Preventing HIV among young people: research priorities for the future

Preventive measures against HIV among Uganda's youth: Strategies, implementation, and effectiveness

Preventing HIV among Uganda's youth is a critical public health priority due to the high prevalence of HIV/AIDS and the disproportionate burden of new infections among young people. This paper examines the preventive measures implemented to combat HIV/AIDS among Uganda's youth, focusing on strategies, implementation efforts, and the effectiveness of interventions. Comprehensive sexuality education programs have been implemented in schools and communities to provide young people with accurate information on HIV transmission, prevention methods, and reproductive health. Condom distribution and promotion campaigns target sexually active youth, while HIV testing and counseling services aim to reach youth in various settings, including health facilities and community outreaches. The implementation of HIV prevention strategies involves collaboration among government agencies, NGOs, healthcare providers, educators, and community leaders. Efforts are made to ensure that prevention programs are culturally appropriate, evidence-based, and responsive to the needs of young people. Despite progress in HIV prevention, challenges persist, including knowledge gaps, stigma, gender inequalities, and socio-economic factors. Continuous monitoring and evaluation are essential to assess the impact of interventions and identify areas for improvement. Recommendations include increasing funding for HIV prevention programs, strengthening policy frameworks, enhancing access to youth-friendly health services, integrating comprehensive sexuality education into school curricula, and fostering community engagement. By addressing these recommendations, Uganda can strengthen its HIV prevention efforts and reduce the incidence of HIV/AIDS among its youth population, ultimately contributing to improved health outcomes and well-being.

Prevalence and predictors of HIV testing among young men in Papua New Guinea: A cross-sectional analysis of a nationally representative sample

BACKGROUND

HIV testing is an important component of HIV prevention and serves as a gateway to other HIV-related services. However, the uptake remains suboptimal among young people, particularly in highly prevalent settings such as Papua New Guinea (PNG). This study aimed to assess the prevalence and determine the predictors of HIV testing uptake among young men aged 15-24 years in PNG.

METHODS

The 2016-2018 PNG Demographic and Health Survey (DHS) data was used. A total of 1,275 young men aged 15-24 years were included in the final analysis. Descriptive, bivariate, and multivariable logistic regression analyses were performed to determine independent predictors of HIV testing. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported. All analyses were adjusted using survey weights to account for unequal sampling probabilities.

RESULTS

The overall prevalence of HIV testing among young men was 17.1% (95% CI: 15-19). Of those who were tested for HIV, about one-third (32.9%) had experienced a sexual debut at age <15 years, and 33.9% inconsistently used condoms during sex. In multivariable analysis, men aged 20-24 years (AOR 1.18, 95% CI: 1.00-2.31), who owned mobile phones (AOR 1.43, 95% CI: 1.00-2.55), who were aware that consistent condom use during sex can reduce HIV risk (AOR 2.18, 95% CI: 1.18-4.04), who had paid for sex (AOR 1.75, 95% CI: 1.01-5.83), and who had two or more sexual partners (AOR 1.37, 95% CI: 1.01-3.14) had increased odds of HIV testing. However, decreased odds of HIV testing were found among men who were never married (AOR 0.51, 95% CI: 0.29-0.88), lived in rural areas (AOR 0.54, 95% CI: 0.32-0.92), and consistently used condoms during sex (AOR 0.59, 95% CI: 0.34-1.01).

CONCLUSION

The findings show that HIV testing is low among young men in PNG. To increase HIV testing uptake among young men, it is crucial to implement comprehensive youth-friendly HIV/STI education and tailored sensitization programs and enable more accessible and affordable HIV testing services. Also, outreach and community-based testing programs for young men in rural and prioritized areas requiring urgent prevention interventions are feasible options in PNG.

Barriers and facilitators to utilizing HIV prevention and treatment services among migrant youth globally: A scoping review

Both migrants and young people experience disproportionately high rates of HIV acquisition and poor access to HIV prevention and treatment services. To develop effective interventions and reach epidemic control, it is necessary to understand the barriers and facilitators to accessing HIV services among migrant youth. We conducted a scoping review to identify these factors for migrant youth ages 15-24, globally. We conducted a PRISMA-concordant scoping review using keyword searches in PUBMED and Web of Science for peer-reviewed primary literature published between January 2012 and October 2022. We included studies that investigated barriers and facilitators to accessing services for migrant youth participants. We used the Socio-Ecological Model as an analytical framework. The 20 studies meeting the inclusion criteria spanned 10 countries, of which 80% (n = 16) were low- and middle-income countries. Study methods included were quantitative (40%), qualitative (55%), and mixed methods (5%). Six studies included refugee youth (30%), 6 included migrant worker youth (30%), 3 included immigrant youth (15%), 2 included rural migrant youth (10%), and 1 included immigrants and refugees. The remainder represented unspecified migrant youth populations (10%). At the individual level, education level and fear of infection acted as barriers and facilitators to HIV services. At the relationship level, social support and power in relationships acted as barriers and facilitators to HIV services. At the community level, barriers to HIV services included discrimination and stigma, while community and religious outreach efforts facilitated access to HIV services. At the structural level, barriers to HIV services included stigmatizing social norms, lack of health insurance, and legal barriers. Migrant youth face significant, unique barriers to accessing HIV services. However, facilitators exist that can be leveraged to enable access. Future implementation science research, enabling policies, and adapted programmatic interventions should prioritize migrant youth as a distinctive sub-population to receive targeted HIV services.

'A difficult conversation': community stakeholders' and key informants' perceptions of the barriers to talking about sex and HIV with adolescents and young people in KwaZulu-Natal, South Africa

Adolescence and young adulthood are important periods of transition and therefore for action and intervention to ensure future sexual and reproductive health (SRH). Caregiver-adolescent communication about sex and sexuality is a protective factor for SRH, but there are often barriers to this. Adults' perspectives are limited within the literature but important as they should lead this process. This paper uses exploratory qualitative data from in-depth interviews with 40 purposively sampled community stakeholders and key informants to explore their insights into the perceived, experienced or expected challenges adults' experience when having these conversations within a high HIV prevalence, South African context. Findings suggest that respondents recognised the value of communication and were generally willing to try it. However, they identified barriers such as fear, discomfort and limited knowledge and perceived capacity to do so. They show that in high prevalence contexts adults grapple with their own personal risks, behaviours and fears that may affect their ability to have these conversations. This demonstrates the need to equip caregivers with the confidence and ability to communicate about sex and HIV, alongside managing their own complex risks and situations to overcome barriers. It is also necessary to shift the negative framing of adolescents and sex.

Using Hierarchical Regression to Examine the Predictors of Sexual Risk-Taking Attitudes among Adolescents Living with Human Immunodeficiency Virus in Uganda

PURPOSE

We explored the factors influencing sexual risk-taking attitudes-defined as beliefs and values regarding sexual activity-among adolescents living with human immunodeficiency virus (ALHIV) in Uganda.

METHODS

The study used baseline data from a five-year cluster-randomized control trial (2012-2018) among 702 ALHIV in Uganda. Participants were aged 10-16 years, HIV-positive, taking antiretroviral therapy, and living within a family. We fitted hierarchical regression models to assess the demographic, economic, psychological, and social predictors of sexual risk-taking attitudes. Using R2, the final model explained 11.4% of the total variance.

RESULTS

Under economic factors, caregiver being formally employed (β = -0.08, 95% confidence interval [CI]: -0.10-0.06, p < .001), and the ALHIV working for pay (β = 1.78, 95% CI: 0.28-3.29, p = .022), were associated with sexual risk-taking attitudes. Among the psychological factors, more depressive symptoms (β = 0.22, 95% CI: 0.11-0.32, p < .001) were associated with more approving attitudes toward sexual risk-taking. Family and social factors including communicating with the caregiver about HIV (β = 1.32, 95% CI: 0.56-2.08, p = .001), sex (β = 1.09, 95% CI: 0.20-1.97, p = .017), and experiencing peer pressure (β = 3.37, 95% CI: 1.85-4.89, p < .001) were also associated with more approving attitudes toward sexual risk-taking. The final model explained 11.54% of the total variance.

DISCUSSION

Economic, psychological, and social factors influence sexual risk-taking attitudes among ALHIV. There is a need for more research to understand why discussing sex with caregivers improves adolescents' positive attitudes toward sexual risk-taking. These findings have significant ramifications in preventing sexual transmission of HIV among adolescents in low-income settings.

Relationships Between Stress-Responsive Biomarkers, ART Adherence, and Viral Suppression Among Adolescent Girls and Young Women Living With HIV in South Africa: An HPTN 068 Analysis

BACKGROUND

Adolescent girls and young women (AGYW) living with HIV who have higher stress levels may be at risk of stress-related biological alterations, which could influence HIV progression and adherence to antiretroviral therapy (ART).

SETTING

We aimed to estimate associations among stress-responsive biomarkers, ART adherence, and viral suppression in AGYW living with HIV in South Africa. We also hypothesized that psychosocial stressors [eg, depression, food insecurity, low socioeconomic status (SES), and HSV-2] would be associated with higher biomarker levels.

METHODS

We used 2018/2019 data from the HIV Prevention Trials Network 068 cohort to assess associations between stress-responsive biomarkers and viral suppression (<1000 copies/mL) and ART adherence measured using dried blood spot cards. Stress-responsive biomarkers included C-reactive protein, herpes simplex virus type 1, and cytomegalovirus infection and reactivation. Associations were estimated using unadjusted log-binomial or ordinal logistic regression models.

RESULTS

In 166 AGYW living with HIV, there was no association between stress-responsive biomarkers and viral suppression or ART adherence. However, increased C-reactive protein levels were associated with higher HSV-2 infection [odds ratio (OR) 1.98; 95% confidence interval (CI) 1.11, 3.52], being a government grant recipient (OR 3.21; 95% CI: 1.30, 7.92), lower food insecurity (OR 0.34; 95% CI: 0.13, 0.90), and increased body mass index (OR 1.07; 95% CI: 1.01, 1.14).

