HIV prevention through social networks: evidence from a randomized controlled trial of a peer advocacy intervention in Kampala, Uganda

There is no question that the stigma and discrimination associated with HIV and AIDS can be reduced through intervention. The inclusion of stigma and discrimination reduction as a critical component of achieving an AIDS-free generation in recent UNAIDS, UN and PEPFAR political initiatives is promising. Yet national governments need evidence on effective interventions at the individual, community and societal levels in order to strategically incorporate stigma and discrimination reduction into national AIDS plans. Currently, the heterogeneity of stigma and discrimination reduction approaches and measurement makes it challenging to compare and contrast evaluated interventions. Moving forward, it is critical for the research community to: (1) clearly link intervention activities to the domains of stigma to be shifted; (2) assess the stigma domains in a consistent manner; and (3) link stigma and discrimination reduction with HIV prevention, care and treatment outcomes (e.g., uptake, adherence and retention of ART). These steps would further advance the scientific evidence base of stigma and discrimination reduction and allow for the identification of effective interventions that could be scaled up by national governments. 10.7448/IAS.16.3.18881 © 2013 Grossman C I et al; licensee International AIDS Society Published 13 November 2013 Corresponding author: Cynthia I Grossman, HIV Care Engagement and Secondary Prevention Program, Division of AIDS Research, National Institutes of Mental Health, 6001 Executive Boulevard, RM 6201, MSC 9619, Bethesda, MD 20892, USA. ([email protected])

Clinical trial data have shown that oral pre-exposure prophylaxis (PrEP) is efficacious when taken as prescribed; however, PrEP adherence is complex and must be understood within the context of variable risk for HIV infection and use of other HIV prevention methods. Different levels of adherence may be needed in different populations to achieve HIV prevention, and the optimal methods for achieving the necessary adherence for both individual and public health benefits are unknown. Guidance for PrEP use must consider these questions to determine the success of PrEP-based HIV prevention programs. In this article, we propose a new paradigm for understanding and measuring PrEP adherence, termed prevention-effective adherence, which incorporates dynamic HIV acquisition risk behaviors and the use of HIV alternative prevention strategies. We discuss the need for daily PrEP use only during periods of risk for HIV exposure, describe key issues for measuring and understanding relevant behaviors, review lessons from another health prevention field (i.e., family planning), and provide guidance for prevention-effective PrEP use. Moreover, we challenge emerging calls for sustained, near perfect PrEP adherence regardless of risk exposure and offer a more practical and public health-focused vision for this prevention intervention.

The HIV epidemic in Latin America: a time to reflect on the history of success and the challenges ahead.

