Rural-Urban Differences in Human Immunodeficiency Virus Testing Among US Adults: Findings From the Behavioral Risk Factor Surveillance System

A qualitative exploration of how to support PrEP adherence among young men who have sex with men

New HIV infections disproportionately affect young men who have sex with men (YMSM). PrEP is effective in preventing HIV acquisition; however, adherence is critical and is often suboptimal among YMSM. Interventions addressing the unique PrEP adherence challenges faced by YMSM are needed. We conducted qualitative interviews with 20 HIV-negative, YMSM (ages 15-24) with a PrEP indication and 11 healthcare professionals to inform adaption of a PrEP adherence intervention (Life-Steps for PrEP) for YMSM. We explored environmental, healthcare, and individual factors influencing uptake, adherence, attitudes, and perspectives (including desired modifications) on the Life-Steps intervention. Interviews were analyzed using content analysis. Of YMSM study participants (mean age 21.6) 55% were White, 15% Hispanic, and 5% Black. Most YMSM were PrEP-experienced (70%). Healthcare professionals (6 prescribers, 1 nurse, 2 health educators, 2 other/unspecified) averaged 6.9 years of experience caring for YMSM. All described stigma as a barrier to PrEP; YMSM expressed concern around being perceived as "risky" and concern about inadvertent PrEP disclosure if family/friends found their medication, or if parental insurance was used. Difficulty with planning for potential adherence challenges were identified by both groups. YMSM highlighted benefits of a nurse-led intervention (i.e., adding "legitimacy"), but stressed need for nonjudgmental, "savvy" interventionists. YMSM expressed a desire for comprehensive YMSM-specific sexual health information. These findings informed modification and expansion of Life-Steps content. Results highlight key potential barriers, many of which center around privacy. Content that addresses PrEP stigma, disclosing PrEP use, navigating insurance, and planning ahead in a nonjudgmental environment by trusted providers emerged as important components of a YMSM-focused delivery of Life-Steps for PrEP.

The prevalence of Human Immunodeficiency Virus infection among voluntary blood donors in mainland China: A systematic review and meta-analysis

Human immunodeficiency virus (HIV) infection through transfusion has been an imperative challenge for blood safety. Despite the implementation of screening strategies, there was still the residual risk of transfusion-transmitted HIV. Considering that the prevalence of HIV infection in blood donors is significant for evaluating blood safety and potential risks to the population, meta-analysis was applied to investigate the HIV prevalence among voluntary blood donors during the past 27 years to characterize the epidemiology and related risk factors of HIV in blood donors. The literature concerning the HIV screening reactive rate and prevalence in Chinese voluntary blood donors was collected through the systematic searching of four electronic databases. After integrating data, following the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses guidelines, data manipulation and statistical analyses were conducted by Stata 12.0. The results indicated that overall HIV prevalence was 0.0178% (95% confidence interval [CI], 0.0169%-0.0187%) with a remarkable rise, which varied from 2000 (0.0034%) to 2015 (0.027%). The HIV window period infection rate was 0.0475‱ (95% CI, 0.0304‱-0.0646‱). Importantly, subgroup analysis revealed the heterogeneity in gender, occupations, education and donation frequency. With the effective control of HIV transmission through blood, HIV prevalence declined in China to some extent in recent years, and the characteristics of HIV epidemic in some provinces have drastically changed. However, remaining relatively high HIV prevalence and overall increased trend of HIV prevalence since the 21th century demonstrates the potential residual risk of blood transfusion, and the whole society is supposed to pay close attention to HIV infection.

Urban and Rural Mpox Incidence Among Persons Aged 15-64 Years - United States, May 10-December 31, 2022

