Outcomes of substance use and sexual power among adolescent girls and young women in Cape Town: Implications for structural and cultural differences

Adolescent girls and young women (AGYW) in South Africa experience contextual barriers to HIV risk reduction including incomplete schooling, unintended pregnancy, substance use, and gender-based violence. A cluster randomised trial in Cape Town allocated 24 Black and Coloured communities to a gender-focused HIV risk-reduction intervention or HIV testing, with 500 AGYW total enrolled. We evaluated intervention efficacy by comparing mean differences overall, by community population group (Black and Coloured) and among those with structural barriers based on neighbourhood, education, and employment (n = 406). Both arms reported reductions in alcohol, cannabis, and condomless sex, with no intervention efficacy overall. Among AGYW with barriers, intervention participants reported fewer days of methamphetamine use at 6 months (t(210) = 2·08, p = ·04). In population group analysis, we found intervention effects on alcohol and sexual communication. Intervention participants in Black communities had fewer days of alcohol use at 12 months (t(136) = 2·10, p = ·04). Sexual discussion (t(147) = -2·47, p = ·02) and condom negotiation (t(146) = -2·51, p = ·01) increased for intervention participants at 12 months in Coloured communities. Gender-focused interventions must address population group differences and intersecting barriers to decrease substance use and increase education, skills, and sexual health protection.

The Importance of the Individual in PrEP Uptake: Multilevel Correlates of PrEP Uptake Among Adolescent Girls and Young Women in Tshwane, South Africa

Adolescent girls and young women (AGYW) account for 25% of new HIV infections in South Africa. Pre-exposure prophylaxis (PrEP) is approved by the South African Government, but the factors that promote PrEP uptake among AGYW are not well understood. This study examines multilevel factors associated with PrEP uptake among AGYW in six clinic catchment areas in Tshwane (Pretoria), South Africa. After consent/assent, PrEP-eligible AGYW (n = 448) completed a questionnaire assessing factors at the individual, network/interpersonal, and community levels and were prescribed PrEP in study clinics, if interested. A multivariable model, adjusting for clustering, assessed factors associated with PrEP uptake over a 9-month period. At the individual level, multiple partners in the past 3 months (OR = 0.47), perceived risk of HIV (OR = 0.71), and PrEP-related shame (OR = 0.63) were correlated with lower odds of PrEP uptake (ps ≤ 0.05). The findings highlight modifiable factors that should be addressed to support PrEP uptake efforts.

Breaking down relationship barriers to increase PrEP uptake and adherence among adolescent girls and young women in Kenya: safety and preliminary effectiveness results from a pilot cluster-randomized trial

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa, a priority population for epidemic control. However, intimate partner violence (IPV) and low relationship power can create significant challenges to PrEP use. The Tu'Washindi intervention aimed to increase PrEP use by addressing relationship- and violence-related barriers among AGYW enrolled in the DREAMS Initiative in Siaya County, Kenya.

METHODS

Our multi-level, community-based intervention was piloted in a cluster-randomized controlled trial conducted at six DREAMS sites from April to December 2019 (NCT03938818). Three intervention components were delivered over 6 months: an eight-session empowerment-based support club, community sensitization targeted towards male partners and a couples' PrEP education event. Participants were ages 17-24, HIV negative and either eligible for, or already taking, PrEP. Over 6 months of follow-up, we assessed IPV (months 3 and 6) and PrEP uptake and continuation (month 6) through interviewer-administered questionnaires; PrEP adherence was assessed with Wisepill electronic monitoring devices. These outcomes were compared using adjusted Poisson and negative binomial regression models.

RESULTS

We enrolled 103 AGYW with median age of 22 years (IQR 20-23); one-third were currently taking PrEP and 45% reported IPV in the past 3 months. Retention was 97% at month 6. Compared to the control arm, intervention arm participants were more likely to initiate PrEP, if not already using it at enrolment (52% vs. 24%, aRR 2.28, 95% CI 1.19-4.38, p = 0.01), and those taking PrEP had more days with device openings (25% of days vs. 13%, aRR 1.94, 95% CI 1.16-3.25, p = 0.01). Twenty percent of participants reported IPV during follow-up. There were trends towards fewer IPV events (aIRR 0.66, 95% CI 0.27-1.62, p = 0.37) and fewer events resulting in injury (aIRR 0.21, 95% CI 0.04-1.02, p = 0.05) in the intervention versus control arm.

CONCLUSIONS

Tu'Washindi shows promise in promoting PrEP uptake and adherence among AGYW without concomitant increases in IPV; however, adherence was still suboptimal. Further research is needed to determine whether these gains translate to increases in the proportion of AGYW with protective levels of PrEP adherence and to evaluate the potential for the intervention to reduce IPV risk.

Effect of a gender-synchronized family planning intervention on inequitable gender norms in a cluster randomized control trial among husbands of married adolescent girls in Dosso, Niger

Gender inequity is pervasive globally and has severe consequences for health and well-being, particularly for women and girls in Niger. The Reaching Married Adolescents in Niger (RMA) intervention aimed to promote equitable gender norms in order to increase modern contraceptive use and reduce intimate partner violence among married adolescent girls and their husbands in Niger. Using data from a 4-arm factorial cluster randomized control trial of the RMA intervention (2016-2019), the current study assesses effects of the RMA intervention on gender norms among husbands. We used an adjusted hierarchical difference-in-differences linear regression model to assess these effects. The mean score for perceived gender inequitable norms at baseline was 4.1 (n=1,055; range: 0-5). Assignment to the RMA small groups intervention was associated with a 0.62 lower score (95% CI: -1.05, -0.18) relative to controls at follow-up, after adjusting for baseline differences. No significant effects were detected for other intervention arms. As a low-cost, simple, scalable, and transferrable intervention with rigorous evidence of being able to change such gender norms, this community health worker-based small group intervention could be valuable to the field of public health for reducing the negative impact of inequitable gender norms on health and wellbeing in similar settings.

Measuring social norms of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy: an item response modelling of the IPV-ASRA scale

BACKGROUND

The field of violence prevention research is unequivocal that interventions must target contextual factors, like social norms, to reduce gender-based violence. Limited research, however, on the social norms contributing to intimate partner violence or reproductive coercion exists. One of the driving factors is lack of measurement tools to accurately assess social norms.

METHODS

Using an item response modelling approach, this study psychometrically assesses the reliability and validity of a social norms measure of the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy with data from a population-based sample of married adolescent girls (ages 13-18) and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019.

RESULTS

A two-dimensional Partial Credit Model for polytomous items was fit, showing evidence of reliability and validity. Higher scores on the "challenging husband authority" dimension were statistically associated with husband perpetration of intimate partner violence.

CONCLUSIONS

This brief scale is a short (5 items), practical measure with strong reliability and validity evidence. This scale can help identify populations with high-need for social norms-focused IPV prevention and to help measure the impact of such efforts.

Synthesis of end-user research to inform future multipurpose prevention technologies in sub-Saharan Africa: a scoping review

Introduction

Women in sub-Saharan Africa (SSA) experience disproportionately high rates of HIV infection and unintended pregnancy compared to their age-matched counterparts in other regions of the world. Multipurpose prevention technologies (MPTs) that offer protection against HIV and unintended pregnancy in a single product stand to address these dual sexual and reproductive health needs simultaneously. The aim of this scoping review is to identify factors that are important for optimizing the likelihood of MPT adoption by end users in SSA.

Methods

Study inclusion criteria included MPT research (HIV and pregnancy prevention dual indication) published or presented in English from 2000 to 2022 and conducted in SSA amongst end-users (women aged 15-44), male partners, health care providers, and community stakeholders. References were identified by searching peer reviewed literature, grey literature, conference presentations (2015-2022), grant databases, and outreach to MPT subject matter experts. Of 115 references identified, 37 references met inclusion criteria and were extracted for analysis. A narrative synthesis approach was used to summarize findings within and across MPT products.

Results

Studies were identified from six countries in SSA and a substantial proportion included a South African (n = 27) and/or Kenyan (n = 16) study site. Most studies utilized a qualitative study design (n = 22) and evaluated MPT acceptability and preferences by presenting hypothetical products through images or a list of product attributes (n = 21). The vaginal ring (n = 20), oral tablet (n = 20), and injection (n = 15) were examined most frequently. Across studies, there was high acceptability and demand for an HIV and pregnancy prevention MPT. End users valued choice in prevention product type as well as discreetness and long-acting options. Provider counseling and community sensitization were reported as essential for future introduction of novel MPT delivery forms.

Conclusion

Recognizing the heterogeneity of women's preferences and changing reproductive and sexual health needs over the life course, choice is important in the delivery of pregnancy and HIV prevention products as well as amongst MPT products with distinct product profiles. End user research with active MPTs, vs. hypothetical or placebo MPTs, is necessary to advance understanding of end-user preferences and acceptability of future products.

