trial of youth ages 15-24 nonadherent to antiretroviral therapy (ART) utilizing daily cell phone support was found to have significant improvement in self-reported adherence and HIV RNA. Understanding acceptability and feasibility is critical for future implementation in clinic settings. Exit interviews were obtained from participants and adherence facilitators (AF). Acceptability was assessed from content analysis of exit interviews. Feasibility was assessed via intervention retention and study retention rates. Thirty-seven eligible youth were enrolled with 19 assigned to the intervention. Seven (37%) discontinued the intervention either due to missing over 20% of calls for two consecutive months (N=5) or missing 10 consecutive calls (N=2). Sixteen participants completed exit interviews, 15 reported the call length was just right, 13 reported they would have liked to continue calls after the 24-week intervention, and all participants reported they would recommend the intervention to friends. Scheduling and making calls required less than 1 h per week per participant. Providing cell phone support to youth nonadherent to ART was acceptable and feasible. While the cost is low compared to the price of ART, healthcare systems will need to explore how to cover the cost of providing cell phones (incentive).

Acceptability of PrEP Uptake Among Racially/Ethnically Diverse Young Men Who Have Sex With Men: The P18 Study

Pre-exposure prophylaxis (PrEP) is considered an effective biomedical approach for HIV prevention. However, there is limited understanding of PrEP uptake among racially/ethnically and socioeconomically diverse young men who have sex with men (YMSM). This study examined attitudes and perceptions toward PrEP uptake among YMSM by conducting semistructured interviews with a sample (N = 100) of YMSM in New York City. Thematic analysis was employed to explore key issues related to attitudes and perceptions toward PrEP utilization. Findings suggest that self-perceived risk for HIV transmission, enjoying unprotected sex, and being in a romantic relationship were associated with PrEP uptake. The most prominent barriers to PrEP uptake included costs, adherence regimen, and access. In summary, these findings underscore the importance of addressing behavioral and structural factors in maximizing the effectiveness of PrEP. In addition, PrEP implementation programs ought to consider the role of social and structural challenges to PrEP uptake and adherence among YMSM.

Motivational interviewing targeting risky sex in HIV-positive young Thai men who have sex with men

Motivational interviewing (MI) has been shown to reduce sexual risks among HIV-positive men who have sex with men (HMSM) in the US. We conducted a randomized trial of Healthy Choices, a 4-session MI intervention, targeting sexual risks among 110 HIV-positive youth ages 16-25 years in Thailand. Risk assessments were conducted at baseline, 1 month, and 6 months post-intervention. This report presents the analysis of 74 HMSM in the study. There were 37 HMSM in the Intervention group and 37 in the control group. The proportions of participants having anal sex and having sex with either HIV-uninfected or unknown partners in past 30 days were significantly lower in Intervention group than in Control group at 6 months post-intervention (38 vs. 65 %, p = .04; and 27 vs. 62 %, p < .01, respectively). There were no significant differences in general mental health scores and HIV stigma scores between the two groups at any study visit. Thirty-five (95 %) HMSM in the Intervention group vs. 31 (84 %) in control group attended ≥ 3 sessions. Loss to follow-up was 8 and 30 %, respectively (p = .04). Healthy Choices for young Thai HMSM was associated with sexual risk reduction. Improvements in mental health were noted in Intervention group. Healthy Choices is a promising behavioral intervention and should be further developed to serve the needs of young HMSM in resource-limited countries.

High levels of heterogeneity in the HIV cascade of care across different population subgroups in British Columbia, Canada

Background

The HIV cascade of care (cascade) is a comprehensive tool which identifies attrition along the HIV care continuum. We executed analyses to explicate heterogeneity in the cascade across key strata, as well as identify predictors of attrition across stages of the cascade.

Methods

Using linked individual-level data for the population of HIV-positive individuals in BC, we considered the 2011 calendar year, including individuals diagnosed at least 6 months prior, and excluding individuals that died or were lost to follow-up before January 1^st, 2011. We defined five stages in the cascade framework: HIV ‘diagnosed’, ‘linked’ to care, ‘retained’ in care, ‘on HAART’ and virologically ‘suppressed’. We stratified the cascade by sex, age, risk category, and regional health authority. Finally, multiple logistic regression models were built to predict attrition across each stage of the cascade, adjusting for stratification variables.