CONCLUSIONS

High prevalence of psychosocial stressors and persistent herpesviruses in AGYW living with HIV has the potential to lead to poorer health outcomes. More research is needed to untangle relationships between economic stability, chronic disease, and chronic stress.

Evaluating the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe programme, what's worked and what more needs to be done?

This paper is a commentary framing a series of papers on the evaluation of several aspects of the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) programme. The paper highlights the scope and challenges with evaluating a large, complex and ambitious programme like DREAMS.

The Effect of PrEP Use Disclosure on Adherence in a Cohort of Adolescent Girls and Young Women in South Africa

Effective strategies to support PrEP adherence among adolescent girls and young women (AGYW) are needed. We examined PrEP use disclosure and its effect on adherence among 200 AGYW ages 16-25 initiating PrEP in South Africa to help inform these  strategies. We estimated the relative prevalence of high adherence (intracellular tenofovir-diphosphate concentration ≥ 700 fmol/punch) 3- and 6-months after PrEP initiation among those who disclosed vs. did not disclose their PrEP use, both overall and by age. Most AGYW disclosed to a parent (58%), partner (58%), or friend (81%) by month 6. We did not observe a strong effect of disclosure on adherence overall; however, among younger AGYW (≤ 18 years), those who disclosed to a parent were 6.8 times as likely to have high adherence at month 6 than those who did not (95% CI 1.02, 45.56). More work is needed to understand parents' roles as allies and identify ways peers and partners can motivate PrEP use for AGYW.

The Efficacy of a Smartphone Game to Prevent HIV Among Young Africans: Protocol for a Randomized Controlled Trial in the Context of COVID-19

BACKGROUND

Adolescents contribute slightly less than one-third of all new HIV infections in sub-Saharan Africa. There is a need for more effective intervention approaches to help young adolescents safely navigate through adolescence and into adulthood. We are assessing the efficacy of Tumaini, a smartphone game designed to prevent HIV among young Africans. Against the background of COVID-19, meaningful alteration of the research protocol was necessary to ensure successful implementation and retention of the study participants in ongoing research.

OBJECTIVE

The objective of our protocol is to determine (1) if Tumaini delays sexual debut and increases condom use at first sex and (2) whether it influences behavioral mediators of early and unprotected sex.

METHODS

Participants were recruited from Kisumu County in Western Kenya. This study is a 2-arm, individual-randomized controlled trial that enrolled 1004 adolescents aged between 12 years and 15 years. The intervention arm participants are playing Tumaini, while the control arm is provided with Brainilis, a commercially available control game. The study period will last 45 months. At baseline, participants in both arms completed a baseline survey and biological testing for HIV and herpes simplex virus, type 2 (HSV-2); participants will have annual game play periods in years 1-3. They will also complete a total of 12 follow-up surveys. At endline, repeat biological testing will be conducted. Protocol adaptations were necessitated by the COVID-19 pandemic and implemented in accordance with local public health guidelines.

RESULTS

Participants were enrolled between October 2020 and November 2020. We plan to complete study procedures in September 2024. The enrolled participant sample was 50.1% (499/996) female and had a mean age of 14.0 (SD 0.6) years.

CONCLUSIONS

This ongoing research demonstrates that, with appropriate revisions to planned protocol activities guided by the need to maintain study integrity, protect both study participants and staff, and adhere to institutional review board and local health authority guidelines, human subject research is possible in the context of a global pandemic. If the trial demonstrates efficacy, Tumaini would provide an alternative, remote means of delivering age-appropriate education to adolescents on safer sex, HIV prevention, and effective life skills on a highly scalable, low-cost, and culturally adaptable platform.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04437667; https://clinicaltrials.gov/ct2/show/NCT04437667.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35117.

Accelerating adolescent HIV research in low-income and middle-income countries: evidence from a research consortium

OBJECTIVE

Many adolescents and young adults (AYA) have unmet HIV prevention needs. We describe the Prevention and Treatment through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3H) consortium organization, transition milestones, and youth engagement strategies. The PATC3H consortium focuses on reducing HIV incidence and related health disparities among AYA.

DESIGN AND METHODS

Organizational data were obtained from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and supplemented with a brief survey completed by study principal investigators. Transition from the initial phase (years 1 and 2) to the subsequent phase (years 3 and 5) was contingent on meeting prespecified milestones. We reviewed the structure and function of the research consortium, identified shared elements of transition milestones, and examined common youth engagement strategies.

RESULTS

The PATC3H consortium supports eight research studies through a milestone transition mechanism. The consortium includes AYA HIV research studies in seven countries - Brazil, Kenya, Mozambique, Nigeria, South Africa, Uganda, and Zambia. The NIH request for applications required transition milestones that included early consultation with stakeholders. The transition milestones required by NIH for the eight studies included early consultation with health and policy stakeholders, pilot intervention data, and commitment from national government stakeholders. All studies provided multiple pathways for AYA engagement, including AYA advisory boards and youth-led research studies.

CONCLUSION

Data suggest that requiring milestones to transition to the final phase may have facilitated health and policy stakeholder engagement and enhanced formative assessment of regulatory protocols. These data have implications for designing engaged research studies in low and middle-income countries.

Modeling Combination Interventions to Prevent Human Immunodeficiency Virus in Adolescent Girls and Young Women in South Africa (HIV Prevention Trials Network 068)

BACKGROUND

Combination interventions may be an effective way to prevent human immunodeficiency virus (HIV) in adolescent girls and young women. However, current studies are not designed to understand which specific interventions and combinations will be most effective. We estimate the possible impacts of interventions on a combination of factors associated with HIV.

METHODS

We used the g-formula to model interventions on combinations of HIV risk factors to identify those that would prevent the most incident HIV infections, including low school attendance, intimate partner violence, depression, transactional sex, and age-disparate partnerships. We used data from the HIV Prevention Trials Network (HPTN) 068 study in rural South Africa from 2011 to 2017. We estimated HIV incidence under a potential intervention that reduced each risk factor and compared this to HIV incidence under the current distribution of these risk factors.

RESULTS

Although many factors had strong associations with HIV, potential intervention estimates did not always suggest large reductions in HIV incidence because the prevalence of risk factors was low. When modeling combination effects, an intervention to increase schooling, decrease depression, and decease transactional sex showed the largest reduction in incident infection (risk difference, -1.4%; 95% confidence interval [CI], -2.7% to -.2%), but an intervention on only transactional sex and depression still reduced HIV incidence by -1.3% (95% CI, -2.6% to -.2%).

CONCLUSIONS

To achieve the largest reductions in HIV, both prevalence of the risk factor and strength of association with HIV must be considered. Additionally, intervening on more risk factors may not necessarily result in larger reductions in HIV incidence.

Prevalence of Sexually Transmitted Infections and Factors Associated with HIV Status Among Vulnerable Women in Northern Uganda: Baseline Results from Pe Atye Kena Cohort Study

Background and Objectives

HIV infection among vulnerable women (VW) has been attributed to unfavourable power relations and limited access to sexual and reproductive health information and services. This work aims to report sexually-transmitted infections (STI) prevalence and assess the impact of HIV awareness, demographic and socio-behavioural factors on HIV status in a rural area of northern Uganda.

Methods

Pe Atye Kena is a longitudinal cohort intervention study enrolling young women aged 18–49 years old living in the municipality of Gulu, Uganda. HIV, HBV, syphilis serologic tests, and a comprehensive electronic questionnaire on sexual high-risk behaviours were administered before intervention. In this work, we report baseline characteristics of the population along with factors associated with HIV status. Statistical analysis was performed by uni- and multivariable regression models.

Results

461 VW were enrolled (mean age: 29 (SD7.7)). 40 (8.7%) were found to be positive for HIV, 42 (9.1%) for syphilis and 29 (6.3%) for HBV. Older age (> 34 years vs. < 24 years; OR 4.95, 95% CI: 1.7 to 14); having done the last HIV test > 12m before the interview (OR 5.21, 95% CI: 2.3 to 11); suspecting the male sexual partner to be HIV+ (OR 2.2; 95% CI: 1.1 to 4.3); not having used condom at first sexual intercourse (OR 2.6; 95% CI 1.3 to 5.15) were all factors associated with an incident HIV diagnosis.

Conclusions

In this cohort, HIV prevalence is high, and sexual high-risk behaviours are multifaced; future interventions will be aimed to reduce HIV/STIs misconceptions and to promote a sense of community, self-determination and female empowerment.

Reaching underserved South Africans with integrated chronic disease screening and mobile HIV counselling and testing: A retrospective, longitudinal study conducted in Cape Town

BACKGROUND

Community-based, mobile HIV counselling and testing (HCT) and screening for non-communicable diseases (NCDs) may improve early diagnosis and referral for care in underserved populations. We evaluated HCT/NCD data and described population characteristics of those visiting a mobile clinic in high HIV disease burden settings in Cape Town, South Africa, between 2008 and 2016.

METHODS

Trained counsellors registered patients ≥12 years old at a mobile clinic, which offered HCT and blood pressure, diabetes (glucose testing) and obesity (body mass index) screening. A nurse referred patients who required HIV treatment or NCD care. Using multivariable logistic regression, we estimated correlates of new HIV diagnoses adjusting for gender, age and year.