During May 10-December 31, 2022, a total of 29,980 confirmed and probable^† U.S. monkeypox (mpox) cases were reported to CDC, predominantly in cisgender adult men reporting recent same-gender sexual partners (1). Urban-rural differences in health (2) and diagnosis of HIV (3,4) and other sexually transmitted infections (5) are well documented nationally. This report describes urban-rural differences in mpox incidence (cases per 100,000 population) among persons aged 15-64 years, by gender and race and ethnicity. Urbanicity was assessed using the 2013 National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme for Counties (2). Substantial differences in incidence by urbanicity, gender, and race and ethnicity were observed; most (71.0%) cases occurred in persons residing in large central urban areas. Among the cases in large central urban areas, most (95.7%) were in cisgender men. The overall incidence of mpox in the United States was 13.5 per 100,000 persons aged 15-64 years and peaked in August in both urban and rural areas. Among cisgender men, incidence in rural areas was approximately 4% that in large central urban areas (risk ratio [RR] = 0.04). Among cisgender women, incidence in rural areas was approximately 11% that in large central urban areas (RR = 0.11). In both urban and rural areas, incidence among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) persons was consistently higher than that among non-Hispanic White (White) persons; RRs between Black and White persons were highest in rural areas. Support and maintenance of mpox surveillance and prevention efforts including vaccinations should focus on urban areas with the highest incidence of mpox during the 2022 outbreak; however, surveillance and prevention efforts should include all genders, persons of color, and persons residing in both urban and rural areas who are at increased risk for mpox.

Area-based comparison of risk factors and testing rates to improve sexual health care access: cross-sectional population-based study in a Dutch multicultural area

OBJECTIVES

Areas with high sexually transmitted infection (STI) testing rates may not require additional strategies to improve testing. However, it may be necessary to intervene in areas with elevated STI risk, but with low STI testing rates. We aimed to compare STI-related risk profiles and STI testing rates by geographical area to determine areas for improvement of sexual healthcare access.

DESIGN

Cross-sectional population-based study.

SETTING

Greater Rotterdam area, the Netherlands (2015-2019).

PARTICIPANTS

All residents aged 15-45 years. Individual population-based register data were matched with laboratory-based STI testing data of general practitioners (GPs) and the only sexual health centre (SHC).

OUTCOME MEASURES

Postal code (PC) area-specific STI risk scores (based on age, migratory background, education level and urbanisation), STI testing rates and STI positivity.

RESULTS

The study area consists of approximately 500 000 residents aged 15-45 years. Strong spatial variation in STI testing, STI positivity and STI risk was observed. PC area testing rate ranged from 5.2 to 114.9 tests per 1000 residents. Three PC clusters were identified based on STI risk and testing rate: (1) high-high; (2) high-low; (3) low, independently of testing rate. Clusters 1 and 2 had comparable STI-related risk and STI positivity, but the testing rate differed greatly (75.8 vs 33.2 per 1000 residents). Multivariable logistic regression analysis with generalised estimating equation was used to compare residents in cluster 1 and cluster 2. Compared with cluster 1, residents in cluster 2 more often did not have a migratory background, lived in less urbanised areas with higher median household income, and more distant from both GP and SHC.

CONCLUSION

The determinants associated with individuals living in areas with high STI-related risk scores and low testing rates provide leads for improvement of sexual healthcare access. Opportunities for further exploration include GP education, community-based testing and service (re)allocation.

Sexually Transmitted Diseases among Saudi Women: Knowledge and Misconceptions

The rate of sexually transmitted diseases is increasing globally. Thus, this study aimed to examine the Al akami female community's knowledge about the nature of sexually transmitted diseases and their associated factors. The STDs-Knowledge Questionnaire (STDs-KQ) was utilized to collect data from the female community (355) in Jeddah, Saudi Arabia. The data were analyzed using JMP Statistics for Windows, version 15. The significance level was set at 0.05. The study reported that participants had a relatively low understanding of STDs in acquisition, protection, prevention, and clinical signs and symptoms; only 33 (9%) had high knowledge scores (10-18), while 70% thought one virus caused all forms of STDs. Also, only 15% of the respondents knew the clinical features of the Chlamydia infection, and 18% identified the correct mode of its transmission. Also, older participants with clinical exposure had a higher knowledge score than young and single females, p < 0.05. A positive correlation between age and knowledge score was reported, r (354) = 0.339, p < 0.0001. The low knowledge scores were associated with marital status, age, and clinical exposure. Practical strategies to minimize literacy toward sexual education and increase the quality of sexual life must be promoted by educators and the academic curriculum.