Results

We identified 7621 HIV diagnosed individuals during the study period; 80% were male and 5% were <30, 17% 30–39, 37% 40–49 and 40% were ≥50 years. Of these, 32% were MSM, 28% IDU, 8% MSM/IDU, 12% heterosexual, and 20% other. Overall, 85% of individuals ‘on HAART’ were ‘suppressed’; however, this proportion ranged from 60%–93% in our various stratifications. Most individuals, in all subgroups, were lost between the stages: ‘linked’ to ‘retained’ and ‘on HAART’ to ‘suppressed’. Subgroups with the highest attrition between these stages included females and individuals <30 years (regardless of transmission risk group). IDUs experienced the greatest attrition of all subgroups. Logistic regression results found extensive statistically significant heterogeneity in attrition across the cascade between subgroups and regional health authorities.

Conclusions

We found that extensive heterogeneity in attrition existed across subgroups and regional health authorities along the HIV cascade of care in B.C., Canada. Our results provide critical information to optimize engagement in care and health service delivery.

African American Emerging Adults’ Perspectives on Taking Asthma Controller Medication

This study included African Americans with asthma in emerging adulthood, a developmental period largely neglected in the research literature but known to be a time of great risk asthma morbidity and mortality. We conducted thematic analysis of semi-structured interviews ( N = 19) to explore barriers to adherence in the context of the transition into adulthood. Key themes for non-adherence emerged after careful follow-up prompting by the interviewer: forgetting to take medications, deciding not to take medications as prescribed, and systemic barriers. Clinicians and researchers interested in improving adherence should carefully assess barriers to adherence when working with this population. Effective adherence interventions should target both intentional and unintentional reasons for non-adherence behavior and take into account the unique developmental needs of emerging adults.

"It is all about the fear of being discriminated [against]…the person suffering from HIV will not be accepted": a qualitative study exploring the reasons for loss to follow-up among HIV-positive youth in Kisumu, Kenya

BACKGROUND

Youth represent 40% of all new HIV infections in the world, 80% of which live in sub-Saharan Africa. Youth living with HIV (YLWH) are more likely to become lost to follow-up (LTFU) from care compared to all other age groups. This study explored the reasons for LTFU among YLWH in Kenya.

METHODS

Data was collected from: (1) Focus group Discussions (n = 18) with community health workers who work with LTFU youth. (2) Semi-structured interviews (n = 27) with HIV + youth (15-21 years old) that had not received HIV care for at least four months. (3) Semi-structured interviews (n = 10) with educators selected from schools attended by LTFU interview participants. Transcripts were coded and analyzed employing grounded theory.

RESULTS

HIV-related stigma was the overarching factor that led to LTFU among HIV + youth. Stigma operated on multiple levels to influence LTFU, including in the home/family, at school, and at the clinic. In all three settings, participants' fear of stigma due to disclosure of their HIV status contributed to LTFU. Likewise, in the three settings, the dependent relationships between youth and the key adult figures in their lives were also adversely impacted by stigma and resultant lack of disclosure. Thus, at all three settings stigma influenced fear of disclosure, which in turn impacted negatively on dependent relationships with adults on whom they rely (i.e. parents, teachers and clinicians) leading to LTFU.

CONCLUSIONS

Interventions focusing on reduction of stigma, increasing safe disclosure of HIV status, and improved dependent relationships may improve retention in care of YLWH.

I Am Men's Health: Generating Adherence to HIV Pre-Exposure Prophylaxis (PrEP) in Young Men of Color Who Have Sex with Men

In 2012, the US Food and Drug Administration approved Truvada as a pre-exposure prophylaxis (PrEP) for adults at risk of HIV. PrEP is highly effective at preventing HIV when taken daily, but no gold standard exists for consistently administering PrEP to populations at highest risk. The "I Am Men's Health" program used an innovative methodology to generate adherence to PrEP in 23 mostly young men who have sex with men of color (yMSMc), during a 28-week period from February to September 2013. Adherence was measured using weekly medication pickup rates. The average age of the participants was 21 years, and the majority were black and lived below the poverty line. Time on PrEP ranged from 1 to 28 weeks (2723 person-days), and the weighted average adherence was 73%. The methodology used in this study was preliminarily effective at generating adherence to PrEP among high-risk yMSMc in a community setting and may help inform large-scale future HIV prevention interventions.