RESULTS

Overall, 43,938 individuals (50% male; 29% <25 years; median age = 31 years) tested for HIV at the mobile clinic, where 27% of patients (66% of males, 34% of females) reported being debut HIV testers. Males not previously tested for HIV had higher rates of HIV positivity (11%) than females (7%). Over half (55%, n = 1,343) of those previously diagnosed HIV-positive had not initiated ART. More than one-quarter (26%) of patients screened positive for hypertension (males 28%, females 24%, p<0.001). Females were more likely overweight (25% vs 20%) or obese (43% vs 9%) and presented with more diabetes symptoms than males (8% vs 4%). Females (3%) reported more symptoms of STIs than males (1%). Reporting symptoms of sexually transmitted infections (aOR = 3.45, 95% CI = 2.84, 4.20), diabetes symptoms (aOR = 1.61, 95% 1.35, 1.92), and TB symptoms (aOR = 4.40, 95% CI = 3.85, 5.01) were associated with higher odds of a new HIV diagnosis after adjusting for covariates.

CONCLUSION

Findings demonstrate that mobile clinics providing integrated HCT and NCD screening may offer the opportunity of early diagnosis and referral for care for those who delay screening, including men living with HIV not previously tested.

Exploring Perceived Barriers and Facilitators of PrEP Uptake among Young People in Uganda, Zimbabwe, and South Africa

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy. Few studies have explored adolescents and young people's perspectives toward PrEP. We conducted 24 group discussions and 60 in-depth interviews with males and females aged 13-24 years in Uganda, Zimbabwe, and South Africa between September 2018 and February 2019. We used the framework approach to generate themes and key concepts for analysis following the social ecological model. Young people expressed a willingness to use PrEP and identified potential barriers and facilitators of PrEP uptake. Barriers included factors at individual (fear of HIV, fear of side effects, and PrEP characteristics), interpersonal (parental influence, absence of a sexual partner), community (peer influence, social stigma), institutional (long waiting times at clinics, attitudes of health workers), and structural (cost of PrEP and mode of administration, accessibility concerns) levels. Facilitators included factors at individual (high HIV risk perception and preventing HIV/desire to remain HIV negative), interpersonal (peer influence, social support and care for PrEP uptake), community (adequate PrEP information and sensitization, evidence of PrEP efficacy and safety), institutional (convenient and responsive services, provision of appropriate and sufficiently resourced services), and structural (access and availability of PrEP, cost of PrEP) levels. The findings indicated that PrEP is an acceptable HIV prevention method. PrEP uptake is linked to personal and environmental factors that need to be considered for successful PrEP roll-out. Multi-level interventions needed to promote PrEP uptake should consider the social and structural drivers and focus on ways that can inspire PrEP uptake and limit the barriers.

The effects of a cash transfer intervention on sexual partnerships and HIV in the HPTN 068 study in South Africa

Evidence on cash transfer interventions for HIV prevention in adolescent girls and young women is unclear and indicates that they may not work uniformly in all settings. Qualitative interviews were conducted with 22 girls and young women post-intervention to determine how a cash transfer study (HPTN 068) in South Africa was perceived to influence sexual behaviours and to explore mechanisms for these changes. Participants described how the intervention motivated them to increase condom use, have fewer partners, end risky relationships and access HIV testing services at local primary health clinics. Changes were attributed to receipt of the cash transfer, in addition to HIV testing and sexual health information. Processes of change included improved communication with partners and increased negotiation power in sexual decision-making. Economic empowerment interventions increase confidence in negotiating behaviours with sexual partners and are complementary to sexual health information and health services that provide young women with a foundation on which to make informed decisions about how to protect themselves.

Nature of, and responses to key sexual and reproductive health challenges for adolescents in urban slums in sub-Saharan Africa: a scoping review

BACKGROUND

Addressing adolescents' sexual and reproductive health and rights (SRHR) requires an understanding of the socio-cultural and spatial settings within which they live. One setting of particular importance is the informal settlements or 'slums' that are gradually dominating the urban space. We undertook a scoping review and synthesis of existing evidence on adolescent SRHR in slums in sub-Saharan Africa (SSA) focusing on the characteristics and nature of existing evidence.

METHODS

The scoping review was conducted based on Arksey and O'Malley framework and in accordance with the guidance on scoping reviews from the Joanna Briggs Institute (JBI) and using PRISMA reporting guidelines for scoping reviews. A comprehensive search was undertaken in PubMed, POPLINE, African Journals Online (AJOL), Bioline International and Google Scholar. The search was confined to studies published in peer reviewed journals and reports published online between January 2000 and May 2019. Studies were included in the review if they addressed SRHR issues among adolescents living in urban slums in SSA.

RESULTS

The review included a total of 54 studies. The majority (79.5%) of studies were quantitative. The bulk of studies (85.2%) were observational studies with only eight intervention studies. While half (27) of the studies focused exclusively on adolescents (10-19 years), 12 studies combined adolescents with other young people (10-24 years). The studies were skewed towards sexual behavior (44%) and HIV/AIDS (43%) with very few studies focusing on other SRHR issues such as contraception, abortion, gender-based violence and sexually transmitted infections (STIs) other than HIV. Most of the studies highlighted the significantly higher risks for poor SRHR outcomes among adolescents in slums as compared to their peers in other settlements.

CONCLUSION

Young people growing up in slums face tremendous challenges in relation to their SRHR needs resulting in poor outcomes such as early and unintended pregnancy, STIs, and sexual violence. The results of this review point to several potential target areas for programming, policy, and research aimed at improved adolescent SRHR in slums in SSA.

Factors associated with HIV testing and intention to test for HIV among the general population of Nonthaburi Province, Thailand

BACKGROUND

Research on HIV testing in Thailand has largely focused on at-risk population groups, with limited information about the prevalence of correlates of HIV testing among the Thai general population. This study addresses this gap in research by using a population-based probability sample to examine correlates of HIV testing experience and intention to test.

METHODS

We conducted a cross-sectional survey in Nonthaburi, Thailand during October-December 2012 using tablet computers to collect self-administered questionnaires from 2138 men and women (aged 15-59 years) identified through three-stage stratified cluster sampling.

FINDINGS

Almost half of the respondents, 962 (45%), reported having been tested for HIV while an almost equal proportion, 1032 (48.3%), indicated their intention to test for HIV. Being sexually experienced, having a history of sexually transmitted infection, personally knowing someone infected with HIV, and youth were associated with both history of HIV testing and intention to test for HIV. High perceived risk of HIV, knowledge of an HIV testing location, and having been married were associated with having been tested for HIV. Having been tested for HIV and HIV/AIDS education were associated with intention to test for HIV. The most common reasons for testing were routine medical checkup and antenatal care. The major reasons for not testing were perception of having no or low risk.

CONCLUSION

A substantially low proportion of the respondents reported a history of HIV testing and intention to test for HIV. Culturally appropriate programs that address HIV risk perception and provide accurate information related to HIV infection and HIV testing may be beneficial in increasing uptake of HIV testing among the general population in Thailand.

Is it time to RE-AIM? A systematic review of economic empowerment as HIV prevention intervention for adolescent girls and young women in sub-Saharan Africa using the RE-AIM framework

BACKGROUND

Economic empowerment (EE) HIV prevention programs for adolescent girls and young women (AGYW) in sub-Saharan Africa are gaining traction as effective strategies to reduce HIV risk and vulnerabilities among this population. While intervention effectiveness is critical, there are numerous factors beyond effectiveness that shape an intervention's impact. The objective of this systematic review was to assess the reporting of implementation outcomes of EE HIV prevention programs for AGYW in SSA, as conceptualized in the RE-AIM (reach, efficacy/effectiveness, adoption, implementation, and maintenance) framework.

METHODS

We searched PubMed, Ovid/MEDLINE, Science Direct, Ebscohost, PsycINFO, Scopus, and Web of Science for EE HIV interventions for AGYW in SSA. Study selection and data extraction were conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Two researchers coded each article using a validated RE-AIM data extraction tool and independently extracted information from each article. The reporting of RE-AIM dimensions were summarized and synthesized across included interventions.

RESULTS

A total of 25 unique interventions (reported in 45 articles) met the predefined eligibility criteria. Efficacy/effectiveness 19(74.4%) was the highest reported RE-AIM dimension, followed by adoption 17(67.2%), reach 16(64.0%), implementation 9(38.0%), and maintenance 7(26.4%). Most interventions reported on RE-AIM components such as sample size 25(100.0%), intervention location 24(96.0%), and measures and results for at least one follow-up 24(96.0%). Few reported on RE-AIM components such as characteristics of non-participants 8(32.0%), implementation costs 3(12.0%), and intervention fidelity 0(0.0%).

CONCLUSIONS

Results of the review emphasize the need for future economic empowerment HIV prevention interventions for AGYW in SSA to report multiple implementation strategies and highlight considerations for translating such programs into real-world settings. Researchers should pay close attention to reporting setting-level adoption, implementation cost, and intervention maintenance. These measures are needed for policy decisions related to the full merit and worth of EE HIV interventions and their long-term sustainability for AGYW.

A smartphone game to prevent HIV among young Kenyans: local perceptions of mechanisms of effect

Electronic games delivered via smartphones have the potential to become valuable tools in HIV prevention in high-prevalence and low-resource international settings. To ground theoretical elaboration around novel mHealth interventions in contextual realities, it is important to understand the mechanisms of their effects as perceived by local populations. Such perspectives are particularly important when working cross-culturally. 'Tumaini' is an interactive narrative-based smartphone game that uses a 'choose-your-own-adventure' format. It is designed to prevent HIV among young African adolescents (aged 11-14) by increasing age and condom use at first sex. It was developed with a US-based commercial game developer and is grounded in social behavioral theory, evidence-based practice and contextually relevant scenarios. In a 2017 randomized pilot study (n = 60) in Western Kenya, 'Tumaini' showed promising effects on behavioral mediators of sexual debut. In subsequent focus group discussions, adolescent participants and their parents shared their perceptions of the game's mechanisms of effect, which included motivation to play, future orientation, decision-making, relationship to a diverse range of characters and a bridging of the virtual and real worlds. These findings align with our theoretical framework, confirm its successful translation into the intervention and will inform mediation analyses in an upcoming efficacy trial.