Racial, Ethnic, and Rural/Urban Disparities in HIV and Sexually Transmitted Infections in South Carolina

Examining the current incidence rates of HIV and STIs among racial and ethnic minority and rural residents is crucial to inform and expand initiatives and outreach efforts to address disparities and minimize the health impact of these diseases. A retrospective, cross-sectional study was conducted using Medicaid administrative claims data over a 2-year period (July 2019-June 2021) in South Carolina. Our main outcomes of interest were claims for chlamydia, gonorrhea, syphilis, and HIV. Any beneficiary with at least one claim for a relevant diagnosis throughout the study period was considered to have one of these diseases. Descriptive analyses and multivariable regression models were used to estimate the association between STIs, HIV, race and ethnicity, and rurality. Overall, 158,731 Medicaid beneficiaries had at least one medical claim during the study period. Most were female (86.6%), resided in urban areas (66.6%), and were of non-Hispanic Black race/ethnicity (42.6%). In total, 6.3% of beneficiaries had at least one encounter for chlamydia, 3.2% for gonorrhea, 0.5% for syphilis, and 0.8% for HIV. In multivariable models, chlamydia, gonorrhea, and HIV claims were significantly associated with non-Hispanic Black or other minority race/ethnicity compared to non-Hispanic white race/ethnicity. Rural residents were more likely to have a claim associated with chlamydia and gonorrhea compared to urban residents. The opposite was observed for syphilis and HIV. Providing updated evidence on disparities in STIs and HIV among racial/ethnic minority and rural populations in a southern state is essential for shaping state Medicaid policies to address health disparities.

Yakima County Incidence Rates of Sexually Transmitted Infections From 2013 to 2018 in Urban-Rural and Area-Deprivation Continua

BACKGROUND

This study aimed to examine variations in the incidence rates of sexually transmitted infections (STIs; i.e., chlamydia, gonorrhea, and syphilis) across the urban-rural and area-deprivation continua from January of 2013 to December of 2018 in Yakima County, Washington. The rates of STIs has been increasing in the United States in the past decade. Historically, Yakima County has higher rates of STIs than state and national rates. In addition, Yakima County contains rural areas and areas with greater deprivation that face gaps in access to care.

METHODS

The Washington State Department of Health Database Surveillance System was used to conduct the study. The data set included diagnosed cases of chlamydia, gonorrhea, and syphilis with positive laboratory test results for the duration of the study period. Incidence rates of STIs were calculated and statistically analyzed across the urban-rural and area-deprivation continua using rural-urban commuting area codes and the area deprivation index.

RESULTS

The incidence rates of STIs increased from January of 2013 to December of 2018. Rates of STI did not differ in micropolitan, small town, and rural block groups compared with the metropolitan block groups. Most-deprived block groups had significantly higher STI rates compared with less deprived block groups.

CONCLUSIONS

There is a need for increased STI intervention in higher deprivation areas including STI education. Public health officials and health care providers should be aware of these risk factors and tailor interventions to the neighborhood they serve.

The impact of syringe services program closure on the risk of rebound HIV outbreaks among people who inject drugs: a modeling study

OBJECTIVE

Despite their effectiveness in preventing the transmission of HIV among people who inject drugs (PWID), syringe services programs (SSPs) in many settings are hampered by social and political opposition. We aimed to estimate the impact of closure and temporary interruption of SSP on the HIV epidemic in a rural United States setting.

METHODS

Using an agent-based model (ABM) calibrated to observed surveillance data, we simulated HIV risk behaviors and transmission in adult populations who inject and do not inject drugs in Scott County, Indiana. We projected HIV incidence and prevalence between 2020 and 2025 for scenarios with permanent closure, delayed closure (one additional renewal for 24 months before closure), and temporary closure (lasting 12 months) of an SSP in comparison to persistent SSP operation.

RESULTS

With sustained SSP operation, we projected an incidence rate of 0.15 per 100 person-years among the overall population (95% simulation interval: 0.06-0.28). Permanently closing the SSP would cause an average of 58.4% increase in the overall incidence rate during 2021-2025, resulting in a higher prevalence of 60.8% (50.9-70.6%) (18.7% increase) among PWID by 2025. A delayed closure would increase the incidence rate by 38.9%. A temporary closure would cause 12 (35.3%) more infections during 2020-2021.