Multi-Level Protective and Risk Factors Longitudinally Associated with Dating Violence Perpetration among Non-Urban Mexican-American Adolescents

To assess the longitudinal relationship between individual and interpersonal risk and protective factors and dating violence perpetration among non-urban Mexican-American youth. With data from a 24-month prospective cohort study (2015-2019; baseline recruitment spanned from 2015-2017; four follow-up interviews every 6 months) of Mexican-American youth (8th grade at baseline) living in an agricultural region (Salinas, California), we utilized multivariable modified Poisson general estimating equations stratified by gender (n = 489) to assess the relationships of religiosity, non-violent problem-solving skills, school connectedness, family cohesion, and bullying victimization with dating violence perpetration. Among girls, but not boys, non-violent problem-solving skills [adjusted relative risk (ARR): 0.7; 95% confidence interval (CI): 0.56-0.99] and family cohesion (ARR: 0.7; 95% CI: 0.48-0.97) were negatively associated with dating violence perpetration, and frequency of bullying victimization was positively associated (ARR: 1.9; 95% CI: 1.37-2.59). Non-urban Mexican-American female youth may benefit from multi-level dating violence prevention that strengthens family cohesion by building upon the Mexican-American cultural value of familismo and addresses common risk factors for bullying and dating violence perpetration. Additionally, results affirm etiological differences between girls' and boys' dating violence perpetration and the need for improved measurement.

Incorporating end-users' voices into the development of an implant for HIV prevention: a discrete choice experiment in South Africa and Zimbabwe

BACKGROUND

Input from end-users during preclinical phases can support market fit for new HIV prevention technologies. With several long-acting pre-exposure prophylaxis (PrEP) implants in development, we aimed to understand young women's preferences for PrEP implants to inform optimal design.

METHODS

We developed a discrete choice experiment and surveyed 800 young women in Harare, Zimbabwe and Tshwane, South Africa between September-November 2020. Women aged 18-30 years who were nulliparous, postpartum, or exchanged sex for money, goods or shelter in prior year were eligible; quotas were set for each subgroup. The DCE asked participants to choose between two hypothetical implants for HIV prevention in a series of nine questions. Implants were described by: size, number of rods and insertion sites, duration (6-months, 1-year, 2-years), flexibility, and biodegradability. Random-parameters logit models estimated preference weights.

RESULTS

Median age was 24 years (interquartile range 21-27). By design, 36% had used contraceptive implants. Duration of protection was most important feature, with strong preference for a 2-year over 6-month implant. In Zimbabwe, the number of rods/insertion sites was second most important and half as important as duration. Nonetheless, to achieve an implant lasting 2-years, 74% were estimated to accept two rods, one in each arm. In South Africa, preference was for longer, flexible implants that required removal, although each of these attributes were one-third as important as duration. On average, biodegradability and size did not influence Zimbabwean women's choices. Contraceptive implant experience and parity did not influence relative importance of attributes.

CONCLUSIONS

While duration of protection was a prominent attribute shaping women's choices for PrEP implants, other characteristics related to discreetness were relevant. Optimizing for longest dosing while also ensuring minimal detection of implant placement seemed most attractive to potential users.

Latina mothers' perspectives on adverse experiences and protection of Latinx youth in an agricultural community

BACKGROUND

Adverse Childhood Experiences (ACEs) are a measure of childhood toxic stress that have a dose-dependent relationship with many adult health outcomes. While ACEs have been validated across diverse populations to measure neglect, abuse, and family dysfunction, they do not specifically assess trauma related to racism/xenophobia and immigration. 54% of Latinx youth in the United States are immigrants or children of immigrants and a large group with potentially unmeasured trauma. This study looks beyond ACEs to identify adverse and protective factors for healthy development among Latinx youth in an agricultural community through the perspectives of their mothers.

METHODS

Twenty mothers of adolescent participants in A Crecer: the Salinas Teen Health Study (a prospective cohort study of 599 adolescents) completed semi-structured interviews in Spanish. Interviews focused on mothers' perspectives on community resources, parenting strategies, parenting support systems, and their future aspirations for their children. Four coders completed iterative rounds of thematic coding drawing from published ACEs frameworks (original ACEs, community ACEs) and immigrant specific adverse events arising from the data.

RESULTS

Mothers in this study reported adverse experiences captured within community-level ACEs but also distinct experiences related to intergenerational trauma and immigrant-related adversities. The most cited community-level ACEs were housing instability and community violence. Immigrant related adversities included experiences of systemic racism with loss of resources, political instability limiting structural resources, and language-limited accessibility. These were exacerbated by the loss of family supports due to immigration related family-child separation including deportations and staggered parent-child migration. Having experienced intergenerational trauma and systemic oppression, mothers discussed their strategies for building family unity, instilling resilience in their children, and improving socioeconomic opportunities for their family.

CONCLUSIONS

Latina mothers shared the impacts of immigrant-related experiences on systemic inequities in the United States which are currently missing from the ACEs framework. Immigrant specific adverse events include language-limited accessibility, or family-child separations, and policies impacting structural resources for immigrant families. Mothers highlighted their capacity to build resilience in their children and buffer impacts of systemic racism. Community-tailored interventions can build on this foundation to reduce health disparities and promote health equity in this population.

Mediating effects of inequitable gender norms on intimate partner violence and contraceptive use in a cluster randomized control trial in Niger: A causal inference mediation analysis

Background

Gender inequity, a deeply-rooted driver of poor health globally, is expressed in society through gender norms, the unspoken rules that govern gender-related roles and behavior. The development of public health interventions focused on promoting equitable gender norms are gaining momentum internationally, but there remain critical gaps in the evidence about how these interventions are working to change behavioral outcomes.

Methods

A four-arm cluster randomized control trial (cRCT) was conducted to evaluate the effects of the Reaching Married Adolescents in Niger (RMA) intervention on modern contraceptive use and intimate partner violence (IPV) among married adolescent girls and their husbands in Dosso, Niger (T1: 1042 dyads; 24 mos. follow-up: 737 dyads, 2016-2019). This study seeks to understand if changes in perceived inequitable gender norms among husbands are the mechanism behind effects on modern contraceptive use and IPV. We estimated natural direct and indirect effects via these gender norms using inverse odds ratio weighting. An intention-to-treat approach and a difference-in-differences estimator in a hierarchical linear probability model was used to estimate prevalence differences, along with bootstrapping to estimate confidence intervals.

Results

The total effects of the RMA small group intervention (Arm 2) is estimated to be an 8% reduction in prevalence of IPV [95% CI: -0.18, 0.01]. For this arm, the natural indirect effect through gender inequitable social norms is associated with a 2% decrease (95% CI: -0.07, 0.12), accounting for 22.3% of this total effect, and the natural direct effect with a 6% decrease (95% CI: -0.20, -0.02) in IPV. Of the total effect of the RMA household visit intervention (Arm 1) on contraceptive use (20% increase), indirect effects via inequitable gender norms were associated with an 11% decrease (95% CI: -0.18, -0.01) and direct effects with a 32% increase (95% CI: 0.13, 0.44) in contraceptive use. For the combination arm, of the total effects on contraceptive use (19% increase), indirect effects were associated with a 9% decrease (95% CI: -0.20, 0.02) and direct effects with a 28% increase (95% CI: 0.12, 0.46).

Conclusion

The present study contributes experimental evidence that the small group RMA intervention reduced IPV partially via reductions in perceived inequitable gender norms among husbands. Evidence also suggests that increases in perceived inequitable gender norms resulted in decreased contraceptive use among those receiving the household visit intervention component. Not only do these results open the "black box" around how the RMA small group intervention may create behavior change to help inform its future use, they provide evidence supporting behavior change theories and frameworks that postulate the importance of changing underlying social norms in order to reduce IPV and increase modern contraceptive use.

Couples' decision making regarding the use of multipurpose prevention technology (MPT) for pregnancy and HIV prevention

We conducted a secondary analysis of discrete choice experiment (DCE) data from 395 couples enrolled in the Microbicide Trials Network (MTN)-045/CUPID study in Uganda and Zimbabwe to understand couple decision making around choice of multipurpose prevention technologies (MPTs) to prevent both HIV and pregnancy. Members of couples completed the same DCE, first separately then jointly, choosing between two hypothetical MPTs in a series of nine questions. Most couples either had similar preferences at the outset or had equal decision-making around MPTs (62%). Couples with male influence (17%) were more likely to use contraceptive pills with a male partner's knowledge and couples with female influence (21%) were less likely to have shared decision making about family planning. Males influenced discussion around MPT duration, side effects, menstrual changes, and how the vagina feels during sex. Decision making was relatively shared, though decisions around certain attributes were more likely to be dominated by male partners.