The eastern European and central Asian (EECA) region is facing the fastest-growing HIV epidemic in the world with 160,000 (130,000–180,000) people newly acquiring HIV in 2021, an overall 48% increase in the number of new acquisitions, and a 32% rise in AIDS-related deaths over the past 10 years [1]. The World Health Organization East European region is estimated to accommodate 1.4 million people living with HIV (PWH), with the majority of new transmissions reported to occur locally and to be unrelated to cross-country migrations [2, 3]. Sadly, according to UNAIDS, in 2022 only 62% of people living in the EECA region were aware of their HIV status and 51% of PWH received HIV treatment, which resulted in an overall viral suppression rate of 48% [1]. Common (>50%) late diagnoses (with either AIDS-defining condition or CD4+ T cell count <350 cells/µl at presentation) [4] further add to the epidemiological issues and complexity of client management [5]. Although the key acquisition risk in the region has changed from unsafe injection practices to heterosexual transmission, access to opioid agonist therapy (OAT) and needle and syringe programmes is often still limited (Kazakhstan) or unavailable (Uzbekistan, Turkmenistan), which results in OAT regional coverage as low as 4%, far below the UNAIDS target of 50%. Furthermore, pre-exposure prophylaxis (PrEP) and combination prevention services are of limited availability or not formally implemented across multiple countries in the region usually due to financial barriers to access, such as lack of state funding for medicines, limited technical capacity or cost of service delivery [6]. This results in a substantially larger HIV PrEP gap (the proportion of populations at risk of acquiring HIV "very likely" to use PrEP if accessible, compared with the proportion currently using PrEP) across countries located in the EECA region (up to 45%) compared to the overall median of 17.4% estimate for the European Union [7]. Moreover, there is a high level of stigma across the countries, especially against gay men and other men who have sex with men. The growing epidemic and the suboptimal access to prevention, testing and treatment are the main reasons that challenge the 2030 targets. The humanitarian crisis related to the Russian invasion and war in Ukraine has challenged the situation even further hindering testing and treatment efforts, forcing both internal displacement (estimated 3.7 million) and external migration of locals as refugees (estimated 6.4 million, as of March 2024) [8]. On top of massive casualties, civilian and healthcare infrastructures were destroyed, forcing refugees to seek safety, protection and assistance, including continued access to medical care. Ukraine is home to ∼260,000 PWH with >130,000 on antiretroviral treatment (ART). Although significant progress was made in the response to the HIV epidemic in Ukraine before the outbreak of war resulting in a 47% reduction in HIV incidence and an 81% reduction in AIDS mortality, the war has significantly affected the HIV and tuberculosis (TB) programmes, with internal displacement resulting in diminished service capacity, difficulty in ART provision and reduction in prevention services [9]. Despite notable hardship, Ukraine managed to maintain full access to ART, increased OAT rollout by 38% (reaching >27,000 people) and doubled the number of people on PrEP, which is now available free of charge [10]. A large proportion of the studies published in this supplement focus on Ukraine and the responses given during the war, providing good examples of resilience and strength and reflecting personal experiences in the setting of mass trauma. Mass traumas are especially important from the perspective of PWH, as these may bring out stress and exacerbate mental health issues. Owczarzak et al. analyse the bioecological model of mass trauma in the context of the Russian invasion and war in Ukraine among PWH with a history of injecting substance use [11]. This study reported the results of 18 interviews with people from four Ukrainian cities in autumn 2022. The study not only outlines personal experiences but also confirms the deep impact of war on the personal and healthcare-related wellbeing of participants, the necessity to respond to the triggering situations, such as the decrease in work opportunities, incremental costs and the necessity for internal displacement. All these factors were shown to be affecting ART access, adherence and general access to healthcare. Lazarus et al. analysed the non-governmental organization (NGO) response during the war and described service provision for key populations in Ukraine, using a mixed-methods project among geographically dispersed non-governmental (n = 24) and governmental (n = 2) organizations representing several Ukrainian regions [12]. Their analysis outlines the impact of the war on NGO work, including HIV prevention and treatment in a time when humanitarian aid is critical. Following the initial shock and the terror of war, the majority of the organizations quickly resumed work, limiting the duration of cessation of services, optimizing response and reallocating work to available staff. This study provides a strong story of resilience and support emphasizing the key work of NGOs in healthcare responses during unfortunate "big events" such as war. The topic of human rights and the context of war in Ukraine is further expanded by Lohman et al. by presenting an assessment related to human rights barriers to the prevention and treatment of HIV and TB [13]. The study consisted of a series of assessments covering the period of the Russian invasion and outbreak of war aiming to examine the progress in the scale-up and outcomes of human rights programmes. The paper describes an implementation learning evaluation using 25 interviews with programme implementers, community advocates and government officials, representing 14 organizations. Interview data clearly reflect the reduction of stigma in several domains, including a decrease in the proportion of PWH who faced unauthorized disclosure in the social environment (−19%), a reduction in the number of reported verbal abuses/personal threats (−13%) and improvement (+33%) in the perceived confidentiality of medical records. The war resulted in the expansion of regional coverage of legal and advocacy programmes and services, allowing a large number of the population to maintain access to key services. Ukraine is also one of few countries in the EECA region that have implemented numerous combination prevention programmes including HIV PrEP, where adherence remains challenging. In the follow-up of the study on oral daily PrEP with tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) [14] in 199 people who inject drugs (PWID) in Ukraine with or without the use of text reminders, Morozova et al. analysed longitudinal reported adherence patterns coupled with the measurement of tenofovir diphosphate and emtricitabine triphosphate in dried blood spots from study participants as objective measures of adherence [15]. The study enrolled people who have been injecting drugs for longer than 20 years (37%) with a high proportion of alcohol use (67%) and >50% with moderate to severe depression. In this highly challenging group, the perceived adherence was high to moderate in >90% of the cases with 81% reporting to take more than 95% of their TDF/FTC