CONCLUSION

Our analysis suggests that temporary interruption and permanent closure of existing SSPs operating in rural United States may lead to 'rebound' HIV outbreaks among PWID. To reach and sustain HIV epidemic control, it will be necessary to maintain existing and implement new SSPs in combination with other prevention interventions.

Factors Associated with HIV Testing among Reproductive Women Aged 15-49 Years in the Gambia: Analysis of the 2019-2020 Gambian Demographic and Health Survey

Voluntary counselling and testing for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) has always been one of the key policy interventions in the management and control of HIV/AIDS transmission. However, the prevalence of HIV testing among reproductive women in the Gambia remains low despite near universal information about HIV and Sexually Transmitted Infections (STIs) in the Gambia. Understanding factors influencing HIV testing uptake provides empirical data for the development of targeted evidenced-based strategies aimed at enhancing HIV testing uptake. Therefore, this study examined the factors associated with HIV testing among reproductive women aged 15−49 years in the Gambia. Data on weighted sample of 11,865 women from the 2019−2020 Gambia Demographic and Health Survey were analyzed in this study. Chi square, bivariate and multivariate logistic regression models were fitted and analysis conducted through Complex Samples Analysis in Statistical Package for Social Sciences (SPSS). Level of significance was set at p < 0.05 and 95% CI. Further analysis was conducted to determine the variability in HIV testing among women stratified by rural and urban centers. Prevalence of HIV testing among reproductive women was 42.1% (95% CI = 40.1−44.2%) in the Gambia. Women aged 20−24 years and 25−29 years (aOR = 3.10, 95% CI = 2.51−3.83) and (aOR = 4.52, 95% CI = 3.61−5.54) were more likely to test for HIV than those aged 15−19 years, respectively. Married women (aOR = 5.90, 95% CI = 4.84−7.02) were more likely to test for HIV compared to those who were not in any union. Respondents with higher education in urban centers (aOR = 2.65, 95% CI = 2.08−3.86) were likely to test for HIV compared to those in rural areas. HIV testing in the Gambia among reproductive women is low. Age, marital status, wealth index, place of residence, educational level, recent sexual activity, previous history of risky sexual behaviors, and history of an STI were associated with HIV testing. Health interventions targeted at increasing HIV testing uptake should factor in these.

HIV testing behaviour and associated factors in men who have sex with men by level of urbanisation: a cross-sectional study in the Netherlands

OBJECTIVES

Regular HIV testing in men who have sex with men (MSM) enables timely entry into care and reduces the likelihood of HIV transmission. We aimed to assess HIV-testing behaviour and associated factors in MSM by urbanisation of place of residence.

DESIGN

Data were derived from online survey ('Men & Sexuality') in the Netherlands, which was mainly advertised on social media (Facebook and Instagram), dating websites, apps for MSM (Grindr and PlanetRomeo) and gay media.

PRIMARY AND SECONDARY OUTCOME MEASURES

HIV testing was defined as recent (<1 year), not recent (≥1 year) or never. Using multinominal regression analyses, factors associated with not recent testing and never testing, compared with recent testing, were assessed among MSM living in highly (>2500 residences/km²) or non-highly (≤2500 residences/km²) urbanised areas.

PARTICIPANTS

The study sample included 3815 MSM, currently living in the Netherlands. The mean age was 36 years (SD 14.7), and 67.6% were highly educated.

RESULTS

In highly urbanised areas, 11.8% was never and 19.8% was not recently HIV-tested. In non-highly urbanised areas, this was 25.2% and 19.6%. Among MSM living in highly urbanised areas, independently associated with never and not recent testing were younger age, self-identification as bisexual, fewer sex partners, never notified of HIV and no recent condomless anal intercourse. Among MSM living in non-highly urbanised areas, lower perceived HIV severity, higher perceived HIV risk and a lower proportion gay friends were associated with never and not recent testing. Among never tested MSM, those in non-highly urbanised areas preferred self-sampling/self-testing over facility-based testing; those in highly urbanised areas preferred testing at healthcare facilities.