Social environment risk factors for violence, family context, and trajectories of social-emotional functioning among Latinx adolescents

INTRODUCTION

High social-emotional functioning, including emotion regulation and nonviolent conflict resolution, constitute developmental competencies of adolescence that promote health and well-being. We used prospective longitudinal data from a predominantly Latinx population to understand how family context and social environment risk factors for violence related to patterns of social-emotional functioning during the transition between middle school and high school.

METHODS

We prospectively interviewed 599 8th graders every 6 months for 2 years. We used trajectory models to explore longitudinal patterns of emotion regulation and nonviolent problem solving and multinomial regression to distinguish how these groups were associated with family context, partner and peer gang involvement, and neighborhood social disorder.

RESULTS

Youth reporting lower neighborhood disorder in 8th grade were more likely to be in the high emotion regulation trajectory group. Youth without exposure to gangs through peers and partners in 8th grade were more likely to be in the high nonviolent problem-solving skills trajectory group. Family cohesion was associated with being in the high trajectory groups for both emotional regulation and problem-solving skills.

CONCLUSION

Emotion regulation and nonviolent problem-solving skills had different associations with the social environment risk factors for violence examined, indicating that mechanisms of influence and strategies for intervention may vary. The association between problem-solving skills and exposure to gangs through peers and partners shows that social norms may be important targets of change. Additionally, interventions with parents that build family cohesion during adolescence may buffer environmental exposures that shape adolescents' ability to practice protective social-emotional behaviors.

Making the Case for Joint Decision-Making in Future Multipurpose Prevention Technology (MPT) Choice: Qualitative Findings on MPT Attribute Preferences from the CUPID Study (MTN-045)

Introduction

Young women in sub‐Saharan Africa account for two‐thirds of all new HIV infections and face high rates of unintended pregnancy. Multipurpose prevention technologies (MPTs) are promising products under development that are designed to simultaneously prevent HIV and unintended pregnancy. Since MPTs will be used in the context of sexual relationships, ensuring acceptability and use requires understanding the role of male partners in MPT use decision‐making.

Methods

This paper draws on qualitative data from 39 couples enrolled in the Microbicide Trials Network (MTN) 045 study, conducted in 2019–2020. Partners completed a discrete choice experiment (DCE), first separately and then jointly, to measure preferences for future MPT attributes and then completed a qualitative interview. We also draw on quantitative data from interviewer observation about who dominated the decision‐making process during the joint DCE. Content analysis was used to examine (1) how couples made decisions on existing non‐MPT HIV and pregnancy prevention products; (2) how couples made decisions on future ideal‐MPT product during the DCE; and (3) how these decision‐making processes varied by decision‐making dominance (10 male, 10 female and 19 equal) and interview type (19 joint and 20 separate).

Results

Existing non‐MPT product decisions focused on trust between partners and product attributes, while future ideal‐MPT product decisions exclusively focused on product attributes. Across existing and future products, preferences for product attributes varied by gender. Male partners were most concerned with limiting side effects impacting sexual pleasure, female partners were most concerned with limiting side effects causing physical symptoms and both were concerned with the return to fertility. Across all dominance and interview types, couples reported making decisions together and female partners were often able to negotiate with male partners for their preferred product or set of product attributes.

Conclusions

Research activities in this study provided an opportunity for couples to openly present their product attribute preferences to their partner, learn about their partner's attribute preferences, negotiate for their ideal set of attributes and ultimately choose attributes that benefited the couple without disempowering the female partner. Future research should focus on the utility of couple‐based decision‐making aids or similar tools for facilitating joint MPT decision‐making.

Relationship Factors Associated With Early Adolescent Dating Violence Victimization and Perpetration Among Latinx Youth in an Agricultural Community

Latinx early adolescents within the United States are particularly vulnerable to dating violence; yet, little research has examined early dating experiences and violence outside large urban settings. Latinxs, in particular, may experience a unique window of opportunity for dating violence (DV) prevention during early adolescence, based on their trends in risk behavior over the adolescent period. This study extends the current research on dating violence by examining a highly understudied population, Latinx early adolescent girls and boys residing in an agricultural community, by assessing victimization and perpetration, and examining interpersonal-level factors as potential risk and protective factors for violence. Using data from a prospective cohort study of Latinx adolescents with relationship experience (past six months) (N = 296; girls: n = 147; boys: n = 149; mean age: 13.8), we assessed the association between dating relationship characteristics and dating violence victimization and perpetration using modified-Poisson regression models with robust standard errors stratified by gender. In multivariable analyses, we found that girls with gang-affiliated partners, partner-related withdrawal from friends, and girls who had used drugs or alcohol with a partner experienced greater risk for dating violence. Additionally, holding beliefs supportive of female sexual naivete and engaging in and communicating about sexual activity were associated with victimization among girls. No significant associations were found among boys. Findings affirm the need for multilevel DV prevention programming that starts in middle school and addresses social isolation, gang exposure, and traditional Latinx gender-norm beliefs regarding marianismo. These findings underscore the imperative to coordinate dating and gang violence prevention efforts by addressing common co-occurring interpersonal and environmental risk factors, including social isolation and culturally-specific traditional beliefs. Such factors could also assist providers, families, and peers in early identification of Latinx early adolescents at risk for DV, especially in rural contexts where resources are often limited.

Female and male partner perspectives on placebo Multipurpose Prevention Technologies (MPTs) used by women in the TRIO study in South Africa and Kenya

Background

Male partner awareness and acceptance of microbicide and family planning product use has been shown to increase women’s own acceptance and adherence of a product. However, little is known about preferences regarding potential Multipurpose Prevention Technology (MPT) product delivery forms. As part of the TRIO study, men’s reactions to their female partner’s TRIO product use and comparisons of men’s and women’s views of TRIO product attributes and use acceptability were explored to better understand product preferences.

Methods

Women in TRIO used three placebo products that represented potential MPTs: daily oral tablets, monthly vaginal rings, and monthly dual injections. Male partners (N = 39) and women (N = 88) completed in-depth interviews on their own and their partner’s experiences with these products. Qualitative coding and analyses followed a conceptual model of HIV prevention product acceptability, and here, we explored themes of disclosure, trust and infidelity as they informed barriers and facilitators to product use.

Results

Men expressed a desire to know of their partner’s product use decisions and be informed and educated on the products to better support their partners, in some cases, expressing a high level of concern regarding maximizing the ease of product adherence for their partner. They also wanted to understand the effects of products on sexual encounters with their partner, but in some cases, wanted more knowledge in order to control their partner’s product use decisions. Similarly to women, men found long-acting, discreet products that have little to no effect on sexual encounters or libido the most acceptable for their female partners’ use. Product use was most acceptable to men if they were informed of use without inadvertent discovery.

Conclusions

Men’s product attribute preferences often aligned with women’s opinions of the same products. To support women’s correct use of MPTs, further research is needed to determine the best strategy for achieving male partner acceptance and support of product use, particularly for less familiar delivery forms, such as the vaginal ring.

The Role of Families in Adolescent and Young Adults' PrEP Use

While pre-exposure prophylaxis (PrEP) is a key HIV prevention tool for adolescents and young adults (AYAs), its initiation and sustained use is shaped by AYAs' unique social contexts, including family. We explored the role of families in AYAs' PrEP use through qualitative in-depth interview (IDI) data from iPrevent, an end-user study designed to identify factors that could optimize PrEP adherence among South African youth (18-24 years old). These data were collected using a semi structured guide and were analysed using an inductive approach. Several themes describing family influence on AYAs' PrEP use emerged including family support; family attitude towards PrEP; and the family's ability to obviate PrEP disclosure challenges. In addition, dimensions of family closeness, categorized as 'close', 'in-between' and 'loose-knit,' appeared important in contextualizing family influence on AYAs' PrEP use. We found that family remains a proximal and fundamental social system in which AYA are socialized and greater family engagement could aid PrEP implementation in this priority population.

Early Sexual Debut and Neighborhood Social Environment in Latinx Youth

OBJECTIVES

To examine whether social aspects of the neighborhood environment are associated with early sexual initiation in a California agricultural community of predominantly Latinx adolescents.

METHODS

In a prospective cohort study of 599 eighth graders recruited from middle schools in Salinas, California (2015-2019), participants completed five interviews over 2 years. Social environment measures included neighborhood social dynamics (neighborhood disorder, social cohesion, and social network gang exposure); experiences of discrimination; and school connectedness. We estimated associations between baseline social environment and early sexual initiation (<15 years) using Poisson regression with robust standard errors. We compared contraceptive self-efficacy and attitudes by sexual initiation status using ANOVA.