Predictors and Barriers to Condom Use in the African Cohort Study

Consistent condom use is an inexpensive and efficacious HIV prevention strategy. Understanding factors associated with condom use and barriers to use can inform strategies to increase condom uptake. The ongoing African Cohort Study prospectively enrolls adults at 12 clinical sites in Uganda, Kenya, Tanzania, and Nigeria. At enrollment, participants are asked about condom use at last sex with a regular partner. Robust Poisson regression models were used to evaluate predictors of self-reported condom use. Participants who reported not using condoms were asked to provide reasons. From January 2013 to September 2019, 2482 participants reported having at least one regular sexual partner in the preceding 6 months. Of those, 1577 (63.5%) reported using a condom at last sex. Condom use was more common among older participants, males, HIV-infected participants, and those with an HIV-infected partner. Married participants, those with a partner of unknown HIV status, and those reporting alcohol use were less likely to report condom use at last sex. Condom use at last sex also varied significantly by clinical site. Partner disapproval or refusal to use a condom was a consistent driver of disparities in condom use among participants who were HIV infected, female, and aged 18-24 years. Effective HIV prevention programs should integrate condom education with the tools necessary to negotiate condom use with regular partners.

Predictors of Health Insurance Enrollment among HIV Positive Pregnant Women in Kenya: Potential for Adverse Selection and Implications for HIV Treatment and Prevention

Background: The global push to achieve the 90-90-90 targets designed to end the HIV epidemic has called for the removing of policy barriers to prevention and treatment, and ensuring financial sustainability of HIV programs. Universal health insurance is one tool that can be used to this end. In sub-Saharan Africa, where HIV prevalence and incidence remain high, the use of health insurance to provide comprehensive HIV care is limited. This study looked at the factors that best predict social health insurance enrollment among HIV positive pregnant women using data from the Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. Methods: Cross-sectional clinical encounter data were extracted from the electronic medical records (EMR) at AMPATH. We used univariate and multivariate logistic regressions to estimate the predictors of health insurance enrollment among HIV positive pregnant women. The analysis was further stratified by HIV disease severity (based on CD4 cell count <350 and 350>) to test the possibility of differential enrollment given HIV disease state. Results: Approximately 7% of HIV infected women delivering at a healthcare facility had health insurance. HIV positive pregnant women who deliver at a health facility had twice the odds of enrolling in insurance [2.46 Adjusted Odds Ratio (AOR), Confidence Interval (CI) 1.24-4.87]. They were 10 times more likely to have insurance if they were lost to follow-up to HIV care during pregnancy [9.90 AOR; CI 3.42-28.67], and three times more likely to enroll if they sought care at an urban clinic [2.50 AOR; 95% CI 1.53-4.12]. Being on HIV treatment was negatively associated with health insurance enrollment [0.22 AOR; CI 0.10-0.49]. Stratifying the analysis by HIV disease severity while statistically significant did not change these results. Conclusions: The findings indicated that health insurance enrollment among HIV positive pregnant women was low mirroring national levels. Additionally, structural factors, such as access to institutional delivery and location of healthcare facilities, increased the likelihood of health insurance enrollment within this population. However, behavioral aspects, such as being lost to follow-up to HIV care during pregnancy and being on HIV treatment, had an ambiguous effect on insurance enrollment. This may potentially be because of adverse selection and information asymmetries. Further understanding of the relationship between insurance and HIV is needed if health insurance is to be utilized for HIV treatment and prevention in limited resource settings.

Mapping and characterising areas with high levels of HIV transmission in sub-Saharan Africa: A geospatial analysis of national survey data

BACKGROUND

In the generalised epidemics of sub-Saharan Africa (SSA), human immunodeficiency virus (HIV) prevalence shows patterns of clustered micro-epidemics. We mapped and characterised these high-prevalence areas for young adults (15-29 years of age), as a proxy for areas with high levels of transmission, for 7 countries in Eastern and Southern Africa: Kenya, Malawi, Mozambique, Tanzania, Uganda, Zambia, and Zimbabwe.

METHODS AND FINDINGS

We used geolocated survey data from the most recent United States Agency for International Development (USAID) demographic and health surveys (DHSs) and AIDS indicator surveys (AISs) (collected between 2008-2009 and 2015-2016), which included about 113,000 adults-of which there were about 53,000 young adults (27,000 women, 28,000 men)-from over 3,500 sample locations. First, ordinary kriging was applied to predict HIV prevalence at unmeasured locations. Second, we explored to what extent behavioural, socioeconomic, and environmental factors explain HIV prevalence at the individual- and sample-location level, by developing a series of multilevel multivariable logistic regression models and geospatially visualising unexplained model heterogeneity. National-level HIV prevalence for young adults ranged from 2.2% in Tanzania to 7.7% in Mozambique. However, at the subnational level, we found areas with prevalence among young adults as high as 11% or 15% alternating with areas with prevalence between 0% and 2%, suggesting the existence of areas with high levels of transmission Overall, 15.6% of heterogeneity could be explained by an interplay of known behavioural, socioeconomic, and environmental factors. Maps of the interpolated random effect estimates show that environmental variables, representing indicators of economic activity, were most powerful in explaining high-prevalence areas. Main study limitations were the inability to infer causality due to the cross-sectional nature of the surveys and the likely under-sampling of key populations in the surveys.

CONCLUSIONS

We found that, among young adults, micro-epidemics of relatively high HIV prevalence alternate with areas of very low prevalence, clearly illustrating the existence of areas with high levels of transmission. These areas are partially characterised by high economic activity, relatively high socioeconomic status, and risky sexual behaviour. Localised HIV prevention interventions specifically tailored to the populations at risk will be essential to curb transmission. More fine-scale geospatial mapping of key populations,-such as sex workers and migrant populations-could help us further understand the drivers of these areas with high levels of transmission and help us determine how they fuel the generalised epidemics in SSA.

There's an App for That: Using Geosocial Networking Apps to Access Young Black Gay, Bisexual, and other MSM at Risk for HIV

PURPOSE

Young black gay, bisexual, and other MSM (YBMSM) that carry a disproportionate HIV burden in the US Geosocial networking applications (GSN apps) are environments that may increase HIV risk among users. This study explored the acceptability and feasibility of using these apps for HIV/sexually transmitted infection (STI) public health outreach.

DESIGN

Semi-structured in-depth qualitative interviews.

SETTING

A frequently reported GSN app for meeting sex partners by newly diagnosed HIV-infected MSM in Baltimore.

PARTICIPANTS

Seventeen YBMSM aged 18 to 24 (mean = 21.5/SD = 1.8) who were logged-on to the GSN app in venues or census tracts in high HIV transmission areas.

METHODS

Participants completed 60 to 90 minute semi-structured interviews, which were audio-recorded and transcribed. Interview data were analyzed in NVivo10 using categorical analysis and double-coded until consistency was achieved.

RESULTS

Participants described GSN apps as acceptable and feasible resources for public health practitioners seeking to access YBMSM to provide HIV/STI treatment and prevention services and resources. Three themes emerged: (1) the need to authenticate public health messages to distinguish from spam; (2) improved access to YBMSM including opportunities to identify and access virtual congregations of youth in non-gay-related spaces; and (3) the importance of avoiding stigmatizing YBMSM when targeting sexual health messages.

CONCLUSION

GSN apps have great potential as tools for identifying and engaging at-risk YBMSM. Additional work is needed to understand limitations of this medium, to develop strategies to engage YBMSM without further stigmatizing them, and to maximize their outreach potential.

Decision-making and cash spending patterns of adolescent girls and young women participating in a cash-transfer intervention in Tanzania: Implications for sexual health

Although cash transfers (CT) have been recommended as a strategy to address structural drivers of HIV, the evidence of the effects of CT on sexual risk and HIV outcomes is mixed. This could partly be due to CT implementation dynamics and beneficiary interpersonal factors. We conducted an assessment of CT component of the DREAMS programme in Tanzania. We explored how AGYW spent their CT over time, to whom they disclosed cash receipt, and where they sought advice on CT use. The study employed qualitative research methods including: 20 longitudinal in-depth interviews (IDIs) and 60 cross-sectional IDIs with AGYW in the CT programme. Data were analysed thematically. AGYW use of CT fell into five categories: business development, survival, self-care, helping family, and savings. The primary uses of CT funds were investment in businesses and livestock for savings. AGYW use of cash changed over instalments. AGYW consulted a variety of sources when deciding on how to use the cash, primarily mothers, programme personnel, and long-term partners/husbands. CT programmes that give cash directly to AGYW and have a strong entrepreneurial mentorship component could have implications for HIV prevention, SRH, and overall social and economic development.

The Political, Research, Programmatic, and Social Responses to Adolescent Sexual and Reproductive Health and Rights in the 25 Years Since the International Conference on Population and Development

Among the ground-breaking achievements of the International Conference on Population and Development (ICPD) was its call to place adolescent sexual and reproductive health (ASRH) on global health and development agendas. This article reviews progress made in low- and middle-income countries in the 25 years since the ICPD in six areas central to ASRH-adolescent pregnancy, HIV, child marriage, violence against women and girls, female genital mutilation, and menstrual hygiene and health. It also examines the ICPD's contribution to the progress made. The article presents epidemiologic levels and trends; political, research, programmatic and social responses; and factors that helped or hindered progress. To do so, it draws on research evidence and programmatic experience and the expertise and experiences of a wide number of individuals, including youth leaders, in numerous countries and organizations. Overall, looking across the six health topics over a 25-year trajectory, there has been great progress at the global and regional levels in putting adolescent health, and especially adolescent sexual and reproductive health and rights, higher on the agenda, raising investment in this area, building the epidemiologic and evidence-base, and setting norms to guide investment and action. At the national level, too, there has been progress in formulating laws and policies, developing strategies and programs and executing them, and engaging communities and societies in moving the agenda forward. Still, progress has been uneven across issues and geography. Furthermore, it has raced ahead sometimes and has stalled at others. The ICPD's Plan of Action contributed to the progress made in ASRH not just because of its bold call in 1994 but also because it provided a springboard for advocacy, investment, action, and research that remains important to this day.