CONCLUSIONS

The proportion of never tested MSM was high (25%) in non-highly urbanised areas in the Netherlands. MSM living in non-highly urbanised areas may possibly be reached with targeted approaches to increase HIV testing uptake such as self-testing/self-sampling strategies.

Factors related to HIV testing frequency in MSM based on the 2011-2018 survey in Tianjin, China: a hint for risk reduction strategy

BACKGROUND

In recent years, HIV testing has become one of the effective strategies to reduce the risk of the infection. Frequent quarterly HIV testing can be cost effective. Therefore, an in-depth study of factors related to the testing behavior of men who have sex with men (MSM) were analyzed to optimize intervention strategies.

METHODS

From March 2011 to October 2018, the project was implemented in a Tianjin (China) bathhouse, and 5165 MSM were surveyed using snowball sampling. Factors related to HIV testing behavior were analyzed by ordinal logistic regression analysis after grouping according to testing frequency, and comprehensive analysis was performed.

RESULTS

The multivariate logistic analysis showed that 6 variables including young MSM (OR = 0.67, 95% CI: 0.49-0.92, p = 0.01), low-educated MSM (OR = 0.60, 95% CI: 0.48-0.77, p < 0.0001), low HIV/AIDS knowledge (95% CI: 0.57-0.83, p < 0.0001), marital status (OR = 1.30, 95% CI: 1.07-1.57, p = 0.007), acceptance of condom promotion and distribution (OR = 14.52, 95% CI: 12.04-17.51, p < 0.0001), and frequency of condom use (p < 0.05) could link to HIV testing behaviors.

CONCLUSIONS

In order to achieve the 95-95-95 goal, target publicity, HIV/AIDS education and promotion of HIV self-testing kits should be carried out to encourage frequent HIV testing among MSM who are young (especially students), married to women, poorly educated and who are reluctant to always use condoms.

Disparities in HIV Education and Testing Between Metropolitan and Nonmetropolitan Adolescents and Young Adults in the U.S

PURPOSE

To examine receipt of formal sexual health education on Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) and receipt of HIV testing in adolescents and young adults (AYAs) residing in nonmetropolitan versus metropolitan areas.

METHODS

A secondary data analysis of the 2015-2017 National Survey of Family Growth of AYAs ages 15-24 years (N = 3,114). Logistic regression models predicted associations between nonmetropolitan versus metropolitan status and outcomes of interest (formal sexual health education on HIV/AIDS and HIV testing).

RESULTS

Most AYAs (85.3%) reported receiving formal sexual health education on HIV/AIDS, while less than half (46.9%) indicated receiving HIV testing. Residing in a nonmetropolitan area was associated with a lower odds of reporting formal sexual health education on HIV/AIDS (OR = .47, CI = [.29, .77]) but not with HIV testing (OR = 1.33, CI = [.89, 2.01]).

CONCLUSIONS

AYAs living in nonmetropolitan areas are less likely to receive formal sexual health education on HIV/AIDS.

The HIV Care Continuum in Small Cities of Southern New England: Perspectives of People Living with HIV/AIDS, Public Health Experts, and HIV Service Providers

The HIV care continuum (HCC), comprised of five steps (screening, linkage to care, treatment initiation, retention, and viral suppression), is used to monitor treatment delivery to people living with HIV (PLWH). The HCC has primarily focused on large urban or metropolitan areas where the situation may differ from that in smaller cities. Three themes (i.e., knowledge, stigma, stability) that shaped HCC outcomes were identified from analysis of two qualitative studies involving HIV service providers, public health experts, and PLWH in smaller cities of southern New England. The findings suggest that enhancing HCC outcomes require a multiprong approach that targets both the individual and organizational levels and includes interventions to increase health literacy, staff communication skills, universal screening to assess patients' religiosity/spirituality and supplemental service needs. Interventions that further ensure patient confidentiality and the co-location and coordination of HIV and other healthcare services are particularly important in smaller cities.

Implementation of Syringe Services Programs to Prevent Rapid Human Immunodeficiency Virus Transmission in Rural Counties in the United States: A Modeling Study

BACKGROUND

Syringe services programs (SSPs) are effective venues for delivering harm-reduction services to people who inject drugs (PWID). However, SSPs often face significant barriers to implementation, particularly in the absence of known human immunodeficiency virus (HIV) outbreaks.