RESULTS

Most youth were Latinx (94%) and age 13 (70%) at enrollment; 53% were female and 49% had a parent employed in agriculture. Additionally, 14% reported first vaginal sex before age 15. Neighborhood disorder (relative risk [RR], 1.13; 95% confidence interval [CI], 1.05-1.21), social network gang exposure (RR, 2.23; 95% CI, 1.49-3.33), and experiences of discrimination (RR, 1.67 [1-2 events versus none], 95% CI, 1.09-2.55; RR, 2.33 [3+ events versus none], 95% CI, 1.07-4.64) were associated with early sexual initiation. School connectedness was protective (RR, 0.44, 95% CI, 0.29-0.69). Youth who initiated sex before age 15 had more negative birth control attitudes and expressed lower motivation to use contraceptives.

CONCLUSIONS

Findings underscore opportunities to promote early adolescent sexual health through strengthening supportive and safe neighborhood environments with the promise of addressing disparities in unintended pregnancy and sexually transmitted infection rates in later adolescence.

iPrevent: Engaging youth as long-acting HIV prevention product co-researchers in Cape Town, South Africa

South African youth are one of the highest risk groups, globally, for HIV acquisition. Identifying prevention methods that will be acceptable and used consistently is an urgent priority. Engaging youth as co-designers is a targeted strategy to achieve the goal of developing prevention products that meet youth's needs. The iPrevent study engaged male and female youth, aged 18-24 years, in Cape Town, South Africa, to co-design critical aspects of the research project aimed at understanding youth preferences for long-acting pre-exposure prophylaxis (PrEP). An established advisory board of young men who have sex with men, women who have sex with men and men-who-have-sex-with-men, as well as a purposively selected youth cohort were involved in film-making, survey design and interpretation of study results. Convening youth as co-designers had several impacts on iPrevent's approach and outputs. Youth input informed the use of local actors in the study's educational video, creating a "real-world" community setting that meaningfully situated the content. Their participation led to the successful development of survey language and images to explain scientific concepts in terms that would resonate (e.g. chili peppers to express product-associated pain). Lastly, their insight reviewing results led to clarifications around misinterpretations of risk perception and confirmed youth's desires for products that fit into their goals around family, future happiness and education. The engagement of youth through creative, interactive activities contributed to adaptations of the study design, research implementation and understanding of results. This was important for connecting with young end-users and translating study findings for product developers in a way that reflected the context of their lives.

Family and School Connectedness Associated with Lower Depression among Latinx Early Adolescents in an Agricultural County

Depression constitutes one of the greatest sources of morbidity and mortality for U.S. adolescents. Latinx are the fastest growing U.S. adolescent population, particularly in rural communities, and suffer from depression at higher rates than other racial/ethnic groups. Informed by community perspectives on adolescent health, we examined factors associated with depression among Latinx early adolescents in an agricultural community. We surveyed 599 predominantly Latinx 8th graders (12 to 15 years old) recruited from middle schools in Salinas, California. Depression was measured cross-sectionally with the Patient Health Questionnaire-8. Exposures included environmental, cultural, and family factors, assessed using validated measures. We used hierarchical logistic regression guided by Garcia Coll's Model for the Study of Developmental Competencies in Minority Children to examine associations between protective factors within each domain and depression. Eighty-six of the 599 youth (14%) scored above the clinical threshold for depression, with higher prevalence among females (19%) than males (10%), p = .001. Environmental (school connectedness and neighborhood social cohesion) and family factors were associated with a lower odds of depression (all p ≤ .01). Social cohesion in neighborhoods and family communication offered similarly strong protective associations with depression. Increased language assimilation was associated with an increased odds of depression (p = .007).

Giving voice to the end-user: input on multipurpose prevention technologies from the perspectives of young women in Kenya and South Africa

Unintended pregnancy and unmet need for modern contraception contribute substantially to reproductive health disparities globally. In sub-Saharan Africa they occur in contexts of disproportionately high rates of HIV infection. Multipurpose prevention technologies (MPTs) can address HIV and pregnancy prevention needs in a single “2-in-1” product; however, few studies have solicited end-user views to inform design of new MPTs. We conducted the Tablets, Ring, Injections as Options (TRIO) study with young women aged 18−30 in Kenya and South Africa (N = 277) to examine preferences and acceptability of future MPTs. In a randomised clinical cross-over study in which women used three placebo delivery forms, we complemented quantitative acceptability assessments with in-depth interviews and focus group discussions (N = 88 participants). We examined anticipated enablers and barriers to adoption and use of future MPTs and synthesised novel product design recommendations. Participants expressed high interest in MPTs. Anticipated side effects constituted a primary concern; however, many expected barriers were not dosage form-specific, but addressed contextual factors instead, such as fears regarding use of new biomedical technologies, misunderstandings and stigma regarding use, and navigating partner disclosure and engagement. Women preferred MPTs that offered discreetness and long-duration protection to minimise user-burden, did not interfere with their relationships, and conferred protection for unanticipated situations. End-user research to identify and pre-emptively address potential barriers while underscoring benefits to a new MPT product is vital. Attention to cultural contexts in implementation of new MPTs is important to communicating perceived benefits, achieving acceptability and maximising public health benefits.

Long-Acting Injection and Implant Preferences and Trade-Offs for HIV Prevention Among South African Male Youth

BACKGROUND

Long-acting pre-exposure prophylaxis (LA-PrEP) formulated as implants and injections are promising prevention method strategies offering simplicity, discretion, and long dose duration. Men are important end users of LA-PrEP, and early assessment of their preferences could enhance downstream male engagement in HIV prevention.

METHODS

A discrete-choice experiment survey was conducted with 406 men, aged 18-24, in Cape Town, South Africa, to assess preferences for 5 LA-PrEP attributes with 2-4 pictorially-depicted levels: delivery form, duration, insertion location, soreness, and delivery facility. Latent class analysis was used to explore heterogeneity of preferences and estimate preference shares.

RESULTS

The median age was 21 (interquartile range 19-22), and 47% were men who have sex with men. Duration was the most important product attribute. Latent class analysis identified 3 classes: "duration-dominant decision makers" (46%) were the largest class, defined by significant preference for a longer duration product. "Comprehensive decision makers" (36%) had preferences shaped equally by multiple attributes and preferred implants. "Injection-dominant decision makers" (18%) had strong preference for injections (vs. implant) and were significantly more likely to be men who have sex with men. When estimating shares for a 2-month injection in the buttocks with mild soreness (HPTN regimen) vs. a 6-month implant (to arm) with moderate soreness (current target), 95% of "injection-dominant decision makers" would choose injections, whereas 79% and 63% of "duration-dominant decision makers" and "comprehensive decision makers" would choose implant.

CONCLUSIONS

Young South African men indicated acceptability for LA-PrEP. Preferences were shaped mainly by duration, suggesting a sizeable market for implants, and underscoring the importance of product choice. Further research into men's acceptability of LA PrEP strategies to achieve engagement in these HIV prevention tools constitutes a priority.

Tu'Washindi na PrEP: Working With Young Women and Service Providers to Design an Intervention for PrEP Uptake and Adherence in the Context of Gender-Based Violence

HIV pre-exposure prophylaxis (PrEP) reduces HIV acquisition among adolescent girls and young women (AGYW). Existing evidence suggests that uptake and adherence are low among AGYW and that relationship factors such as gender-based violence (GBV) are important barriers. Through a community-based participatory research (CBPR) process, a youth advisory board (YAB), service providers (SP), and a study team developed the Tu'Washindi na PrEP intervention to support AGYW PrEP use in the context of GBV. The YAB also guided the formative research and interpretation of results. The authors pretested the intervention with SP, AGYW and their partners, and community change agents, and then developed guides for AGYW support clubs, community-based male sensitization sessions, and couples-based events that included formulation of story lines for dramatized PrEP negotiation and information dissemination skills. Stakeholder engagement led to an intervention responsive to AGYW's needs for PrEP support in the context of their relationships, which was evaluated through a 6-month pilot community randomized controlled trial.

Perceptions matter: Narratives of contraceptive implant robbery in Cape Town, South Africa

Uptake of contraceptive implants has declined in South Africa since their introduction in 2014, with side effects and inadequate health provider training cited as primary contributors underlying a poor community perception of implants. In this paper we explore a theme that emerged unexpectedly during analysis of our research in Cape Town that may be an additional factor in this decline: narratives of women being assaulted by robbers who physically remove the implants for smoking as drugs. Narratives were described consistently across interviews and focus groups with youth (aged 18-24 years) and in interviews with health providers, with six participants (two young people, four health providers) sharing personal experiences of robbery. While there was a range of perspectives on whether narratives are based on real experiences or are myths, there was strong consensus that narratives of implant robbery may be influencing women's decisions around implant use in Cape Town. This is a potent example of how perceptions of new products can affect uptake and offers important lessons for implementers to reflect on in planning for rollout of other health technologies.

Factors influencing women's decisions about pregnancy spacing: Findings from a focus group discussion study

OBJECTIVES

Very short interpregnancy intervals are associated with negative health outcomes for mothers and children, and pregnancies with very short interpregnancy intervals are more likely to be unintended than pregnancies that are more widely spaced. The objective of this study was to improve understanding of women's motivations regarding pregnancy spacing.