doses. Alarmingly, data from the dried blood spot metabolite analysis revealed the reality to be divergent from patient-reported adherence with >50% of participants without detectable TDF/FTC metabolite levels. This study provides unique data confirming the divergence between perceived and measured adherence among PWID, indicating that novel telemedicine or online interventions in combination prevention of HIV can be particularly useful in marginalized or difficult-to-reach populations. Migrants from central Asia moving to central eastern countries to work are disproportionately affected by HIV and sexually transmitted infections due to high-level stigma and poor working conditions, and have lower or no access to the health system and prevention tools compared to other groups. Kovtun et al. [16] focused on human rights violations related to sexual orientation, gender identity (SOGI), and HIV in six countries in eastern Europe, Caucasus and central Asia in 2022 (Armenia, Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine and Uzbekistan), which have a background of a rapidly rising HIV epidemic, strict social and religious norms, high level of stigma and discrimination associated with sexual and gender minorities and HIV, and regional conflict. Using the Rights—Evidence—ACTion (REAct) tool, they analysed the data on rights violations upon complaints from gay and bisexual men who have sex with men and transgender women. The strikingly higher numbers of rights violations and violations solely based on SOGI in Ukraine compared to the Caucasus and central Asian countries suggest that despite all the achievements made in the country in the last decade in terms of harm reduction, testing, and access to ART and care, stigma and discrimination still prevails in the country. The effect of the recent war in Ukraine was also evident with more human rights violations by police and military staff, denials of private or social services, refusals of temporary accommodation services and denial of border crossings. The results of this study underscore the diversity of the region in terms of stigma, discrimination and human rights violations. Mackesy-Amiti et al. define a social intervention that aimed to reduce high-risk behaviours for HIV among Tajik migrants who inject drugs working in the Russian Federation [17]. This was a cluster-randomized controlled trial comparing the network-based, peer educator training with the general health education training. Male Tajik migrants were recruited as peer educators and trained on how to reduce personal risk for HIV acquisition and to deliver knowledge to peers. The interviews showed that the baseline percentages of binge drinking, condomless sex, and syringe and equipment sharing behaviours were considerably high, and needle cleaning behaviour and HIV testing were extremely low in both peer educators and peers. There was a significant reduction in needle-sharing behaviour following study intervention, but a modest effect on sexual behaviour. This study suggests that interventions tailored to the needs of specific groups and the inclusion of peers may be effective even in populations that are hard to reach. Stigma-associated issues were also addressed by Davis et al. who used a citizen science approach to address HIV-related stigma and increase HIV testing in adolescents and young adults in Kazakhstan [18]. These populations were called to develop digital materials, which would be assessed and rated in a contest with the aim to reduce HIV-related stigma and promote HIV self-testing. The submitted materials were judged by a board including peers of the contestants, healthcare professionals and representatives of NGOs, and highly rated submissions were awarded. Adolescents and young adults showed a high level of interest in the project both as contestants, which resulted in a high number of submissions, and as board members providing input in the development and implementation of the study, running social media procedures, creating promotional materials and providing feedback on the submission system. Inclusion of the community stimulated collaboration among adolescents and young adults, and increased knowledge of HIV-related stigma and the importance of HIV testing. Lastly, a study also from Kazakhstan on adherence to ART among PWH in association with mental health and cognitive disorders was presented by Mergenova et al. [19]. The size of the HIV epidemic in this country is increasing with the majority of acquisitions reported among people who inject psychoactive substances. The authors performed a cross-sectional questionnaire-based analysis of 230 PWH on stable (>6 months) ART, with the assessment of self-reported ART adherence in addition to depression, anxiety, post-traumatic stress disorder (PTSD) symptoms, and cognitive and memory assessments. Notably, a third of the patients reported a history of mental illness, while only 25% reported injection drug use and 17% hazardous alcohol drinking. Moreover, mild depression or anxiety was reported in 20−32%, while in 6−10%, these mood disorders were at least moderate including PTSD symptoms observed in 7% of cases. Not surprisingly, these symptoms were associated with lower adherence—missing ART was more likely among participants with mild or moderate depressive symptoms, mild or moderate anxiety symptoms, PTSD symptoms or forgetfulness. On the contrary, better cognitive function was associated with better adherence to therapy. This study emphasizes the need for precise and regular assessment of not only ART but also mental health and cognitive function for better care of PWH in order to tailor specific responses and to provide mental health support for improving treatment adherence and maintaining optimal viral suppression rates. The long history of neglecting HIV in EECA resulted in rapid increases of transmissions. The high number of PWID and migrants who are disproportionately affected by HIV and the unique characteristics of each country with different cultures, beliefs and structures challenge the long-term efforts to address the epidemic. This supplement on the HIV epidemic in eastern Europe and central Asia presents a story of resilience, continued efforts to improve human rights, and innovative approaches to combination prevention, and summarizes key challenges related to stigma and other societal issues. While continuing these efforts, further international support, commitment and collaboration will be vital to achieve the new goals for 2030 to end AIDS in the region. The authors declare no competing interests. MP and DG jointly drafted and revised the editorial. All the authors read and approved the final version. We would like to express our sincere thanks to all the authors who prepared, submitted and revised manuscripts in response to this supplement request. We are grateful to all the research participants who volunteered to take part in studies in this supplement. We are also thankful to our co-Guest Editor, Dr Andriy Klepikov, Executive Director of the Alliance for Public Health, for his valuable role in the conceptualization and development of this supplement. The authors alone are responsible for the views expressed in this supplement and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Promotion of Research on the HIV Continuum of Care in the United States: The CFAR HIV Continuum of Care/ECHPP Working Group.