Parental Communication, Engagement, and Support During the Adolescent Voluntary Medical Male Circumcision Experience

Background

Voluntary medical male circumcision (VMMC) is one of few opportunities in sub-Saharan Africa to engage male adolescents in the healthcare system. Limited data are available on the level of parental communication, engagement, and support adolescents receive during the VMMC experience.

Methods

We conducted 24 focus group discussions with parents/guardians of adolescents (N = 192) who agreed to be circumcised or were recently circumcised in South Africa, Tanzania, and Zimbabwe. In addition, male adolescents (N = 1293) in South Africa (n = 299), Tanzania (n = 498), and Zimbabwe (n = 496) were interviewed about their VMMC experience within 7-10 days postprocedure. We estimated adjusted prevalence ratios (aPRs) using multivariable Poisson regression with generalized estimating equations and robust standard errors.

Results

Parents/guardians noted challenges and gaps in communicating with their sons about VMMC, especially when they did not accompany them to the clinic. Adolescents aged 10-14 years were significantly more likely than 15- to 19-year-olds to report that their parent accompanied them to a preprocedure counseling session (56.5% vs 12.5%; P < .001). Among adolescents, younger age (aPR, 0.86; 95% confidence interval [CI], .76-.99) and rural setting (aPR, 0.34; 95% CI, .13-.89) were less likely to be associated with parental-adolescent communication barriers, while lower socioeconomic status (aPR, 1.37; 95% CI, 1.00-1.87), being agnostic (or of a nondominant religion; aPR, 2.87; 95% CI, 2.21-3.72), and living in South Africa (aPR, 2.63; 95% CI, 1.29-4.73) were associated with greater perceived barriers to parental-adolescent communication about VMMC. Parents/guardians found it more difficult to be involved in wound care for older adolescents than for adolescents <15 years of age.

Conclusions

Parents play a vital role in the VMMC experience, especially for younger male adolescents. Strategies are needed to inform parents completely throughout the VMMC adolescent experience, whether or not they accompany their sons to clinics.

Acceptability and Barriers to HIV Pre-Exposure Prophylaxis in Atlanta's Adolescents and Their Parents

Adolescents aged 13-24 years account for 23% of new HIV infections in Atlanta, indicating need for better HIV prevention strategies in this population. Pre-exposure prophylaxis (PrEP) is now approved for adolescent use. This study aims to understand the acceptability of and barriers to PrEP in adolescents and parents. We administered PrEP acceptability and barrier measures to HIV(-) 13-17 year olds and their parents from January to April 2016 in an adolescent clinic and emergency department in Atlanta, GA, stratifying by adolescent sexual activity. Acceptability scores (AS) and barrier scores (BS) were calculated by averaging survey answers 1-3. For AS, 1 was very unlikely to accept PrEP; concomitantly, BS near 3 indicated fewer barriers. Two-sample hypothesis testing, Pearson correlations, and linear regression were used. Of the 102 adolescent/parent dyads, 67% of adolescents were female, 94% black, with a mean age of 15.7 ± 1.5 years, and 31% were sexually active. Parents were 94% female, 96% black, with a mean age of 42.4 ± 8.9 years. AS averaged between somewhat to very likely to accept PrEP (2.4 ± 0.5 and 2.2 ± 0.6) in adolescents and parents, respectively. BS averaged between unlikely and somewhat likely to perceive barriers to PrEP (2.0 ± 0.4 and 1.9 ± 0.5) in adolescents and parents, respectively. The adolescent/parent dyad is likely to accept PrEP, regardless of sexual activity. Limitations include that nearly 70% of adolescents were not sexually active, and the study was conducted before PrEP approval by the Food and Drug Administration for those who are younger than 18 years. These results support future parent and adolescent education on PrEP.

Mobile sexual health services for adolescents: investigating the acceptability of youth-directed mobile clinic services in Cape Town, South Africa

BACKGROUND

The Human Immunodeficiency Virus (HIV) epidemic is growing rapidly among South African adolescents and young adults (AYA). Although HIV counselling and testing, HIV prevention and treatment options are widely available, many AYA delay health-seeking until illness occurs, demonstrating a need for youth responsive, integrated sexual and reproductive health services (SRHS). While feasibility and cost-effectiveness have been evaluated, acceptability of mobile clinics among AYA has yet to be established. The objective of this study was to investigate patient acceptability of mobile AYA SRHS and compare mobile clinic usage and HIV outcomes with nearby conventional clinics.

METHODS

Patients presenting to a mobile clinic in Cape Town were invited to participate in an acceptability study of a mobile clinic after using the service. A trained researcher administered an acceptability questionnaire. Mobile clinic medical records during the study period were compared with the records of AYA attending four clinics in the same community.

RESULTS

Three hundred three enrolled participants (16-24 years, 246 (81.2%) female) rated mobile AYA SRHS acceptability highly (median = 4,6 out of 5), with 90% rating their experience as better or much better than conventional clinics. The mobile clinic, compared to conventional clinics, attracted more men (26% v 13%, p < 0,000), younger patients (18 v 19 years, p < 0,000), and yielded more HIV diagnoses (4% v 2%, p < 0,000).

CONCLUSIONS

Given the high ratings of acceptability, and the preference for mobile clinics over conventional primary health clinics, the scalability of mobile clinics should be investigated as part of a multipronged approach to improve the uptake of SRHS diagnostic, prevention and treatment options for AYA.

The future of a partially effective HIV vaccine: assessing limitations at the population level

OBJECTIVES

Mathematical models have unanimously predicted that a first-generation HIV vaccine would be useful and cost-effective to roll out, but that its overall impact would be insufficient to reverse the epidemic. Here, we explore what factors contribute most to limiting the impact of such a vaccine.

METHODS

Ranging from a theoretical ideal to a more realistic regimen, mirroring the one used in the currently ongoing trial in South Africa (HVTN 702), we model a nested hierarchy of vaccine attributes such as speed of scale-up, efficacy, durability, and return rates for booster doses.

RESULTS

The predominant reasons leading to a substantial loss of vaccine impact on the HIV epidemic are the time required to scale up mass vaccination, limited durability, and waning of efficacy.

CONCLUSIONS

A first-generation partially effective vaccine would primarily serve as an intermediate milestone, furnishing correlates of immunity and platforms that could serve to accelerate future development of a highly effective, durable, and scalable next-generation vaccine capable of reversing the HIV epidemic.

HIV care continuum among newly diagnosed student and non-student youths between 2012 and 2016 in Hangzhou, China

BACKGROUND

Youths are disproportionally affected by the human immunodeficiency virus (HIV) infection. We aimed to assess anti-retroviral therapy (ART) initiation and viral suppression rates among student and non-student youths in Hangzhou, China.

METHODS

Data were taken from the Chinese HIV/acquired immune deficiency syndrome Comprehensive Response Information Management System. Youths aged 15 to 24 years who were newly diagnosed with HIV between 2012 and 2016 and were living in Hangzhou were included in the study. Comparisons between student and non-student youths were made for ART initiation within 30 days, 90 days, and 12 months of HIV diagnosis, and the viral suppression rate at 12 months of HIV diagnosis and at 12 months of ART initiation.

RESULTS

A total of 707 cases met inclusion criteria, 29.6% of which were students and 70.4% were non-student youths. The student group had a higher proportion of ART initiation compared with the non-student group within 30 days of diagnosis (45.5% vs. 37.0%, P = 0.044), and a slightly higher but not statistically significant proportion at 90 days (67.0% vs. 62.7%), and 12 months (83.7% vs. 78.5%) of HIV diagnosis. ART initiation within 30 days improved from <15% in 2012 to over 65% in 2016 in both groups, and ART initiation within 90 days improved from <30% in 2012 to >90% in 2016. A smaller proportion of students experienced viral suppression compared with the non-student group (9.6% vs. 17.1%, P = 0.011) at 12 months after HIV diagnosis, but the suppression rate was similar at 12 months of ART initiation (69.9% vs. 71.1%, P = 0.743).

CONCLUSIONS

ART initiation in both student and non-student youths has significantly improved between 2012 and 2016. However, the viral suppression rate remained unacceptably low at 12 months of HIV diagnosis in both student and non-student groups. Specific intervention strategies must be taken to address this challenge.

A Smartphone Game to Prevent HIV Among Young Africans (Tumaini): Assessing Intervention and Study Acceptability Among Adolescents and Their Parents in a Randomized Controlled Trial

Background

Young people aged 15 to 24 years account for one-third of new adult HIV infections. Controlling the HIV epidemic requires effective interventions targeted toward young people and their needs. Smartphone games offer a promising avenue for reaching this population with evidence-based HIV prevention interventions. It is crucial to the effectiveness of these interventions that they be acceptable and intrinsically motivating to adolescents as well as acceptable to their parents.

Objective

Tumaini is a narrative-based smartphone game designed to help prevent HIV among young Africans aged 11 to 14 years by delaying first sex and increasing condom use at first sex. Following a 16-day feasibility study of Tumaini, we assessed the acceptability (1) of the intervention, where acceptability was operationalized as appeal, relevance, value, usability, and understandability, and (2) of this study and a planned future randomized controlled efficacy trial.