METHODS

In 2017, we conducted 8 focus group discussions with 49 English- and Spanish-speaking postpartum women in central North Carolina. The groups explored participants' preferences for birth spacing and factors that influenced their decisions. We recorded, transcribed, and coded the discussions and analyzed these data for core themes.

RESULTS

Participants' ideas about when and whether to have more children were fluid-some had specific ideas during pregnancy or after delivery that changed over time; others had no definite plans. The primary reason for close birth spacing was to promote their children's having a closer relationship. Reasons for wider spacing included recovery from the previous pregnancy, challenges related to having 2 babies concurrently, and desire to wait for more favorable life circumstances. Participants did not mention health risks to children of short interpregnancy intervals and said that no health care providers discussed these risks with them. They had mixed perspectives about whether this information would influence their own child-spacing preferences but agreed that it should be shared with women to promote informed decision-making.

CONCLUSION

This study adds to limited research regarding the factors that women consider when determining pregnancy spacing. Better understanding of women's motivations can help inform counseling to help women achieve their desired pregnancy spacing.

The PrEPARE Pretoria Project: protocol for a cluster-randomized factorial-design trial to prevent HIV with PrEP among adolescent girls and young women in Tshwane, South Africa

BACKGROUND

Despite increased prevention efforts, HIV remains the leading cause of death among adolescent girls and young women in South Africa. Although research indicates important determinants of HIV acquisition at the individual and interpersonal levels, structural-level stigma and discrimination continue to be critical barriers to reaching and retaining this key population for HIV prevention and sexual and reproductive health services. Innovative and multilevel interventions are needed that can address the intersectional structural and gender issues that young women face, including stigma, alcohol and drug use, gender-based violence, and other risk factors when seeking health services. Oral pre-exposure prophylaxis (PrEP) taken daily has been found to be an effective biomedical HIV prevention tool. Testing a comprehensive gender-focused biobehavioral HIV prevention intervention that is inclusive of social ecological determinants, such as stigma and discrimination reduction in clinics, is critical for reducing HIV among adolescent girls and young women.

METHODS

This project involves both a Community Collaborative Board and a Youth Advisory Board in helping to adapt the Young Women's Health CoOp intervention and the Health Policy Project (HPP) Stigma and Discrimination (S&D) reduction training curriculum to the setting and population. This study uses a two-by-two factorial design with stratified randomization of 12 clinics, each with distinct catchment areas. The Young Women's Health CoOp addresses substance use, sexual risk, violence prevention and sexual negotiation, condom demonstration, and problem solving with the following additions: knowledge of PrEP, the importance of PrEP adherence, and sexual and reproductive health. Adolescent girls and young women will be assessed with behavioral and biological measures at baseline, 3-, 6- and 9-month follow-up. The S&D reduction training is provided for all staff in the clinics randomized to this condition. Clinic staff will be surveyed at baseline, 4- and 8-month follow-up. We will recruit 900 AGYW from communities in the 12 clinic catchment areas.

DISCUSSION

The study findings, if efficacious across the outcomes, will be incorporated into the gender-focused HIV prevention intervention toolkit and disseminated to inform multilevel prevention approaches.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT04048551 (Recruiting). Registered: August 7, 2019 (Retrospectively registered).

Preferences for long-acting Pre-Exposure Prophylaxis (PrEP) for HIV prevention among South African youth: results of a discrete choice experiment

INTRODUCTION

Existing biomedical HIV prevention options, though highly effective, present substantial adherence challenges. End-user input on early-stage design of new HIV prevention approaches is critical to yielding products that achieve high uptake and adherence. The iPrevent Study examined youths' preferences for key attributes of long-acting Pre-Exposure Prophylaxis (PrEP), with a focus on characteristics pertinent to product delivery alongside key modifiable product attributes.

METHODS

A discrete choice experiment was conducted with female and male youth aged 18 to 24 in two high-density communities in Cape Town, South Africa during the period July 2017 to January 2019. Sexually active, PrEP-naïve youth were recruited using population-based sampling; targeted sampling was used to enrol men who have sex with men (MSM). In a series of nine questions, participants were asked to choose between two hypothetical products composed of five attributes (form, dosing frequency, access, pain, insertion site). We used a random-parameters logit model to estimate preference weights and trade-offs among product alternatives. We examined differences across three subgroups: females, men who have sex with only women (MSW) and MSM.

RESULTS

A total of 807 participants (401 female) were enrolled with a median age of 21 years. Males included 190 MSM. Most youth had tested for HIV (95%) and reported being HIV-negative (91%). Across all groups, duration of effectiveness was the most important attribute, with strong preference for less frequent dosing. Injections were favoured over implants, though these preferences were strongest for females and MSM. Females preferred a product offered at a health clinic and disliked pharmacy access; all groups preferred the arm as the insertion site. Youth were willing to trade their preferred product form for longer duration.

CONCLUSIONS

Youth indicated strong preferences for longer duration products. Each attribute nonetheless influenced preferences, offering insight into trade-offs that inform long-acting PrEP development.

Instagram as a tool for study engagement and community building among adolescents: A social media pilot study

Objective

Social media has been recognized as a promising tool for delivering health interventions and facilitating study recruitment. However, research is needed to understand how social media might be used to enhance the experiences of adolescent participants in ongoing studies. In a prospective cohort study addressing social and structural influences on health trajectories among 599 adolescents in a California agricultural community, we evaluated the effectiveness of and engagement with a human-centered, Instagram-based outreach campaign, with a focus on study retention, enhancement of participants’ experiences, and increasing community awareness of the study.

Methods

We adopted a youth-centered approach to design a three-month pilot study, which included participatory design sessions, a geo-targeted Instagram campaign, and in-person events at schools. We conducted pre-/post-pilot surveys with study participants, analyzed social media metrics, and collected process measures, such as study visit show rates.

Results

After three months, the study Instagram account had 209 followers and 806 total engagements. Survey responses showed little change in study participants’ attitudes about the study; most survey respondents agreed that the study is very important for the community (54% pre-pilot and 52% post-pilot). However, the study’s Instagram account appeared to influence study participation, with 43% of post-pilot respondents who use Instagram (n=65 of 153) indicating that the Instagram account influenced their decision to continue coming to study visits.

Conclusion

Despite little change in the participants’ attitudes about the study, the findings of this pilot study suggest that Instagram is a promising tool to support engagement of adolescent participants in ongoing research, particularly if the content is designed with adolescents as partners. In addition to assessing the effectiveness of an Instagram outreach campaign to support retention, this paper also presents suggestions and insights for creating similar social media interventions targeting youth.

Cyber Sexual Harassment: Prevalence and association with substance use, poor mental health, and STI history among sexually active adolescent girls

INTRODUCTION

The current study aims to assess the prevalence, perpetrators, and consequences of cyber sexual harassment (CSH) among adolescent females.

METHODS

Sexually active adolescent females (N = 159) ages 15-19 were recruited from a health clinic in a low-income, urban area of southeast San Diego County, California to complete a tablet-administered survey that included items on sexual violence and harassment, including CSH. Using logistic regression models, we assessed CSH in relation to substance use, poor mental health outcomes and STI history.

RESULTS

Participants were, on average, 17 years of age and half were currently in a relationship. The majority of girls (68%) reported at least one form of CSH, which included receiving unwanted sexual messages/photos (53%), receiving unwanted messages asking them to do something sexual (49%), being pressured to send sexual photos (36%), and having sexual photos shared without permission (6%). Perpetrators included known and unknown males; almost a third (27%) reported perpetration by a relationship partner. In logistic regression models adjusting for race, CSH was associated with: past 30-day alcohol use, drug use (ever), feeling depressed (past 30 days), and feeling anxious (past 30 days) (Odds Ratios ranged: 2.9-7.5). CSH was also associated with past-year suicidal thoughts and STI diagnosis (ever) (p < 0.05, ORs not presented due to small numbers).

CONCLUSIONS

Our findings suggest that in some subgroups, CSH appears to be affecting the majority of girls, which is especially concerning given its association with multiple poor health outcomes.