Background In the United States, high rates of HIV transmission persist, particularly due to sexual transmission in marginalized populations. Transactional sex (TS) is a known risk factor for HIV transmission, yet risk behaviors and engagement in HIV treatment and prevention among those who have TS are poorly understood. Methods GRAVITY is cross-sectional investigation of people living with HIV (PLWH) or HCV in Washington, DC and Baltimore, MD. Epidemiologic survey data were collected at a single timepoint. Patients who endorsed previous year sex in exchange for drugs, money, or shelter were considered positive for TS. Fisher’s exact test was used for statistical analysis. Results Of 500 participants, 81(16%) endorsed TS, the majority of whom were HIV+ (51, 63%) and used drugs daily or more (57,70%; see Table 1). PLWH with TS were more likely to be Black (44, 86%, p= 0.05) and Trans female (17, 33%, p&amp;lt;0.01) than HIV- participants with TS. In the TS cohort, PLWH were more likely to engage in anal sex (38, 75%, p&amp;lt; 0.01), have sex weekly or more (46, 90%; p&amp;lt; 0.01), have sex with more than 2 partners (27, 77%, p=0.03), and have a history of syphilis (14, 27% p= 0.04) compared to HIV- participants. Only 21% and 35% of PLWH and 17% and 22% of HIV- always used condoms in vaginal sex and anal sex, respectively (p &amp;gt;0.05). Though 41 (80%) PLWH took ART, only 19 (41%) reported viral suppression. Of HIV- participants, 59% had interest in starting Pre-Exposure Prophylaxis (PrEP), but few had been offered (3,10%), or ever taken PrEP (2,7%). Table 1: Participant Characteristics and Associations with Transactional Sex and HIV Status Conclusion In this cohort of people with TS, there were high rates of HIV and racial, sexual, and gender minorities. Notably, PLWH had higher rates of frequent sex, multiple partners, and anal sex, as well as suboptimal viral suppression and condom use during anal sex. As such, PLWH +TS may be a consequential part of HIV transmission networks. While those without HIV also had frequent sex and suboptimal condom use, PrEP experience was limited. As the majority had interest in PrEP, targeted strategies to initiate and maintain PrEP in people with TS may be critical in preventing HIV acquisition. Interventions to identify TS, address high-risk behaviors, achieve and maintain viral suppression amongst +TS PLWH, and connect +TS HIV- individuals to PrEP are key to a comprehensive strategy to end the HIV epidemic. Disclosures Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