Methods

During the randomized feasibility study (n=60) of Tumaini in western Kenya in spring 2017, 30 participants used the intervention on a study-provided smartphone. The app automatically logged participant interaction with the game in time-stamped log files. All 30 participants completed an Audio Computer-Assisted Self-Interview–based game experience survey, and 27 took part in 4 focus group discussions (FGDs) about the game’s appeal, relevance, value, usability, and understandability. Their parents (n=22) also participated in 4 FGDs about the acceptability of the intervention, of this study, and of a planned efficacy trial. Survey data were analyzed using SAS software (SAS Institute Inc); FGD transcripts were coded and analyzed in MAXQDA 12 (Verbi GmbH); and gameplay log files were analyzed using Microsoft Excel.

Results

Adolescent participants’ survey responses indicated that Tumaini scored well with players on all indicators of acceptability (appeal, relevance, value, usability, and understandability). Focus group analyses aligned with these findings and emphasized a high degree of player engagement with the game, which was supported by log file analysis. Adolescent participants were eager for additional content, and parents were receptive to a longer study involving biomarkers, based on their positive experiences with this study. There is scope to improve communication with parents about their role in the intervention. As the game was tested in beta version, there is also scope to fine-tune some of the game mechanics to increase usability.

Conclusions

This study shows the strong acceptability of an interactive smartphone-based game both to adolescents and their parents in western Kenya and that of the study methods used to pilot-test the intervention. It also suggests that longitudinal efficacy studies of this type of intervention, including those using biomarkers, have the potential to be acceptable among parents.

Trial Registration

ClinicalTrials.gov NCT03054051; https://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW)

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

PURPOSE

Evidence suggests that young adults experiencing homelessness (YEH) are at elevated risk of HIV compared to housed youth. Given the limited research on pre-exposure prophylaxis (PrEP) awareness among YEH, this study examined their PrEP knowledge and attitudes.

METHODS

Data from a cross-sectional survey among YEH (ages 18-26) (n = 1,427) in seven U.S. cities were used to assess their knowledge and attitudes regarding PrEP to inform HIV prevention efforts.

RESULTS

Participants were primarily male youth of color. The mean age was 20.9years. While 66% felt at risk for HIV, only 14% strongly agreed that they try to protect themselves from getting infected with HIV. Most (84%) were eligible for PrEP based on risk, yet only 29% had knowledge of PrEP. Despite this, 59% reported they were likely/extremely likely to take PrEP. Access to free PrEP (55%), HIV testing (72%), healthcare (68%), and one-on-one (62%), and text messaging support (57%) were rated as very/extremely important for PrEP uptake and adherence.

CONCLUSIONS

The results of this study suggest missed opportunities to prevent new HIV infections among YEH. Efforts to increase PrEP uptake among this population should consider provider- and system-level interventions to increase PrEP awareness, decrease PrEP-associated healthcare costs, improve access to PrEP providers, and provide in-person and text messaging support.

A Smartphone Game to Prevent HIV Among Young Africans: Protocol for a Randomized Pilot Study of a Mobile Intervention

Background

Young people aged under 25 years make up an increasing proportion of the population in emerging economies such as Kenya, where half of new adult HIV infections are among 15- to 24-year olds. Interventions targeting this age group have the potential to avert HIV infections among an increasingly large at-risk population. Interactive communication technologies offer a promising platform for reaching young people in engaging ways.

Objective

Tumaini is a narrative-based smartphone game designed to help young Africans protect themselves from HIV. The objective of this study was to pilot test the game, focusing on the data needed to inform a future randomized controlled efficacy trial, including assessments of study feasibility and safety.

Methods

The study took place in Kisumu Town, western Kenya, in spring 2017. The game-based intervention was pilot tested for 16 days with a sample of 60 preadolescents aged 11 to 14 years. Participant recruitment was initiated through schools. Participants were randomly assigned to the control or intervention arms of the study. One parent for each of the intervention arm participants was also recruited (n=30). The intervention arm participants were provided with smartphones on which Tumaini was loaded so that they could play the game at home. Youth completed behavioral surveys at baseline, posttest, and 6-week follow-up. The intervention arm participants provided quantitative feedback on their experience of the game-based intervention at posttest. They and their parents further participated in postintervention focus group discussions. Feasibility-related study metrics were collected on recruitment, enrollment, attrition, safety of participants, and return of phones.

Results

Recruitment and enrollment of the 60 preadolescents and parents were successfully completed within 18 days. No participants were lost to follow-up: all youth completed all 3 waves of the survey and 27 intervention arm youth and 22 parents and caregivers participated in the focus groups. No safety concerns were reported. All phones were returned after the intervention period; none were damaged or lost. All intervention arm participants initiated gameplay, recording a mean exposure time just under 27 hours.

Conclusions

Findings indicate that it is feasible and safe to test a smartphone-based HIV prevention intervention for very young adolescents in urban and peri-urban sub-Saharan Africa by initiating recruitment in schools and temporarily providing youth participants with smartphones on which the game is loaded. A randomized controlled trial powered to assess the efficacy of the game-based intervention is being designed to be carried out in the same geographic area as the pilot, using similar methods.

Trial Registration

ClinicalTrials.gov NCT03054051; https://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/6wjwpX8Bg.)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11209

Who is sexually active? Using a multi-component sexual activity profile (MSAP) to explore, identify and describe sexually-active high-school students in rural KwaZulu-Natal, South Africa

BACKGROUND

Understanding sexual activity is necessary to prevent sexually transmitted infections. Evidence from Sub-Saharan Africa suggests that 10-20% of youth aged 15-24 are sexually active before reaching 15 years, yet estimating sexual activity remains challenging. This study explored the use of multiple sexual health outcomes to identify sexually-active young women in rural KwaZulu-Natal, South Africa.

METHODS

Using a multi-component sexual activity profile (MSAP), we aimed to identify sexually active students. Based on data from 2675 grade 9 and 10 students attending 14 high schools) in rural KwaZulu-Natal, we constructed a descriptive diagram identifying students who were sexually active by self-report vs MSAP profile. T-tests for two independent samples was performed to compare by sex and ecological variables that characterise students newly-identified as sexually active.

RESULTS

Using self-report only, 40.3% self-reported as sexually active, whilst the MSAP identified 48.7% (223 additional students). More females were identified than males. Younger adolescents were more likely to underreport sexual activity but were identified using MSAP. Newly-identified as sexually active were more likely to be female (p = < 0.000), 15 years old or younger (p = 0.008), less likely to perceive being at risk (p = 0.037) or have ever used alcohol (p = < 0.000). At a relational level, they were less likely to report having ever had a boyfriend/girlfriend (p = 0.000) or to have felt pressured to have sex by their peers (p = < 0.000) or partners (p = 0.008). At a familial level they more likely to be of medium socioeconomic (SES) status (p = 0.037) whilst at a school and community level they were less likely to have repeated a grade (p = 0.024) and were more likely to be engaged in social activities (p = 0.032).

CONCLUSIONS

The MSAP profile identified more potentially sexually active students, and gave insight into the characteristics of students who may be unwilling to self-report sexual activity Future work should investigate how this approach could enhance and describe sexually-active adolescents for research and healthcare provision.

The DREAMS core package of interventions: A comprehensive approach to preventing HIV among adolescent girls and young women

In sub-Saharan Africa, adolescent girls and young women (AGYW) are 5 to 14 times more likely to be infected with HIV than their male peers. Every day, more than 750 AGYW are infected with HIV. Many factors make girls and young women particularly vulnerable to HIV, including gender-based violence, exclusion from economic opportunities, and a lack of access to secondary school. The President's Emergency Plan for AIDS Relief (PEPFAR) is dedicating significant resources through the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) partnership to impact the lives of women and girls based on PEPFAR's mission to help countries achieve epidemic control of HIV/AIDS. The data show that new HIV infections must be reduced in AGYW, or the global community risks losing the extensive progress made towards reaching epidemic control. With support from PEPFAR and private sector partners-the Bill & Melinda Gates Foundation, Gilead Sciences, Girl Effect, Johnson & Johnson and ViiV Healthcare, DREAMS works together with partner governments to deliver a core package of interventions that combines evidence-based approaches that go beyond the health sector, addressing the structural drivers that directly and indirectly increase girls' HIV risk. Not only is DREAMS an effort to reduce new HIV infections, but it aims to reduce other critical vulnerabilities such as gender-based violence. When girls and young women thrive, the effects are felt throughout their families, communities and countries.

Navigating stigma, survival, and sex in contexts of social inequity among young transgender women and sexually diverse men in Kingston, Jamaica

Social inequities, including stigma, criminalisation of same-sex practices, and poverty, elevate HIV exposure among young transgender women and sexually diverse men in Jamaica. Yet the ways transgender women and sexually diverse men in Jamaica navigate sex and HIV in contexts of social inequity are underexplored. The study objective was to explore experiences and perceptions of sexual decision-making and HIV risk among young (aged 18-30) sexually diverse men and transgender women in Kingston, Jamaica. We conducted a community-based qualitative study in Kingston that involved in-depth individual interviews (transgender women: n = 20; sexually diverse men: n = 20), 2 focus groups (transgender women: n = 8; sexually diverse men: n = 10) and 13 key informant interviews. Focus groups and interviews were digitally recorded, transcribed verbatim, and analysed with a thematic approach. Findings suggest that transgender women and sexually diverse men in Kingston are aware of, and managing survival challenges and HIV risks in contexts of social inequity. Daily survival challenges include stigma and a lack of human rights protections that contributed to barriers to employment, housing, healthcare, education, and exposure to violence. Challenges maintaining sexual relationships included the need to hide for safety, often resulting in difficulties forming lasting relationships. These survival and relationship challenges converged to lower self-esteem and self-acceptance. In the face of these challenges, participants navigated sexual risk and pleasure. Findings provide insight into agency and sexual decision-making processes in contexts of social inequities. Findings can inform multi-level strategies to promote social equity, sexual health, and HIV prevention with young transgender women and sexually diverse men in Jamaica.