Engaging study participants in interpreting results: lessons from the TRIO study in Kenya and South Africa

Background: Women account for 56% of new HIV infections in sub-Saharan Africa. Multipurpose Prevention Technologies (MPTs) are promising interventions because they combine HIV prevention with a less stigmatizing indication, such as pregnancy. We conducted a study with three placebo-only MPT products in Kisumu, Kenya and Soshanguve, South Africa, to assess preferences for attributes of tablets, vaginal rings and injectable products for dual prevention of HIV and pregnancy (TRIO Study). Here, we present former TRIO participants' views on the study results. Methods: After study completion in 2017, we held five dissemination sessions (two in Kisumu and three in Soshanguve) and five one-on-one sharing sessions in Soshanguve. Key results were discussed, with a focus on why some study products were more popular than others, which findings were surprising and why some women changed products over time. A thematic approach was used for analysis. Results: All 277 TRIO participants were telephoned, 168 (60.6%) were reached and 117 (42.2%) attended the dissemination sessions: 71 in Kisumu and 46 in Soshanguve. Participants were engaged and interested in the TRIO findings and willingly shared their perspectives and views candidly. Ease of use, discretion and familiarity were highlighted as drivers of product choice whereas novelty presented a challenge. In explaining the discrepancy between preference ratings and choices, participants cited features such as tablets being easy to explain to a partner or to discontinue. In explaining why 20% of participants switched products after practical experience, issues related to relationships with partners and product attributes perceived as unfavorable were paramount. Conclusion: The dissemination sessions provided an important forum for study participants to interrogate and explain the results to minimize possible misinterpretation. This exercise helped give context to the results, ensured correct lessons were derived from those results and increased credibility of the findings reported by the investigators.

Design of an Implant for Long-Acting HIV Pre-Exposure Prophylaxis: Input from South African Health Care Providers

Implants are in the pre-clinical stage for long-acting HIV pre-exposure prophylaxis (PrEP), with an opportunity to solicit end-users' feedback early in development. Health care providers (HCPs) have been key gatekeepers for contraceptive implant uptake, and uniquely understand both technical considerations and the social context of use. Given their influential role, we gathered South African HCP perspectives on contraceptive implant implementation and features of PrEP implant prototypes that may influence future provider and patient acceptability. We conducted in-depth interviews with 30 HCPs (20 nurses and 10 doctors) in Cape Town and Soshanguve, South Africa. Interviews were conducted by a bioengineer and later transcribed, coded, and analyzed for key themes. HCPs described health system barriers such as understaffed clinics and inadequate training on contraceptive implant removal as major influences to their PrEP implant design preferences. They preferred a PrEP implant that is long lasting (>6 months) to minimize patient-clinic interactions, biodegradable to avoid need for removal, and flexible (but still palpable in case of removal). Commenting on negative experiences with contraceptive implant rollout, they recommended prioritizing both HCP and community education on the PrEP implant, with emphasis on expected side effects, and planning ahead for adequate training of HCPs before rollout. Challenges experienced with past contraceptive implant rollout may taint perspectives on future PrEP implants and must be carefully considered during product development and planning for clinical studies. Particular consideration should be given to the health system context of future distribution, including staff who would be providing and monitoring implants.

"We are not the same": African women's view of multipurpose prevention products in the TRIO clinical study

Purpose

Unintended pregnancy and HIV infection present dual risks for young women in sub-Saharan Africa. New multipurpose prevention technologies (MPTs) are in development to simultaneously prevent unintended pregnancy and HIV, but there is a need for end-user research to ensure these products suit women’s needs. The Tablet, Rings and Injectables as Options (TRIO) for women study took place in Kisumu, Kenya, and Soshanguve, South Africa, with the goal of eliciting young women’s feedback on three potential MPTs.

Methods

Women in TRIO used three placebo products that represented potential MPTs: daily oral tablets, monthly vaginal rings, and monthly dual injections in a randomized crossover design followed by a period in which they chose a product to use. Eighty-eight TRIO participants completed in-depth interviews and focus group discussions to understand their experiences using each product. Qualitative analyses were conducted after stratifying by product preference at the end of the crossover period.

Results

The majority (65%) of participants preferred injections, with the remainder evenly split between tablets and rings. Discussions of preference for one product were closely linked with expressed dislike of another product’s attributes. Participants recognized heterogeneity in preferences and choices across users and stressed the need for multiple MPT options that confer a low burden on women’s daily lives.

Conclusion

Rather than choosing a product to use based on the product’s perceived advantages, women’s choices were based on the unfavorable attributes of other TRIO products. Moreover, the importance that women placed on a given disadvantage varied. Disadvantages that women deemed as most important emerged as a greater driver of product preference than selecting products based on their advantages and favorable characteristics.

Young Women's Ratings of Three Placebo Multipurpose Prevention Technologies for HIV and Pregnancy Prevention in a Randomized, Cross-Over Study in Kenya and South Africa

End-user input is critical to inform development of multipurpose prevention technology (MPT) products that prevent HIV and pregnancy. The TRIO Study, conducted in Kenya and South Africa, enrolled 277 HIV-negative women aged 18-30 in a randomized cross-over study to use each placebo MPT (daily oral tablets, monthly injections, and monthly vaginal ring) for one month. At the end of each month, participants rated how much they liked using the product on a 5-point Likert scale (5 = liked very much). We compared mean ratings using paired t-tests and examined sociodemographic-, attribute-, and behavior-related characteristics associated with ratings using multivariable linear regression and data from in-depth interviews. After use, mean ratings were significantly higher for injections [4.3 (SD = 1.0)] compared with tablets [3.0 (SD = 1.3)] and rings [3.3 (SD = 1.4)] (p < 0.001); mean ratings for rings were significantly higher than for tablets (p = 0.013). Mean ratings of a hypothetical active MPT increased for all products after the one-month period of use, with the greatest increase for rings, the least familiar product. In multivariable analysis, acceptability of key product attributes (e.g., product look) were associated with a significant increase of ≥ 1 point in the mean rating across all three products (p ≤ 0.001). Perceived ability to use the product without partner knowledge was associated with a higher mean rating for rings (b = 0.50; p = 0.006). The acceptability of product attributes contributed significantly to the rating of all products, highlighting the value of choice in pregnancy and HIV prevention to accommodate diverse users.

Healthy Weight in Lesbian and Bisexual Women Aged 40 and Older: An Effective Intervention in 10 Cities Using Tailored Approaches

BACKGROUND

Lesbian and bisexual women are more likely to be overweight or obese than heterosexual women, leading to increased weight-related health risks.

METHODS

Overweight women aged 40 or older who self-identified as lesbian, bisexual, or "something else" participated in five pilot interventions of 12 or 16 weeks' duration. These tailored interventions took place at lesbian and bisexual community partner locations and incorporated weekly group meetings, nutrition education, and physical activity. Three sites had non-intervention comparison groups. Standardized questionnaires assessed consumption of fruits and vegetables, sugar-sweetened beverages, alcohol, physical activity, and quality of life. Weight and waist-to-height ratio were obtained through direct measurement or self-report.

ANALYTICAL PLAN

Within-person changes from pre-intervention to post-intervention were measured using paired comparisons. Participant characteristics that influenced the achievement of nine health objectives were analyzed. Achievement of health objectives across three program components (mindfulness approach, gym membership, and pedometer use) was compared with the comparison group using generalized linear models.

RESULTS

Of the 266 intervention participants, 95% achieved at least one of the health objectives, with 58% achieving three or more. Participants in the pedometer (n = 43) and mindfulness (n = 160) programs were more likely to increase total physical activity minutes (relative risk [RR], 1.67; 95% confidence interval [CI], 1.18-2.36; p = .004; RR, 1.38; 95% CI, 1.01-1.89; p = .042, respectively) and those in the gym program (n = 63) were more likely to decrease their waist-to-height ratio (RR, 1.89; 95% CI, 0.97-3.68, p = .06) compared with the comparison group (n = 67).

CONCLUSION

This effective multisite intervention improved several healthy behaviors in lesbian and bisexual women and showed that tailored approaches can work for this population.

A Computerized Family Planning Counseling Aid: A Pilot Study Evaluation of Smart Choices

CONTEXT

Resource constraints may make it challenging for family planning clinics to provide comprehensive contraceptive counseling; technological tools that help providers follow recommended practices without straining resources merit evaluation.

METHODS

A pilot study using a two-group, posttest-only experimental design evaluated Smart Choices, a computer-based tool designed to help providers offer more patient-centered counseling and enable patients to participate proactively in the counseling session. In two North Carolina family planning clinics, 214 women received usual counseling in March-May 2013, and 126 women used Smart Choices in May-July 2013. Exit interviews provided data for the evaluation. Multivariate Poisson and multinomial logistic regression analyses were performed to examine group differences in counseling outcomes.

RESULTS

Three of 12 hypotheses tested were supported: Compared with controls, women in the intervention group knew more contraceptive methods (adjusted mean, 11.1 vs. 10.7); discussed more topics related to sexual health during counseling (1.2 vs. 0.9 among those reporting any discussion); and rated counseling as more patient-centered, an indication of how well they felt providers understood their family planning circumstances and ideas (3.9 vs. 3.7 on a scale of 1-4). Contrary to another hypothesis, controls were more likely than women in the intervention group to choose IUDs and implants.

CONCLUSIONS

Computerized counseling aids like Smart Choices are in an early stage of development. Future research is warranted to develop tools that lead to more productive and individualized clinic visits and, ultimately, to more effective contraceptive use and reduced levels of unintended pregnancy.