A number of studies have shown strong evidence of the association between HIV testing and an increase in consistent condom use. These studies have shown that HIV testing has contributed to a reduction in risk behaviours, since knowledge of HIV status can motivate both HIV-positive and HIV-negative people to practise safer sex. However, the extent to which knowledge of one's HIV status contributes to behavioural change among people living with HIV (PLHIV) has not been comprehensively documented. Drawing on an analysis of 37 in-depth interviews and five focus group discussions with PLHIV, this paper examines the nature of sexual activity and condom use among PLHIV in Swaziland. The paper explores issues pertaining to behavioural change and safer sex, and how these are influenced by the individual's HIV-positive status and the prevailing social-structural forces. Several factors inhibit the adoption of protective sexual behaviour among HIV-positive sexual partners, some of whom have access to life-saving drug therapy. These factors include a lack of adequate social support structures and prevailing gender power imbalances that deny women control over their sexual lives. To promote behavioural change among PLHIV, the paper proposes the expansion of the scope of information, education and communication strategies to include activities aimed at continually sensitising PLHIV regarding safer sex, as well as activities geared towards improving communication between PLHIV and their health-caregivers with regard to HIV-protective behaviours.

Awareness and Willingness to Use HIV Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Rwanda: A Cross-Sectional Descriptive Survey.

To determine whether a site-based Priorities for Local AIDS Control Efforts (PLACE) HIV prevention intervention in Kingston, Jamaica increased condom use among persons with new or multiple sex partners. A total of 147 sites where persons go to meet new sex partners were grouped into 50 geographic clusters and randomized to receive or not receive a multilevel PLACE prevention intervention. Baseline cross-sectional surveys of sites and patrons at sites were conducted in 2005 to determine the nature of social activities at sites to better plan the intervention and to ensure that the two arms of the trial were similar. The intervention was delivered by 50 trained outreach workers between January and June 2006. After the intervention two cross-sectional surveys were conducted to assess the extent of intervention implementation and to estimate the proportion of patrons at sites with recent new or concurrent partnerships and inconsistent condom use. Characteristics of sites and patrons were similar for most variables at intervention and control sites at both baseline and post-intervention. A total of 1535 patrons (723 men, 812 women) were interviewed at intervention sites and 1324 patrons (661 men, 663 women) at control sites 6-9 months after the intervention. There were no significant differences between intervention and control groups in the proportions of men (37.8% and 31.6%) and women (24.6% and 22.6%) who reported new or multiple relationships in the past year and inconsistent condom use. There was no significant difference in the proportion of men or women showing a condom at interview, having a HIV test in the past 12 months or being exposed to the intervention. An intent-to-treat analysis did not show any intervention effect. This was probably because of difficulty in implementing the intervention, the extent of patron mixing among sites, the intensity of national education campaigns, delay in conducting the post-intervention survey and evidence of other interventions at some control sites.