Stigma reduction in adolescents and young adults newly diagnosed with HIV: findings from the Project ACCEPT intervention

This article describes the influence of a group-based behavioral intervention for adolescents and young adults newly diagnosed with HIV (Project ACCEPT) on four dimensions of HIV-related stigma-personalized stigma, disclosure concerns, negative self-image, and concern with public attitudes about people with HIV-as measured by the Berger HIV Stigma Scale. Stigma was addressed in a holistic manner during the intervention by providing HIV/AIDS-related information, facilitating the acquisition of coping skills, and providing contact with other youth living with HIV in order to improve social support. Fifty youth (28 male, 22 female; mean age=19.24 years) newly diagnosed with HIV from four geographically diverse clinics participated in a one-group pretest-posttest design study whereby they received the intervention over a 12-week period, and completed assessments at baseline, post-intervention, and 3-month follow-up. Results from the combined sample (males and females) revealed overall reductions in stigma in three dimensions: personalized stigma, disclosure concerns, and negative self-image, although only the combined-sample effects for negative self-image were maintained at 3-month follow-up. Gender-specific analyses revealed that the intervention reduced stigma for males across all four dimensions of stigma, with all effects being maintained to some degree at the 3-month follow-up. Only personalized stigma demonstrated a decrease for females, although this effect was not maintained at the 3-month follow-up; while the other three types of stigma increased at post-intervention and 3-month follow-up. Findings are discussed in terms of gender specific outcomes and the need for a different type of intervention to reduce stigma for young women.

Effects of family treatment on parenting beliefs among caregivers of youth with poorly controlled asthma

OBJECTIVE

Caregiver involvement is critical in ensuring optimal adolescent asthma management. The study investigated whether multisystemic therapy (MST), an intensive home-based family therapy, was superior to family support for changing beliefs regarding asthma-related positive parenting among caregivers of African-American youth with poorly controlled asthma. The relationship between parenting beliefs and asthma management at the conclusion of the intervention was also assessed.

METHODS

A randomized controlled trial was conducted with 167 adolescents with moderate-to-severe, persistent, poorly controlled asthma and their primary caregivers. Families were randomly assigned to MST or family support (FS), a home-based family support condition. Data were collected at baseline and 7-month posttest. Changes in caregiver ratings of importance and confidence for engaging in asthma-related positive parenting were assessed through questionnaire. Illness management was assessed by the Family Asthma Management System Scale.

RESULTS

Participation in MST was associated with more change in caregiver beliefs as compared with FS for both importance (t = 2.39, p = .02) and confidence (t = 2.04, p = .04). Caregiver beliefs were also significantly related to youth controller medication adherence at the conclusion of treatment (importance: r = .21, p = .01; confidence: r = .23, p = .004).

CONCLUSION

Results support the effectiveness of MST for increasing parental beliefs in the value of asthma-related positive parenting behaviors and parental self-efficacy for these behaviors among families of minority adolescents with poorly controlled asthma.

The use of cell phone support for non-adherent HIV-infected youth and young adults: an initial randomized and controlled intervention trial

This randomized behavioral trial examined whether youth living with HIV (YLH) receiving cell-phone support with study funded phone plans, demonstrated improved adherence and viral control during the 24 week intervention and 24 weeks post-intervention compared to controls. Monday through Friday phone calls confirmed medications were taken, provided problem-solving support, and referred to services to address adherence barriers. Of 37 participants (ages 15-24), 62 % were male and 70 % were African American. Self-reported adherence was significantly higher in the intervention group compared to the control at 24 and 48 weeks for the past month (P = 0.007) and log 10 HIV VL was significantly lower at both 24 weeks (2.82 versus 4.52 P = 0.002) and 48 weeks (3.23 versus 4.23 P = 0.043). Adherence and viral load showed medium to large effect sizes across the 48 week study. This is the first study to demonstrate sustained clinically significant reductions in HIV VL using youth friendly technology.

Motivational interviewing targeting risk behaviors for youth living with HIV in Thailand

Healthy Choices, a four-session motivational interviewing-based intervention, reduces risk behaviors among US youth living with HIV (YLWH). We randomized 110 Thai YLWH (16-25 years) to receive either Healthy Choices or time-matched health education (Control) over 12 weeks. Risk behaviors were assessed at baseline, 1, and 6 months post-session. The pilot study was not powered for between-group differences; there were no statistical differences in sexual risks, alcohol use, and antiretroviral adherence between the two groups at any visit. In within-group analyses, Healthy Choices group demonstrated decreases in the proportion of HIV-negative partners (20 vs 8.2%, P = 0.03) and HIV sexual risk scores (4.3 vs 3.3, P = 0.04), and increased trends in the proportion of protected sex (57 vs 76.3%, P = 0.07) from baseline to 1 month post-session. These changes were not sustained 6 months later. No changes were observed in Control group. Healthy Choices has potential to improve sexual risks among Thai YLWH.