Condom Use and its Associated Factors Among Iranian Youth: Results From a Population-Based Study

Background: Given the young structure of Iran’s population and the fact that extramarital sexual relationships are both prohibited by legislation and shunned by society and religion, examining condom use practices among Iranian youth is highly important. The aim of this study was to explore condom use and its correlates among Iranian young adults.

Methods: In a sample of 3,045 individuals aged 19-29 who were recruited from a nation-wide study, we analyzed data from 633 participants who reported a history of extramarital sex. Subjects were asked about their condom use practices during their last penetrative sex. Data were collected through a self-administered questionnaire where the respondents completed the survey on their own and passed it to trained gender-matched interviewers. Multivariable regression models were constructed to report adjusted odds ratios (AOR) along with 95% CI.

Results: Of the 633 participants, 222 (35.1%) reported condom use at last sex. Men reported significantly higher condom use than women (38.5% vs. 25.7%). Having a stable job (AOR = 1.86, 95% CI: 1.01, 3.43), higher knowledge of condom use (AOR = 1.57, 95% CI: 1.03, 2.37) and sexual transmission of HIV (AOR = 1.83, 95% CI: 1.18, 2.85) were positively associated with condom use at last sex. Conversely, experience of sex under the influence of substances (AOR = 0.66, 95% CI: 0.45, 0.94) was significantly associated with reduced odds of condom use at last sex.

Conclusion: This study shows that only one out of every three young adults reported using condoms at last sex. While educational programs are helpful, multi-sectoral approaches (eg, individual-, community-, and structural-level interventions) are required to change sexual behaviours towards safe sex practices and reinforce negotiating condom use among youth.

Does Partner Selection Mediate the Relationship Between School Attendance and HIV/Herpes Simplex Virus-2 Among Adolescent Girls and Young Women in South Africa: An Analysis of HIV Prevention Trials Network 068 Data

OBJECTIVE

School attendance prevents HIV and herpes simplex virus-2 (HSV-2) in adolescent girls and young women, but the mechanisms to explain this relationship remain unclear. Our study assesses the extent to which characteristics of sex partners, partner age, and number mediate the relationship between attendance and risk of infection in adolescent girls and young women in South Africa.

DESIGN

We use longitudinal data from the HIV Prevention Trials Network 068 randomized controlled trial in rural South Africa, where girls were enrolled in early adolescence and followed in the main trial for more than 3 years. We examined older partners and the number of partners as possible mediators.

METHODS

We used the parametric g-formula to estimate 4-year risk differences for the effect of school attendance on the cumulative incidence of HIV/HSV-2 overall and the controlled direct effect (CDE) for mediation. We examined mediation separately and jointly for the mediators of interest.

RESULTS

We found that young women with high attendance in school had a lower cumulative incidence of HIV compared with those with low attendance (risk difference = -1.6%). Partner age difference (CDE = -1.2%) and the number of partners (CDE = -0.4%) mediated a large portion of this effect. In fact, when we accounted for the mediators jointly, the effect of schooling on HIV was almost removed, showing full mediation (CDE = -0.3%). The same patterns were observed for the relationship between school attendance and cumulative incidence of HSV-2 infection.

CONCLUSION

Increasing school attendance reduces the risk of acquiring HIV and HSV-2. Our results indicate the importance of school attendance in reducing partner number and partner age difference in this relationship.

Risk factors for HIV infection among 15 to 25-year-old rural unmarried Yi adolescents in an ethnic minority region of China

We aimed to analyze factors related to human immunodeficiency virus (HIV) infection among 15 to 25-year-old rural unmarried Yi adolescents in Liangshan Yi Autonomous Prefecture from 2011 to 2016, and to investigate the relationship among the HIV-related risk factors.Three sites (Butuo, Zhaojue, and Ganluo counties) with a Yi population were selected from 2011 to 2016 in Liangshan prefecture. We used questionnaires to investigate demographic and behavioral characteristics and performed HIV testing. Logistic regression analysis and multiple correspondence analysis (MCA) were used to analyze the data.A total of 6311 qualified rural unmarried Yi adolescents were involved in this study, with an HIV infection rate of 4.18% (264/6311). Logistic regression analysis indicated that males (OR = 1.56, 95% CI = 1.17-2.08), illiteracy (OR = 2.70, 95% CI = 1.79-4.08), primary school education or below (OR = 1.62, 95% CI = 1.12-2.36), history of out-migrating for work (OR = 1.58, 95% CI = 1.18-2.13), and injecting drug user (IDU) (OR = 6.42, 95% CI = 3.06-13.46) contributed to the risk of HIV infection. MCA revealed a strong interrelationship between the following risk factors and HIV infection: aged 23 to 25 years, IDU, history of out-migrating for work, and ever having sexual behaviors.HIV infection among 15 to 25-year-old rural unmarried Yi adolescents in Liangshan is a serious issue. MCA and logistic regression analysis can be used to assess the relationship between risk factors for HIV infection.

Sexual Self-Efficacy and Gender: A Review of Condom Use and Sexual Negotiation Among Young Men and Women in Sub-Saharan Africa

Sexual self-efficacy (SSE), one's perceived control of or confidence in the ability to perform a given sexual outcome, predicts sexual behavior; however, important questions remain regarding whether gender modifies observed associations. In a comprehensive review of peer-reviewed HIV-prevention literature focusing on youth (ages 10 to 25) in sub-Saharan Africa, we measured and assessed the influence of SSE on condom use and sexual refusal, overall and by gender. Our results, after reviewing 63 publications, show that SSE is inconsistently measured. Most studies measured condom use self-efficacy (CUSE) (96.8%) and/or sexual refusal self-efficacy (SRSE) (63.5%). On average, young men had higher CUSE than young women, while young women had higher SRSE than young men. While cross-sectional studies reported an association between high SSE and sexual behaviors, this association was not observed in interventions, particularly among young women who face a disproportionate risk of HIV acquisition. In all, 25% of intervention studies demonstrated that fostering CUSE increased condom use among young men only, and one of two studies demonstrated that higher SRSE led to reduced frequency of sexual activity for both men and women. Future research and HIV-prevention interventions must be gender targeted, consider improving CUSE for young men, and move beyond limited individual-level sexual behavior change frameworks.

Contexts of vulnerability and the acceptability of new biomedical HIV prevention technologies among key populations in South Africa: A qualitative study

BACKGROUND

New biomedical prevention technologies (NPTs) may contribute to substantially reducing incident HIV infections globally. We explored acceptability and preferences for NPTs among key and other vulnerable populations in two South African townships.

METHODS

We conducted six focus groups and 12 in-depth interviews with adolescents, and adult heterosexual men, women, and men who have sex with men (MSM) (n = 48), and eight in-depth interviews with key informant healthcare workers. The interview guide described pre-exposure prophylaxis (PrEP), vaginal rings, rectal microbicides and HIV vaccines, and explored acceptability and product preferences. Focus groups and in-depth interviews (45-80 minutes) were conducted in Xhosa, audiotaped, and transcribed and translated into English. Data were coded and reviewed using framework analysis with NVivo software.

RESULTS

Overall, initial enthusiasm and willingness to use NPTs evolved into concerns about how particular NPTs might affect or require alterations in one's everyday lifestyle and practices. Different product preferences and motivations emerged by population based on similarity to existing practices and contexts of vulnerability. Adult women and female adolescents preferred a vaginal ring and HIV vaccine, motivated by longer duration of protection to mitigate feared repercussions from male partners, including threats to their marriage and safety, and a context of ubiquitous rape. Male adolescents preferred an HIV vaccine, seen as protection in serodiscordant relationships and convenient in obviating the HIV stigma and cost involved in buying condoms. Adult men preferred PrEP, given familiarity with oral medications and mistrust of injections, seen as enabling serodiscordant couples to have a child. MSM preferred a rectal microbicide given familiarity with gel-based lubricants, with concerns about duration of protection in the context of unplanned consensual sex and rape.

CONCLUSIONS

Biomedical interventions to prevent HIV transmission, rather than obviating social-structural factors that produce vulnerability, may be limited by these same factors. Implementation of NPTs should engage local communities to understand real-world constraints and strategise to deliver effective, multi-level combination prevention.

Recruitment of Underrepresented Minority Researchers into HIV Prevention Research: The HIV Prevention Trials Network Scholars Program

Most U.S. investigators in the HIV Prevention Trials Network (HPTN) have been of majority race/ethnicity and sexual orientation. Research participants, in contrast, have been disproportionately from racial/ethnic minorities and men who have sex with men (MSM), reflecting the U.S. epidemic. We initiated and subsequently evaluated the HPTN Scholars Program that mentors early career investigators from underrepresented minority groups. Scholars were affiliated with the HPTN for 12-18 months, mentored by a senior researcher to analyze HPTN study data. Participation in scientific committees, trainings, protocol teams, and advisory groups was facilitated, followed by evaluative exit surveys. Twenty-six trainees have produced 17 peer-reviewed articles to date. Research topics typically explored health disparities and HIV prevention among black and Hispanic MSM and at-risk black women. Most scholars (81% in the first five cohorts) continued HIV research after program completion. Alumni reported program-related career benefits and subsequent funding successes. Their feedback also suggested that we must improve the scholars' abilities to engage new research protocols that are developed within the network. Mentored engagement can nurture the professional development of young researchers from racial/ethnic and sexual minority communities. Minority scientists can benefit from training and mentoring within research consortia, whereas the network research benefits from perspectives of underrepresented minority scientists.

