HIV Prevention Cascade Research Articles

Intimate partner violence, behaviours associated with risk of HIV acquisition and condom use in married women in Manicaland, East Zimbabwe: An HIV prevention cascade analysis

BackgroundIntimate partner violence (IPV) is widespread in the WHO African region with generalised HIV epidemics and may contribute to ongoing HIV transmission through its associations with behaviours associated with HIV acquisition risk and low use of prevention methods particularly in marital relationships.MethodsWe conducted a male condom HIV prevention cascade analysis using data from a general-population survey in Manicaland, Zimbabwe (July 2018-December 2019) to develop an understanding of how interventions that reduce IPV might be built upon to also reduce HIV incidence. Multivariable logistic regression was used to measure associations between currently-married HIV-negative women’s experience of IPV and: (1) being in the priority population for HIV prevention methods (i.e. married women engaging in behaviours associated with HIV acquisition risk or with a spouse who engages in similar behaviours or is living with HIV), and (2) male condom use by women in this priority population. Male condom HIV prevention cascades, with explanatory barriers for gaps between successive cascade bars (motivation, access and effective use), were compared for women in the priority population reporting and not reporting IPV.ResultsWe found a positive association between IPV and being in the priority population for HIV prevention methods (72.3% versus 58.5%; AOR = 2.26, 95% CI:1.74–2.93). Condom use was low (< 15%) for women in the priority population and did not differ between those reporting and not reporting IPV. The HIV prevention cascades for women reporting and not reporting IPV were similar; both showing large gaps in motivation and capacity to use male condoms effectively. Women reporting motivation and access to male condoms were more likely to report their partner being a barrier to condom use if they experienced IPV (84.8% versus 75.5%; AOR = 2.25, 95% CI:1.17–4.31).ConclusionThe findings of this study support the case for trials of integrated IPV/HIV prevention interventions that are tailored to improve HIV risk perception among HIV-negative married women and to make condom provision more acceptable for this group.

Contextualizing HIV testing experiences within the HIV prevention cascade: qualitative insights from refugee youth in Bidi Bidi refugee settlement, Uganda

BackgroundThere remain key knowledge gaps regarding HIV testing needs and priorities among refugee youth in low and middle-income country (LMIC) humanitarian settings. The HIV prevention cascade framework focuses on three domains (motivation, access, effective use) central to prevention uptake, yet is understudied in relationship to HIV testing, particularly among refugee youth. Uganda is an exemplar context to explore refugee youth HIV testing needs and priorities as it hosts 1.5 million refugees and is Africa’s largest refugee hosting nation. In this study, we explored perceptions and experiences regarding HIV testing among refugee youth living in Bidi Bidi refugee settlement, Uganda.MethodsWe conducted a community-based research study in Bidi Bidi Refugee Settlement, one of the world’s largest refugee settlements with over 195,000 residents. This qualitative study involved four focus groups (2 with young women, 2 with young men) with refugee youth aged 16–24 living in Bidi Bidi refugee settlement. We applied thematic analysis informed by the HIV prevention cascade to understand domains of motivation, access, and effective use that emerged as salient for HIV testing engagement.ResultsParticipants (n = 40; mean age: 20 years, standard deviation: 2.2) included refugee young women (n = 20) and young men (n = 20), of whom 88% had a lifetime HIV test and 58% had ever heard of HIV self-testing. Participant discussions described HIV testing motivation was influenced by dimensions of: HIV treatment and testing knowledge; risk perception; positive and negative consequences of use; and social norms regarding gender and age. Access to HIV testing was shaped by: limited availability; distance and language barriers; confidentiality concerns; and affordability. Effective use of and engagement with HIV testing was related to HIV serostatus knowledge self-efficacy and in/equitable partner dynamics.ConclusionsComplex, multi-level factors shape motivation for, access to, and effective use of HIV testing among refugee youth in Bidi Bidi. Findings align with the HIV prevention cascade framework that helps to identify gaps to inform intervention development with youth in humanitarian settings. HIV testing approaches tailored for refugee youth in contexts such as Bidi Bidi can foster HIV prevention and treatment literacy, gender equity, gender-based violence prevention, and intersectional stigma reduction.

Viral load non-suppression among adolescents and youth living with HIV in South Africa.