BackgroundThe advent of antiretroviral therapy (ART) has transformed the management of living with HIV into a chronic condition, however, barriers to access persist. Utilization management techniques (UMTs) used by payers to optimize care and resource efficiency often pose challenges for people living with HIV (PLWH) and individuals with increased likelihood of HIV exposure. This study examined the burden of ART-specific UMTs across access pathways in the US, and impact on PLWH, individuals vulnerable to HIV acquisition, and the healthcare system.MethodsA systematic literature review was conducted in MEDLINE®, Embase®, JSTOR, PubMed, and government/non-government HIV management websites focusing on ART-specific UMTs in treatment and pre-exposure prophylaxis (PrEP) of HIV in the US. The search covered publications from the last 10 years and conference abstracts from the last 4 years. Studies that met predefined inclusion criteria, based on the PICOTS framework, were included.ResultsOf 1,863 records, 21 met the study criteria, mostly from the private setting (76%). Prior authorization (PA) was the most common UMT identified (71%), followed by step therapy (5%) and quantity limits (5%) for both HIV treatment and PrEP. For oral HIV PrEP, PAs ranged from 2.3% (Northeast) to 37.3% (South). PA-led rejection rates of up to 21% for HIV PrEP regimens were identified, with formulary restrictions contributing to worse clinical outcomes for HIV treatment and PrEP. While there was a paucity of economic burden data for individuals, formulary restrictions imposed substantial costs to the healthcare system ($2.19 billion higher vs. the open formulary). Provider-based studies reported UMTs substantially impact HIV care, with one study reporting that 76% of providers indicate interference with optimal care, 72% citing UMTs and formularies impede prescribing optimal HIV treatment/PrEP.ConclusionUMT may pose substantial barriers to timely HIV care and prevention. While intended to control costs, they often result in treatment delays, worsening outcomes, and higher expenses. Despite national efforts to eliminate UMTs for HIV treatment and PrEP, access to ART remains unequal. Policy reforms for UMTs may help facilitate equitable access to HIV care, improve health outcomes, and reduce the HIV burden.DisclosuresGirish Prajapati, M.B.B.S., MPH , Merck & Co., Inc.: Employee|Merck & Co., Inc.: Stocks/Bonds (Private Company) Sean P. Fleming, PhD, MSW, Merck & Co., Inc., Rahway, NJ, USA: Employee|Merck & Co., Inc., Rahway, NJ, USA: Stocks/Bonds (Public Company) David E. Koren, PharmD, BCPS, AAHIVP, Gilead Sciences: Advisor/Consultant|Merck Sharp and Dohme: Advisor/Consultant|ViiV Healthcare: Advisor/Consultant Orbit R. Clanton, AOS, Global Community HIV Advocate, Merck & Co., Inc: Advisor/Consultant Harshil Patel, BSc, Merck & Co., Inc: Advisor/Consultant Lucia Perez-Kempner, BPharm, MSc, MBS, Merck & Co., Inc: Advisor/Consultant Astha Jain, M.Pharmacy, Merck & Co., Inc: Advisor/Consultant Sugandh Sharma, M.Sc., Merck & Co., Inc: Advisor/Consultant

Pre-exposure Prophylaxis Uptake, Adherence, and Persistence: A Narrative Review of Interventions in the U.S.