Motivational Enhancement System for Adherence (MESA): pilot randomized trial of a brief computer-delivered prevention intervention for youth initiating antiretroviral treatment

OBJECTIVE

To pilot test a two-session computer-delivered motivational intervention to facilitate adherence among youth with HIV newly prescribed antiretroviral treatment (ART).

METHODS

Youth (N = 76) newly prescribed ART were recruited from 8 sites, and were randomized to the intervention or an active nutrition and physical activity control. Primary outcomes were HIV-1 viral load at baseline, 3 months, and 6 months, and self-reported adherence at 3 and 6 months.

RESULTS

Satisfaction ratings were high. Effect sizes suggested that the intervention group showed a greater drop than controls in viral load from baseline to 6 months (Cohen's d = 0.39 at 3 months; d = 0.19 at 6 months), and had greater percent undetectable by 6 months (d = 0.28). Effects sizes were medium to large for 7-day and weekend adherence.

CONCLUSIONS

A brief computer-delivered motivational intervention showed promise for youth starting ART and is ready to be tested in a full-scale clinical trial.

A meta-analysis of adherence to antiretroviral therapy and virologic responses in HIV-infected children, adolescents, and young adults

The relationship between adherence to antiretroviral therapy (ART) and virologic outcomes in HIV+ children, adolescents, and young adults has been notably understudied, with much of the extant research focused on specific sub-literatures, such as resource-limited regions, specific clinical outcomes and time frames. The authors sought to better characterize the relationship between adherence to ART and virologic functioning along various sample and methodological factors. The authors conducted a meta-analysis of thirty-seven studies and utilized a random effects model to generate weighted mean effect sizes. In addition, the authors conducted meta-ANOVAs to examine potential factors influencing the relationship between adherence and three categories of clinical outcomes, specifically Viral Load (VL) <100, VL < 400, and continuously measured VL. The analyses included 5,344 HIV+ children, adolescents, and young adults. The relationship between adherence behaviors and virologic outcomes varied across different methods of measurement and analysis. The relationship between adherence and continuously measured VL was significantly larger than for dichotomously-coded VL < 400 at Qb (20.69(1), p < .0005). Caregiver self-report indices elicited very small to small magnitude effects across both VL < 100 and VL < 400 outcomes and combined informant reporting (youth/adolescent and parent) produced significantly larger effects than caregiver report alone with adherence and VL < 400 outcomes at Qb (9.28(1), p < .005). More recently published trials reported smaller relationships between adherence and categorical clinical outcomes, such that year of publication significantly negatively correlated with VL < 100 (r = -.71(14), p < .005) and VL < 400 (r = -.43(26), p < .02). The data suggest that the magnitude of the relationship between ART adherence and virologic outcomes among heterogeneous samples of HIV+ children, adolescents and young adults varies across virologic outcomes and may be affected by moderating sample and methodological factors. Methodological and research recommendations for the interpretation of the current findings as well as for future HIV adherence related research are presented.

The role of multiple identities in adherence to medical appointments among gay/bisexual male adolescents living with HIV

Adolescents living with HIV require engagement with care providers in order to access the critical medical and psychosocial services they need. The current study sought to explore developmental determinants of adherence to medical appointments as one aspect of engagement in care among a geographically diverse sample of 200 gay/bisexual male adolescents (16-24 years) living with HIV, with a specific focus on ethnic identity, sexual orientation identity, and identity as a young man living with HIV. Ethnic identity affirmation (OR = 0.6; 95% CI: 0.3, 0.9), morality of homosexuality (OR = 1.7; 95% CI: 1.2, 2.5), and HIV-positive identity salience (OR = 1.5; 95% CI: 0.9, 2.4) were associated with significantly higher risk for missed appointments in the past 3 months. These findings highlight the importance of attending to developmental factors, such as the development of multiple identities, when attempting to increase engagement in care for gay/bisexual male adolescents living with HIV.