Testosterone and sexual risk among transmen: a mixed methods exploratory study

Little research has explored the link between the behavioural effects of testosterone use among transmen and HIV risk. We conducted a mixed methods study to explore testosterone use among transmen and the behavioural effects on HIV risk. A sample of 122 transmen from San Francisco participated in a cross-sectional quantitative survey and 14 transmen participated in 2 focus group discussions. Most participants (81.9%) were currently taking hormones. Participants attributed testosterone use to new sexual behaviours among 69% of transmen, changes in sexual attraction (49%), and increased frequency of sexual activity (72%). Among current testosterone users, 3.3% had cisgender men as partners before starting testosterone, whereas after starting testosterone, 25.4% did. Similarly, 4.1% had a transgender woman as a sexual partner before starting testosterone and 13.9% after starting testosterone. Findings suggest that testosterone's side effects were associated with transmen's desires for sex with cisgender men who have sex with men. The reported increase in attraction to and sex with partners from populations with a high HIV prevalence may have important implications for HIV risk among transmen, especially as the availability of transgender health services may draw transmen to a context in which HIV prevalence is high.

Pre-exposure Prophylaxis Adherence Measured by Plasma Drug Level in MTN-001: Comparison Between Vaginal Gel and Oral Tablets in Two Geographic Regions

Despite strong evidence that daily oral pre-exposure prophylaxis (PrEP) reduces HIV risk, effectiveness across studies has varied. Inconsistent adherence constitutes one explanation. Efforts to examine adherence are limited when they rely on self-reported measures. We examined recent adherence as measured by plasma tenofovir (TFV) concentration in participants of MTN-001, a phase 2 cross-over trial comparing oral tablet and vaginal gel formulations of TFV among 144 HIV-uninfected women at sites in the United States (U.S.) and sub-Saharan Africa (SSA). Adherence to daily product use was higher in the U.S. than in the SSA sites. Within region, however, adherence was similar between products. In the U.S., gel adherence was higher among married women, and lower among women using male condoms and injectable contraceptives. At the SSA sites, gel adherence was lower for younger women. Inconsistent adherence points to challenges in use of daily PrEP, even during a trial of short duration.

The Social Environment and Childbearing Expectations: Implications for Strength-Based Sexual Health Interventions for Latino Youth

In the United States, adolescent childbearing is disproportionately higher among Latino youth, a growing population facing substantial social exclusion. Exploring the relationship between the social environment and sexual health outcomes among Latino youth may offer insights into the development of novel interventions. In this study, Latino youth in partnerships were recruited from neighborhood venues in San Francisco and completed in-depth interviews. Youth reported a desire to complete higher education goals prior to starting a family to improve future opportunities and further personal development. Youth stated that social network members, family and partners, were supportive of their individual childbearing expectations. Social environment barriers tied to poverty, immigration status, and gang violence hindered educational attainment. Some differences were noted by gender and immigrant generation. Building on protective social ties and creating avenues in poor, urban neighborhoods for Latino youth to fully access educational opportunities may counter early childbearing and improve sexual health.

The male factor: Outcomes from a cluster randomized field experiment with a couples-based HIV prevention intervention in a South African township

BACKGROUND

This study examined the effects of the Couples Health CoOp intervention on heavy drinking, condom use, and HIV incidence.

METHODS

Thirty neighborhoods from one South African township were cluster randomized into three intervention arms: Couples Health CoOp (CHC), Women's Health CoOp/Men's Health CoOp (WHC/MHC), or a comparison arm. We recruited 290 men from informal drinking establishments who reported drinking alcohol regularly. We also recruited their main heterosexual sex partners.

RESULTS

At 6-month follow-up, men in the CHC arm were less likely to report heavy drinking (OR 0.47, 95% CI: 0.25, 0.90) and were more likely to report consistent condom use during the past month (OR 2.66, 95% CI: 1.23, 5.76) than men in the comparison arm. At baseline, 26% of women and 13% of men were HIV-infected; at 6-month follow-up, 16 females and 5 males had seroconverted. HIV incidence was significantly lower among women in the CHC arm (IRR 0.22, 95% CI: 0.04, 1.01) than in the WHC/MHC arm.

CONCLUSIONS

A couples-based intervention focusing on intersecting risks for HIV can improve biobehavioral outcomes, underscoring the importance of engaging couples together in HIV prevention.

Impact of Adverse Childhood Experiences on Intimate Partner Violence Perpetration among Sri Lankan Men

In Sri Lanka, over one in three women experience intimate partner violence (IPV) victimization in their lifetime, making it a serious public health concern. Adverse childhood experiences (ACEs) such as child abuse and neglect, witnessing domestic violence, parental separation, and bullying are also widespread. Studies in Western settings have shown positive associations between ACEs and IPV perpetration in adulthood, but few have examined this relationship in a non-Western context. In the present study, we examined the association of ACEs with IPV perpetration among Sri Lankan men surveyed for the UN Multi-Country Study on Men and Violence in Asia and the Pacific. We found statistically significant positive associations between the number of ACE categories (ACE score) and emotional, financial, physical, and sexual IPV perpetration among Sri Lankan men. We analyzed the contributions of each ACE category and found that childhood abuse was strongly associated with perpetration of IPV in adulthood, with sexual abuse associated with the greatest increase in odds of perpetration (Adjusted odds ratio 2.36; 95% confidence interval: 1.69, 3.30). Witnessing abuse of one’s mother was associated with the greatest increase in the odds of perpetrating physical IPV (AOR 1.82; 95% CI: 1.29, 2.58), while lack of a male parental figure was not associated with physical IPV perpetration (AOR 0.76; 95% CI: 0.53, 1.09). These findings support a social learning theory of IPV perpetration, in which children who are exposed to violence learn to perpetrate IPV in adulthood. They also suggest that in Sri Lanka, being raised in a female-headed household does not increase the risk of IPV perpetration in adulthood compared to being raised in a household with a male parental figure. The relationship between being raised in a female-headed household (the number of which increased dramatically during Sri Lanka’s recent civil war) and perpetration of IPV warrants further study. Interventions that aim to decrease childhood abuse in Sri Lanka could both protect children now and reduce IPV in the future, decreasing violence on multiple fronts.

Seek, Test and Disclose: knowledge of HIV testing and serostatus among high-risk couples in a South African township

OBJECTIVES

HIV testing and disclosure of results to partners is an important strategy in HIV prevention but is under-researched within heterosexual partnerships. To address this gap, we describe patterns of HIV testing, discrepancies between beliefs and biologically confirmed HIV status of each partner, and characteristics of mutually correct knowledge of HIV status among heterosexual couples in a high-prevalence community.

METHODS

The study recruited 290 high-risk heterosexual couples in stable relationships from a township in Cape Town, South Africa. Male patrons of shebeens (drinking establishments) were approached to participate with their main partner in an intervention designed to reduce substance use, violence and unsafe sex. All participants were tested for HIV at baseline and asked about their partner's past HIV testing and current status. Using the couple as the unit of analysis, we conducted logistic regression to identify partnership and individual characteristics associated with having mutually correct knowledge of partner's HIV status.

RESULTS

Half (52%) of women and 41% of men correctly knew whether their partner had ever been tested for HIV. 38% of women, 28% of men and in 17% of couples, both members reported mutually correct knowledge of their partner's HIV status. Correlates of correct knowledge included married/cohabitating (aOR 2.69, 95% CI 1.35 to 5.40), both partners HIV-negative (aOR 3.32 (1.38 to 8.00)), women's acceptance of traditional gender roles (aOR 1.17 (1.01 to 1.40)) and men's relationship satisfaction (aOR 2.22 (1.01 to 4.44)).

CONCLUSIONS

Findings highlight the need to improve HIV testing uptake among men and to improve HIV disclosure among women in heterosexual partnerships.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov registration NCT01121692.

Relationship power, communication, and violence among couples: results of a cluster-randomized HIV prevention study in a South African township

Background

Inequitable gender-based power in relationships and intimate partner violence contribute to persistently high rates of HIV infection among South African women. We examined the effects of two group-based HIV prevention interventions that engaged men and their female partners together in a couples intervention (Couples Health CoOp [CHC]) and a gender-separate intervention (Men’s Health CoOp/Women’s Health CoOp [MHC/WHC]) on women’s reports of power, communication, and conflict in relationships.

Methods

The cluster-randomized field experiment included heterosexual couples from a high-density South African township in which neighborhoods were randomized to one of the intervention arms or a control arm that received the WHC only. Participants completed in-person study visits at baseline and 6-month follow-up. We examined group differences using one-way analysis of variance and multivariable regression models.