BackgroundMen who have sex with men (MSM) continue to be the predominately impacted risk group in the United States HIV epidemic and are a priority group for risk reduction in national strategic goals for HIV prevention. Modeling studies have demonstrated that a comprehensive package of status-tailored HIV prevention and care interventions have the potential to substantially reduce new infections among MSM. However, uptake of basic prevention services, including HIV testing, sexually transmitted infection (STI) testing, condom distribution, condom-compatible lubricant distribution, and preexposure prophylaxis (PrEP), is suboptimal. Further, stronger public health strategies are needed to promote engagement in HIV care and viral load suppression among MSM living with HIV. Mobile health (mHealth) tools can help inform and encourage MSM regarding HIV prevention, care, and treatment, especially among men who lack access to conventional medical services. This protocol details the design and procedures of a randomized controlled trial (RCT) of a novel mHealth intervention that comprises a comprehensive HIV prevention app and brief, tailored text- and video-based messages that are systematically presented to participants based on the participants’ HIV status and level of HIV acquisition risk.ObjectiveThe objective of the RCT was to test the efficacy of the Mobile Messaging for Men (M-Cubed, or M3) app among at least 1200 MSM in Atlanta, Detroit, and New York. The goal was to determine its ability to increase HIV testing (HIV-negative men), STI testing (all men), condom use for anal sex (all men), evaluation for PrEP eligibility, uptake of PrEP (higher risk HIV-negative men), engagement in HIV care (men living with HIV), and uptake of and adherence to antiretroviral medications (men living with HIV). A unique benefit of this approach is the HIV serostatus-inclusiveness of the intervention, which includes both HIV-negative and HIV-positive MSM.MethodsMSM were recruited through online and venue-based approaches in Atlanta, Detroit, and New York City. Men who were eligible and consented were randomized to the intervention (immediate access to the M3 app for a period of three months) or to the waitlist-control (delayed access) group. Outcomes were evaluated immediately postintervention or control period, and again three and six months after the intervention period. Main outcomes will be reported as period prevalence ratios or hazards, depending on the outcome. Where appropriate, serostatus/risk-specific outcomes will be evaluated in relevant subgroups. Men randomized to the control condition were offered the opportunity to use (and evaluate) the M3 app for a three-month period after the final RCT outcome assessment.ResultsM3 enrollment began in January 2018 and concluded in November 2018. A total of 1229 MSM were enrolled. Data collection was completed in September 2019.ConclusionsThis RCT of the M3 mobile app seeks to determine the effects of an HIV serostatus–inclusive intervention on the use of multiple HIV prevention and care-related outcomes among MSM. A strength of the design is that it incorporates a large sample and broad range of MSM with differing prevention needs in three cities with high prevalence of HIV among MSM.Trial RegistrationClinicalTrials.gov NCT03666247; https://clinicaltrials.gov/ct2/show/NCT03666247International Registered Report Identifier (IRRID)DERR1-10.2196/16439

Evidence-informed and human rights-based combination prevention combines behavioural, biomedical, and structural interventions to address both the immediate risks and underlying causes of vulnerability to HIV infection, and the pathways that link them. Because these are context-specific, no single prescription or standard package will apply universally. Anchored in 'know your epidemic' estimates of where the next 1000 infections will occur and 'know your response' analyses of resource allocation and programming gaps, combination prevention strategies seek to realign programme priorities for maximum effect to reduce epidemic reproductive rates at local, regional, and national levels. Effective prevention means tailoring programmes to local epidemics and ensuring that components are delivered with the intensity, quality, and scale necessary to achieve intended effects. Structural interventions, addressing the social, economic, cultural, and legal constraints that create HIV risk environments and undermine the agency of individuals to protect themselves and others, are also public goods in their own right. Applying the principles of combination prevention systematically and consistently in HIV programme planning, with due attention to context, can increase HIV programme effectiveness. Better outcome and impact measurement using multiple methods and data triangulation can build the evidence base on synergies between the components of combination prevention at individual, group, and societal levels, facilitating iterative knowledge translation within and among programmes.

The objectives were to assess the self-efficacy and consistent condom use by people living with HIV (PLHIV). A cross-sectional, comparative study was carried out in outpatient clinics in Ceará State, Brazil, with a sample of 190 PLHIV, 95 serodiscordant and 95 seroconcordant. Interviews were conducted using the Socio-Demographic, Clinical, Epidemiological and Vulnerability Form and the Condom Use Self-Efficacy Scale. Descriptive analysis, associations between variables, odds ratio and 95% confidence interval were determined. P < 0.05 was considered statistically significant. Of the sample, 43.1% consistently used condoms (50.5% serodiscordant and 35.7% seroconcordant). Serodiscordant PLHIV without guidance on HIV prevention (P = 0.027) and without access to testing (P = 0.002) had lower self-efficacy and 11.5 times more chances for inconsistent condom use (P = 0.006), while those satisfied with follow-up in health were less likely to use condoms inconsistently (P = 0.011). We conclude that there is low consistent use of condoms among PLHIV, which increases the risk of HIV transmission and the acquisition of other sexually transmitted infections. Consistent condom use was greater among serodiscordant individuals, although there was no difference in self-efficacy in condom use between the groups.

Toward Greater Pre-exposure Prophylaxis Equity: Increasing Provision and Uptake for Black and Hispanic/Latino Individuals in the U.S.