METHODS

Using an agent-based model, we simulated HIV transmission in Scott County, Indiana, a rural county with a 1.7% prevalence of injection drug use. We compared outcomes arising in the absence of an SSP, in the presence of a pre-existing SSP, and with implementation of an SSP after the detection of an HIV outbreak among PWID over 5 years following the introduction of a single infection into the network.

RESULTS

In the absence of an SSP, the model predicted an average of 176 infections among PWID over 5 years or an incidence rate of 12.1/100 person-years. Proactive implementation averted 154 infections and decreased incidence by 90.3%. With reactive implementation beginning operations 10 months after the first infection, an SSP would prevent 107 infections and decrease incidence by 60.8%. Reductions in incidence were also observed among people who did not inject drugs.

CONCLUSIONS

Based on model predictions, proactive implementation of an SSP in Scott County had the potential to avert more HIV infections than reactive implementation after the detection of an outbreak. The predicted impact of reactive SSP implementation was highly dependent on timely implementation after detecting the earliest infections. Consequently, there is a need for expanded proactive SSP implementation in the context of enhanced monitoring of outbreak vulnerability in Scott County and similar rural contexts.

HIV testing among pregnant women with prenatal care in the United States: An analysis of the 2011-2017 National Survey of Family Growth

Although there has been significant progress in reducing perinatal human immunodeficiency virus (HIV) transmission, the United States is yet to meet the proposed elimination goal of less than one infection per 100,000 live births. Failure to screen all pregnant women for HIV as recommended by the Centers for Disease Control and Prevention can result in missed opportunities for preventing vertical transmission of HIV with antiretroviral drugs. Using the 2011-2017 National Survey of Family Growth, this study examined HIV testing among pregnant women during prenatal care. We estimated the weighted proportion of self-reported HIV testing among women whose last pregnancy ended within 12 months prior to the interview. Logistic regression models were used to determine the factors associated with HIV testing. Of the 1566 women included in the study, 76.4% (95% confidence intervals [CI] = 72.8-80.0) reported receiving an HIV test during prenatal care. In the multivariable regression model, high school diploma (adjusted odds ratio [aOR] = 1.9, 95% CI = 1.1-3.1), two completed pregnancies (aOR = 1.7, 95% CI = 1.1-2.7), health insurance coverage in the last 12 months (aOR = 1.6, 95% CI = 1.0-2.6), Hispanic race/ethnicity (aOR = 2.8, 95% CI = 1.8-4.4), and non-Hispanic black race/ethnicity (aOR = 2.2, 95% CI = 1.3-3.8) were associated with higher odds of reporting being tested for HIV. However, household income of 300% or more of the federal poverty level (aOR = 0.6, 95% CI = 0.3-0.9) and urban residence (aOR = 0.5, 95% CI = 0.3-0.9) were associated with lower odds of reporting HIV testing. These findings suggest that HIV testing among pregnant women during prenatal care is not universal and may affect achieving the goal of elimination of mother-to-child transmission of HIV in the United States.

Women's healthcare decision-making capacity and HIV testing in sub-Saharan Africa: a multi-country analysis of demographic and health surveys

BACKGROUND

Global commitment to stop Human Immunodeficiency Virus (HIV) and ensure access to HIV treatment calls for women empowerment, as these efforts play major roles in mother-to-child transmission. We examined the association between women's healthcare decision-making capacity and uptake of HIV testing in sub-Saharan Africa.

METHODS

We used data from the current Demographic and Health Surveys (DHS) of 28 countries in sub-Saharan Africa, conducted between January 1, 2010 and December 31, 2018. At the descriptive level, we calculated the prevalence of HIV testing in each of the countries. This was followed by the distribution of HIV testing across the socio-demographic characteristics of women. Finally, we used binary logistic regression assess the likelihood of HIV testing uptake by women's health care decision-making capacity and socio-demographic characteristics. The results were presented as Crude Odds Ratios (COR) and Adjusted Odds Ratios (AOR) with their corresponding 95% confidence intervals signifying precision. Statistical significance was set at p-value < 0.05.