Quality improvement as a framework for behavior change interventions in HIV-predisposed communities: a case of adolescent girls and young women in northern Uganda

Background

Despite the conventional approaches to HIV prevention being the bedrock for early reductions in HIV infections in Uganda, innovations that demonstrate reduction in risk to infection in vulnerable populations need to be embraced urgently. In the past 2 years, a USAID-funded project tested a quality improvement for behavior change model (QBC) to address barriers to behavioral change among adolescent girls and young women (AGYW) at high risk of HIV infection. The model comprised skills building to improve ability of AGYW to stop risky behavior; setting up and empowering community quality improvement (QI) teams to mobilize community resources to support AGYW to stop risky behavior; and service delivery camps to provide HIV prevention services and commodities to AGYW and other community members.

Methods

We recruited and followed a cohort of 409 AGYW at high risk of HIV infection over a 2-year period to examine the effect of the QBC model on risky behaviors. High-risk behavior was defined to include transactional sex, having multiple sexual partners, and non-use of condoms in high-risk sex. We documented unique experiences over the period to assess the effect of QBC model in reducing risky behavior. We analyzed for variances in risk factors over time using repeated measures ANOVA.

Results

There were statistically significant declines in high-risk behavior among AGYW over the QBC roll-out period (p < 0.05). Univariate analysis indicated reduction in AGYW reporting multiple sexual partners from 16.6% at baseline to 3.2% at follow up and transactional sex from 13.2 to 3.6%. The proportion of AGYW experiencing sexual and other forms of gender based violence reduced from 49% a baseline to 19.5% at follow up due to the complementary targeting of parents and partners by QI teams.

Conclusion

The QBC model is appropriate for the context of northern Uganda because it provides a framework for the community to successfully drive HIV prevention efforts and therefore is recommended as a model for HIV prevention in high-risk groups.

Factors Driving the HIV Epidemic in Southern Africa

The HIV pandemic has disproportionately impacted sub-Saharan Africa and Southern Africa in particular. The concurrent presence of overlapping epidemic drivers likely underpins how and why the HIV epidemic is so explosive in this region, with implications for understanding approaches to reduce transmission. In this review, we discuss the relative contribution and interaction between epidemic drivers in the Southern African context, including factors both distally and proximally associated with the likelihood and degree of exposure to HIV and factors that increase the probability of transmission when exposure occurs. In particular, we focus on young women as a key population in need of HIV prevention and highlight factors that increase their risk on several levels.

Associations between friendship characteristics and HIV and HSV-2 status amongst young South African women in HPTN-068

INTRODUCTION

Prevalence of HIV among young women in South Africa remains extremely high. Adolescent peer groups have been found to be an important influence on a range of health behaviours. The characteristics of young women's friendships might influence their sexual health and HIV risk via connections to sexual partners, norms around sexual initiation and condom use, or provision of social support. We investigated associations between young women's friendships and their Herpes Simplex Virus Type 2 (HSV-2) and HIV infection status in rural South Africa.

METHODS

Our study is a cross-sectional, egocentric network analysis. In 2011 to 2012, we tested 13- to 20-year-old young women for HIV and HSV-2, and collected descriptions of five friendships for each. We generated summary measures describing friend socio-demographic characteristics and the number of friends perceived to have had sex. We used logistic regression to analyse associations between friend characteristics and participant HIV and HSV-2 infection, excluding likely perinatal HIV infections.

RESULTS

There were 2326 participants included in the study sample, among whom HIV and HSV-2 prevalence were 3.3% and 4.6% respectively. Adjusted for participant and friend socio-demographic characteristics, each additional friend at least one year older than the participant was associated with raised odds of HIV (odds ratio (OR) = 1.37, 95% CI 1.03 to 1.82) and HSV-2 (adjusted OR=1.41, 95% CI 1.18 to 1.69). Each additional friend perceived to have ever had sex also raised the odds of HIV (OR = 1.29, 95% CI 1.03 to 1.63) and HSV-2 (OR=1.18, 95% CI 1.03 to 1.35).

DISCUSSION

We found good evidence that a greater number of older friends and friends perceived to have had sex were associated with increased risk for HSV-2 and HIV infection among young women.

CONCLUSIONS

The characteristics of young women's friendships could contribute to their risk of HIV infection. The extent to which policies or programmes influence age-mixing and young women's normative environments should be considered.

The Botsha Bophelo Adolescent Health Study: A profile of adolescents in Soweto, South Africa

Background

Youth between the ages of 15 years to 24 years account for almost half of new HIV infections in South Africa.

Objectives

To describe the study details of the Botsha Bophelo Adolescent Health Study (BBAHS) which was an investigation of HIV risk among adolescents living in Soweto, South Africa.

Methods

Eligibility criteria for the BBAHS included being 14 years – 19 years old and living in one of the 41 identified formal and informal areas in the township of Soweto. A cross-sectional survey was developed between investigators and an adolescent community advisory board consisting of previously validated scales and original questions including demographics, sexual and reproductive health, health service utilisation and psychosocial behaviours.

Results

Between 2010 and 2012, interviewers administered surveys among 830 adolescents (57% females), whose median age was 17 years (Q1, Q3: 16, 18), and found that 43% of participants identified their ethnicity as Zulu, 52% reported high food insecurity, 37% reported at least one parent had died, 15% reported living in a shack and 83% identified as heterosexual. Over half of the participants (55%) reported ever having sex (49% of females and 64% of males), 11% of whom initiated sex at < 15 years of age (3% females and 21% males). Almost half (47%) reported ever testing for HIV, 3% (n = 12) of whom self-reported being HIV-positive and 33% (n = 4) were on antiretroviral therapy.

Conclusion

Our study highlights important individual, relational and structural level determinants of HIV risk for adolescent men and women growing up within HIV hyperendemic settings.

Video Game Intervention for Sexual Risk Reduction in Minority Adolescents: Randomized Controlled Trial

Background

Human immunodeficiency virus (HIV) disproportionately impacts minority youth. Interventions to decrease HIV sexual risk are needed.

Objective

We hypothesized that an engaging theory-based digital health intervention in the form of an interactive video game would improve sexual health outcomes in adolescents.

Methods

Participants aged 11 to 14 years from 12 community afterschool, school, and summer programs were randomized 1:1 to play up to 16 hours of an experimental video game or control video games over 6 weeks. Assessments were conducted at 6 weeks and at 3, 6, and 12 months. Primary outcome was delay of initiation of vaginal/anal intercourse. Secondary outcomes included sexual health attitudes, knowledge, and intentions. We examined outcomes by gender and age.

Results

A total of 333 participants were randomized to play the intervention (n=166) or control games (n=167): 295 (88.6%) were racial/ethnic minorities, 177 (53.2%) were boys, and the mean age was 12.9 (1.1) years. At 12 months, for the 258 (84.6%) participants with available data, 94.6% (122/129) in the intervention group versus 95.4% (123/129) in the control group delayed initiation of intercourse (relative risk=0.99, 95% CI 0.94-1.05, P=.77). Over 12 months, the intervention group demonstrated improved sexual health attitudes overall compared to the control group (least squares means [LS means] difference 0.37, 95% CI 0.01-0.72, P=.04). This improvement was observed in boys (LS means difference 0.67, P=.008), but not girls (LS means difference 0.06, P=.81), and in younger (LS means difference 0.71, P=.005), but not older participants (LS means difference 0.03, P=.92). The intervention group also demonstrated increased sexual health knowledge overall (LS means difference 1.13, 95% CI 0.64-1.61, P<.001), in girls (LS means difference 1.16, P=.001), boys (LS means difference 1.10, P=.001), younger (LS means difference 1.18, P=.001), and older (LS means difference=1.08, P=.002) participants. There were no differences in intentions to delay the initiation of intercourse between the two groups (LS means difference 0.10, P=.56).

Conclusions

An interactive video game intervention improves sexual health attitudes and knowledge in minority adolescents for at least 12 months.

Trial Registration

Clinicaltrials.gov NCT01666496; https://clinicaltrials.gov/ct2/show/NCT01666496 (Archived by WebCite at http://www.webcitation.org/6syumc9C0).

Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study

Introduction: Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV-related stigma is a barrier to HIV testing among Jamaica’s general population, yet little is known of MSM and transgender women’s HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica.

Methods: We implemented a community-based research project in collaboration with HIV and lesbian, gay, bisexual and transgender (LGBT) agencies in Kingston. We held two focus groups, one with young (aged 18–30 years) transgender women (n = 8) and one with young MSM (n = 10). We conducted 53 in-depth individual semi-structured interviews focused on HIV testing experiences with young MSM (n = 20), transgender women (n = 20), and community-based key informants (n = 13). We conducted thematic analysis to identify, analyze, and report themes.

Results: Participant narratives revealed social-ecological barriers and facilitators to HIV testing. Barriers included healthcare provider mistreatment, confidentiality breaches, and HIV-related stigma: these spanned interpersonal, community and structural levels. Healthcare provider discrimination and judgment in HIV testing provision presented barriers to accessing HIV services (e.g. treatment), and resulted in participants hiding their sexual orientation and/or gender identity. Confidentiality concerns included: clinic physical arrangements that segregated HIV testing from other health services, fear that healthcare providers would publicly disclose their status, and concerns at LGBT-friendly clinics that peers would discover they were getting tested. HIV-related stigma contributed to fear of testing HIV-positive; this intersected with the stigma of HIV as a “gay” disease. Participants also anticipated healthcare provider mistreatment if they tested HIV positive. Participants identified individual (belief in benefits of knowing one’s HIV status), social (social support) and structural (accessible testing) factors that can increase HIV testing uptake.

Conclusions: Findings suggest the need for policy and practice changes to enhance confidentiality and reduce discrimination in Jamaica. Interventions to challenge HIV-related and LGBT stigma in community and healthcare settings can enhance access to the HIV prevention cascade among MSM and transgender youth in Jamaica.