Results

Of the 290 couples enrolled, 255 women remained in the same partnership over 6 months. Following the intervention, women in the CHC arm compared with those in the WHC arm were more likely to report an increase in relationship control (β=0.92, 95% confidence interval [CI]: 0.02, 1.83, P=0.045) and gender norms supporting female autonomy in relationships (β=0.99, 95% CI: 0.07, 1.91, P=0.035). Women in the MHC/WHC arm were more likely to report increases in relationship equity, relative to those in the CHC arm, and had a higher odds of reporting no victimization during the previous 3 months (MHC/WHC vs WHC: odds ratio =3.05, 95% CI: 1.55, 6.0, P=0.001; CHC vs MHC/WHC: odds ratio =0.38, 95% CI: 0.20, 0.74, P=0.004).

Conclusion

Male partner engagement in either the gender-separate or couples-based interventions led to modest improvements in gender power, adoption of more egalitarian gender norms, and reductions in relationship conflict for females. The aspects of relationship power that improved, however, varied between the couples and gender-separate conditions, highlighting the need for further attention to development of both gender-separate and couples interventions.

Homies with aspirations and positive peer network ties: associations with reduced frequent substance use among gang-affiliated Latino youth

In marginalized urban neighborhoods across the USA, Latino youth are disproportionately represented among the growing number of youth gangs. Substance use among gang-involved youth poses both immediate and long-term health risks and can threaten educational engagement, future socioeconomic stability, and desistance. Conventional assessments of gang-affiliated youth and their peer network overlook the possibility that positive peer ties may exist and can foster health promoting behavior norms. Drawing on a positive deviance framework, in this study, we examine the relationship between positive peer network characteristics tied to post-secondary educational aspirations and frequent alcohol and marijuana use among Latino, gang-affiliated youth from a neighborhood in San Francisco. Using generalized estimating equations regression models across 72 peer network clusters (162 youth), we found that having close friends who plan to go to a 4-year college was associated with a lower odds of frequent marijuana and alcohol use (OR 0.27, p = 0.02; OR 0.29, p = 0.14, respectively) and that this association persisted when adjusting for risk characteristics (OR 0.19, p < 0.01; OR 0.25, p = 0.12). Public health can advance gang intervention efforts by identifying protective and risk factors associated with non-criminal health outcomes to inform participatory research approaches and asset-based interventions that contribute to building healthy communities.

Are hormonal contraceptive users more likely to misreport unprotected sex? Evidence from a biomarker validation study in Zimbabwe

We analyzed biomarker validation data of unprotected sex from women in Zimbabwe to determine whether condom and sexual behavior misreporting differs between users of different contraceptive methods. Self-reported sexual behavior was compared with the presence of prostate-specific antigen (PSA) in vaginal fluid, a biomarker of semen exposure. Of the 195 women who were PSA positive, 94 (48 %) reported no sex or only condom-protected sex. Hormonal contraceptive users misreported sexual behavior less than women using non-hormonal methods (45 vs. 67 %, P = 0.03). This misclassification pattern could have implications on the elevated risk of HIV infection associated with hormonal contraception in some studies.

Provider counseling to young women seeking family planning services

CONTEXT

Contraceptive nonuse and misuse contribute to rates of unintended pregnancy and STDs among young women in the United States. Clinical providers assume an important role in guiding youths' contraceptive method choices.

METHODS

Sixty-seven women aged 16-21 were recruited as part of a cohort study, conducted in 2009-2012, that examined provider-patient interactions during family planning visits at six San Francisco clinics. Interactions between patients and providers were audio-recorded. Participants completed questionnaires about method preference immediately before seeing the provider; they reported on method choice immediately after the visit and by telephone three and six months later. Transcripts were analyzed to examine providers' strategies for guiding decision making and addressing youths' contraceptive concerns. Missed opportunities for promoting young women's reproductive health were identified.

RESULTS

Twenty-one percent of young women who did not report desiring a hormonal or long-acting reversible method (IUD or implant) before seeing their provider chose one after counseling. Use of a hormonal or long-acting reversible contraceptive method at follow-up was more common among women who had received interactive counseling by providers who guided them to consider contextual influences than among those who had not received such counseling. Attention to relationship characteristics, sexual behavior patterns and STD risk was largely absent from contraceptive counseling.

CONCLUSION

High-quality strategies used by providers to guide contraceptive decision making were tailored to adolescents' developmental and environmental needs. Several areas of counseling require increased attention and seem vital to providing comprehensive reproductive health care to adolescents.

Yo Puedo--a conditional cash transfer and life skills intervention to promote adolescent sexual health: results of a randomized feasibility study in san francisco

PURPOSE

We designed and evaluated for feasibility an intervention-Yo Puedo-that addresses social network influences and socioeconomic opportunities in a neighborhood with substantial gang exposure and early childbearing.

METHODS

Yo Puedo combined conditional cash transfers for completion of educational and reproductive health wellness goals with life skills sessions, and targeted youth 16-21 years of age and same-aged members of their social network. We conducted a two-arm study with social networks randomized to the intervention or a standard services control arm. We evaluated intervention uptake, adherence, and safety; and assessed evidence of effects on behavioral outcomes associated with unintended pregnancy and sexually transmitted infection risk.

RESULTS

A total of 72 social networks composed of 162 youth enrolled, with 92% retention over 6 months. Seventy-two percent of youth randomized to the intervention participated in intervention activities: 53% received at least one conditional cash transfer payment and 66% came to at least one life skills session. We found no evidence that cash payments financed illicit or high-risk behavior. At 6 months, compared with controls, intervention participants had a lower odds of hanging out on the street frequently (odds ratio [OR], .54; p = .10) and a lower odds of reporting that their close friends had been incarcerated (OR, .6; p = .12). They reported less regular alcohol use (OR, .54; p = .04) and a lower odds of having sex (OR, .50; p = .04).

CONCLUSIONS

The feasibility evaluation of Yo Puedo demonstrated its promise; a larger evaluation of effects on pregnancy and sustained behavioral changes is warranted.

Trust - that's a big one: intimate partnership values among urban Latino youth

Romantic relationships play a central role in young people's social development and sexual health. This paper examines romantic relationship ideals valued by urban Latino youth in San Francisco and their experiences in achieving their ideals in their current relationship. We draw on in-depth interviews with 33 young men and women aged 16-22 years in San Francisco, California. In spite of, or perhaps related to, the prevailing perception that their peers were unfaithful in their relationships, young people in this study identified trust as one of the most important characteristics of a romantic relationship. Trust was related not only to fidelity, but also vulnerability and emotional intimacy. Understanding valued relationship ideals and factors that facilitate and impede their attainment is critical in promoting healthy relationships.

Feasibility and acceptability of a computer-based tool to improve contraceptive counseling

OBJECTIVE

The objective was to test the feasibility and acceptability of a computerized tool, Smart Choices, designed to enhance the quality of contraceptive counseling in family planning clinics. The tool includes (a) a questionnaire completed by patients and summarized in a printout for providers and (b) a birth control guide patients explore to learn about various contraceptive methods.

STUDY DESIGN

In 2 family planning clinics, we conducted interviews with 125 women who used the Smart Choices computerized tool and 7 providers.

RESULTS

Smart Choices integrated into clinic flow well in one clinic, but less well in the other, which had very short waiting times. Patients were generally enthusiastic about Smart Choices, including its helpfulness in preparing them and their providers for the counseling session and increasing their knowledge of contraceptive methods. Providers varied in how much they used the printout and in their opinions about its usefulness. Some felt its usefulness was limited because it overlapped with the clinic's intake forms or because it did not match with their concept of counseling needs. Others felt it provided valuable information not collected by intake forms and more honest information. Some found Smart Choices to be most helpful with patients who were unsure what method they wanted.

CONCLUSIONS

Smart Choices is feasible to implement and well received by patients, but modifications are needed to increase provider enthusiasm for this tool.

IMPLICATIONS

The Smart Choices tool requires refinement before widespread dissemination.

Limited socioeconomic opportunities and Latina teen childbearing: a qualitative study of family and structural factors affecting future expectations

The decrease in adolescent birth rates in the United States has been slower among Latinas than among other ethnic/racial groups. Limited research has explored how socioeconomic opportunities influence childbearing among Latina adolescents. We conducted in-depth interviews with 65 pregnant foreign- and US-born Latina women (31 adolescents; 34 adults) in two California counties. We assessed perceived socioeconomic opportunities and examined how family, immigration and acculturation affected the relationships between socioeconomic opportunities and adolescent childbearing. Compared with women who delayed childbearing into adulthood, pregnant adolescents described having few resources for educational and career development and experiencing numerous socioeconomic and social barriers to achieving their goals. Socioeconomic instability and policies limiting access to education influenced childbearing for immigrant adolescents. In contrast, family disintegration tied to poverty figured prominently in US-born adolescents' childbearing. Limited socioeconomic opportunities may play a large role in persistently high pregnancy rates among Latina adolescents.