RESULTS

We found that prevalence of HIV testing uptake in the 28 sub-Saharan African countries was 64.4%, with Congo DR having the least (20.2%) and the highest occurred in Rwanda (97.4%). Women who took healthcare decisions alone [COR = 3.183, CI = 2.880-3.519] or with their partners [COR = 2.577, CI = 2.335-2.844] were more likely to test for HIV, compared to those whose healthcare decisions were taken by others, and this persisted after controlling for significant covariates: [AOR = 1.507, CI = 1.321-1.720] and [AOR = 1.518, CI = 1.334-1.728] respectively.

CONCLUSION

Sub-Saharan African countries intending to improve HIV testing need to incorporate women's healthcare decision-making capacity strategies. These strategies can include education and counselling. This is essential because our study indicates that the capacity of women to make healthcare decisions has an association with decision to test for their HIV status.

Social norms associated with nonmedical opioid use in rural communities: a systematic review

Prescription and illicit opioids were involved in over 42,000 deaths in the USA in 2016. Rural counties experience higher rates of opioid prescribing and, although opioid prescribing rates have fallen in recent years, the rate of decline is less in rural areas. The sociocultural context of rural life may impact opioid misuse in important ways; however, little research directly explores this possibility. We performed a systematic review of English-language manuscripts in U.S. context to determine what is known about social networks, norms, and stigma in relation to rural opioid misuse. Of nine articles identified and reviewed, two had only primary findings associated with social networks, norms, or stigma, five had only secondary findings, and two had both primary and secondary findings. The normalization of prescription opioid use along with environmental factors likely impacts the prevalence of opioid misuse in rural communities. Discordant findings exist regarding the extent to which social networks facilitate or protect against nonmedical opioid use. Lastly, isolation, lack of treatment options, social norms, and stigma create barriers to substance use treatment for rural residents. Although we were able to identify important themes across multiple studies, discordant findings exist and, in some cases, findings rely on single studies. The paucity of research examining the role of social networks, norms, and stigma in relation to nonmedical opioid use in rural communities is evident in this review. Scholarship aimed at exploring the relationship and impact of rurality on nonmedical opioid use is warranted.

Proximity to Screening Site, Rurality, and Neighborhood Disadvantage: Treatment Status among Individuals with Sexually Transmitted Infections in Yakima County, Washington

Background: Early sexually transmitted infections (STIs) diagnosis facilitates prompt treatment initiation and contributes to reduced transmission. This study examined the extent to which contextual characteristics such as proximity to screening site, rurality, and neighborhood disadvantage along with demographic variables, may influence treatment seeking behavior among individuals with STIs (i.e., chlamydia, gonorrhea, and syphilis). Methods: Data on 16,075 diagnosed cases of STIs between 2007 and 2018 in Yakima County were obtained from the Washington State Department of Health Database Surveillance System. Multilevel models were applied to explore the associations between contextual and demographic characteristics and two outcomes: (a) not receiving treatment and (b) the number of days to receiving treatment. Results: Contextual risk factors for not receiving treatment or having increased number of days to treatment were living ≥10 miles from the screening site and living in micropolitan, small towns, or rural areas. Older age was a protective factor and being female was a risk for both outcomes. Conclusions: Healthcare providers and facilities should be made aware of demographic and contextual characteristics that can impact treatment seeking behavior among individuals with STIs, especially among youth, females, and rural residents.

Understanding the association between caregiver sex and HIV infection among orphans and vulnerable children in Tanzania: learning from the USAID Kizazi Kipya project

Background

Tanzania has met only 50.1% of the 90% target for diagnosing HIV in children. The country’s pediatric case finding strategy uses global best practices of index testing, provider-initiated counselling and testing, and targeted community testing of at-risk populations to find about 50,000 children living with HIV (CLHIV) who are undiagnosed. However, context-specific strategies are necessary to find the hidden children to meet the full 90% target. This study assesses whether sex of the caregiver is associated with HIV status of orphans and vulnerable children (OVC) as a valuable strategy for enhanced pediatric case findings.

Methods

Data originate from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya Project, which works towards increasing OVC’s and their caregivers’ uptake of HIV/AIDS and other health and social services in Tanzania. Included in this study are 39,578 OVC ages 0–19 years who the project enrolled during January through March 2017 in 18 regions of Tanzania and who voluntarily reported their HIV status. Data analysis involved multi-level logistic regression, with OVC HIV status as the outcome of interest and caregiver’s sex as the main independent variable.

Results

Three-quarters (74.3%) of the OVC included in the study had female caregivers, and their overall HIV prevalence was 7.1%. The prevalence was significantly higher (p < 0.001) among OVC with male caregivers (7.8%) than among OVC with female caregivers (6.8%), and indeed, multivariate analysis showed that OVC with male caregivers were significantly 40% more likely to be HIV-positive than those with female caregivers (OR = 1.40, 95% CI 1.08–1.83). This effect was the strongest among 0–4 year-olds (OR = 4.02, 95% CI 1.61–10.03), declined to 1.72 among 5–9 year-olds (OR = 1.72, 95% CI 1.02–2.93), and lost significance for children over age 9 years. Other significant factors included OVC age and nutritional status; caregiver HIV status and marital status; household health insurance status, and family size; and rural versus urban residence.

Conclusions

OVC in Tanzania with male caregivers have a 40% higher likelihood of being HIV-positive than those with female caregivers. HIV risk assessment activities should target OVC with male caregivers, as well as OVC who have malnutrition, HIV-positive caregivers, or caregivers who do not disclose their HIV status to community volunteers. Further, younger HIV-positive OVC are more likely to live in rural areas, while older HIV-positive OVC are more likely to live in urban areas. These factors should be integrated in HIV risk assessment algorithms to enhance HIV testing yields and pediatric case-finding in the OVC population in Tanzania.

Intention to Screen for Alzheimer's Disease by Residential Locale

A random digit dialing sample from Missouri (USA) was used to compare associations between psychosocial factors and Alzheimer's disease (AD) screening intention based on residential locale. Linear regression associations between demographics and five psychosocial constructs (dementia knowledge, perceived screening benefits, preventive health behaviors, perceived susceptibility, and self-efficacy) and screening intention were compared by residential locale. Participants (n = 932) had a mean age of 62 years (urban: n = 375; suburban: n = 319, rural: n = 238). African Americans more often lived in urban than suburban/rural neighborhoods, and more urban than suburban/rural residents reported insufficient income. Preventative health behaviors (e.g., dentist visits) were higher in urban and suburban versus rural participants. AD screening intention did not differ by residential locale. Among urban participants, self-efficacy to get screened was associated with screening intention. Among rural participants, dementia knowledge was associated with screening intention. Perceived screening benefits and perceived susceptibility to AD were associated with screening intention regardless of locale. Unlike urban participants, rural participants demonstrated greater screening intention with greater dementia knowledge. Our findings suggest that psychosocial factors associated with AD screening intention differ depending on residential locale. Strategies to increase dementia screening may need to account for regional variations to be maximally effective.

Influence of Rurality on HIV Testing Practices Across the United States, 2012-2017

In the US, HIV testing has been key in the identification of new HIV cases, allowing for the initiation of antiretroviral treatment and a reduction in disease transmission. We consider the influence of living in a rural area (rurality) on HIV testing between different US regions and states as existing work in this area is limited. Using the 2012-2017 Behavioral Risk Factor Surveillance Systems surveys, we explored the independent role of rurality on having ever been tested for HIV and having a recent HIV test at the national, regional, and state levels by calculating average adjusted predictions (AAPs) and average marginal effects (AMEs). Suburban and urban areas had higher odds and AAPs of having ever been tested for HIV and having a recent HIV test compared to rural areas across the US. The Midwest had the lowest AAPs for both having ever been tested for HIV (17.57-20.32%) and having a recent HIV test (37.65-41.14%) compared to other regions. For both questions on HIV testing, regions with the highest AAPs had the greatest rural-urban differences in probabilities and regions with the lowest AAPs had the smallest rural-urban difference in probabilities. The highest rural-urban testing disparities were observed in states with high AAPs for HIV testing. HIV testing estimates were higher in urban compared to rural areas at the national, regional, and state level. This study examines the isolated influence of rurality on HIV testing and identifies specific US areas where future efforts to increase HIV testing should be directed to.