Despite the increased initiation and uptake of antiretroviral therapy (ART) in South Africa, some people living with HIV (PLHIV) who are on ART still have non-suppressed viral load (VL). This study aimed to determine the prevalence of VL non-suppression among adolescents and youth (aged 12 years - 24 years) living with HIV and on ART in South Africa, as well as the factors associated with it. Data from the 2017 South African national HIV prevalence, incidence, behaviour, and communication survey were analysed. The survey used a multistage-stratified cluster sampling design. A backward stepwise multivariable generalised linear model was used to identify factors associated with VL non-suppression. The study included 340 participants aged 12 years - 24 years, with a median age of 21 (interquartile range [IQR]: 18-23). The proportion of adolescents and youth living with HIV and on ART with non-suppressed VL was 19.2% (95% confidence interval [CI]: 14.4-25.3). Approximately 60% of the participants were not on ART. The odds of VL non-suppression were significantly higher among youth aged 15 years - 19 years (adjusted odds ratio [AOR] = 1.63 [95% CI: 1.24-2.13], p = 0.001) and aged 20 years - 24 years (AOR = 1.22 [95% CI: 1.06-1.41], p = 0.005) compared to adolescents aged 12 years - 14 years. The odds were significantly lower among individuals of other races (AOR = 0.80 [95% CI: 0.69-0.92], p = 0.003) compared to black African people. Findings suggest a need for ART education and counselling as part of treatment support. In addition, the promotion of HIV awareness as part of strengthening the HIV treatment and prevention cascade. The article showed the prevalence of VL non-suppression and associated factors among adolescents and youth.

Appraising the HIV Prevention Cascade methodology to improve HIV prevention targets: Lessons learned from a general population pilot study in east Zimbabwe.

Multiple HIV Prevention Cascades (HPC) formulations have been proposed to assist advocacy, monitoring of progress of HIV prevention implementation and research to identify ways to increase use of HIV prevention methods. Schaefer and colleagues proposed a unifying formulation suitable for widespread use across different populations which could be used for routine monitoring or advocacy. Robust methods for defining and interpreting this HPC formulation using real world data is required. Data collected as part of the Manicaland Pilot HIV Prevention Cascades Study, east Zimbabwe, in 2018-19, was used to validate the HPC framework for PrEP, VMMC, male condom and combination prevention method use. Validation measures included feasibility of populating the HPC, contrasting simple vs complex measures of the HPC (using 2-sample proportion test), and testing ability of main bars to predict prevention use and testing whether sub-bars explained why people were lost from the HPC using logistic regression. It was possible to populate the HPC for both individual and combined prevention methods using pilot survey data. Most steps were associated with prevention method usage outcomes, except for VMMC. There were significant overlaps between individuals reporting positive responses for the main bar and those citing barriers to motivation. To refine the HPC's access bar definition, it is suggested to also consider individuals who report access barriers. While the HPC framework identifies barriers to individual prevention methods, challenges arise in identifying those for combined prevention. Our study successfully utilised questionnaires from the Manicaland HPC pilot survey to measure the HPC for individual and combined prevention methods. This demonstrates the feasibility of populating this framework using general population survey data and designated questionnaire modules. We propose a final formulation of the HPC, questionnaire modules and methods to create it. With proper evaluation and promotion, the HPC can enhance prevention services, aiding in the crucial reduction of HIV incidence.

A risk-differentiated, community-led intervention to strengthen uptake and engagement with HIV prevention and care cascades among female sex workers in Zimbabwe (AMETHIST): a cluster randomised trial

Female sex workers remain disproportionately affected by HIV. The aim of this study was to determine the effect of risk-differentiated, peer-led support for female sex workers in Zimbabwe on the risk of HIV acquisition and HIV transmission from sex among female sex workers. In this cluster randomised, open-label, controlled study, 22 clinics dedicated to female sex workers co-located in government health facilities throughout Zimbabwe were allocated (1:1, through restricted randomisation) to usual care or AMETHIST intervention. Usual care comprised HIV testing, pre-exposure prophylaxis (PrEP), referral to government antiretroviral therapy (ART) services, contraception, condoms, syndromic management of sexually transmitted infections, health education, legal advice, and peer support. AMETHIST added peer-led microplanning tailored to individuals' risk and participatory self-help groups. All cisgender women (aged >18 years) who had sold sex within the past 30 days and lived or worked within trial cluster areas were eligible. Intervention status was not masked to programme implementers but was masked to survey teams and laboratory staff. After 28 months, a respondent-driven sampling (RDS) survey was done in the female sex worker population around each clinic, which measured the primary outcome, the combined proportion of female sex workers in the surveyed population at risk of transmitting HIV (ie, were HIV positive, not virally suppressed, and not consistently using condoms) or at risk of acquiring HIV (ie, were HIV negative and not consistently using condoms or PrEP). We report prespecified analyses of the disaggregated proportions of female sex workers in the surveyed population at risk of either transmission or acquisition of HIV. Analyses were prespecified, RDS-weighted, and age-adjusted. This trial is registered with the Pan African Clinical Trials Registry, PACTR202007818077777. The AMETHIST intervention was started on May 15, 2019, and data were collected from June 1, 2019, until Dec 13, 2021. The RDS survey was done from Oct 18 to Dec 13, 2021, with 2137 women included in the usual care group (11 clusters) and 2131 in the AMETHIST intervention group (11 clusters) after excluding survey seeds (n=132) and women with missing key data (n=44). 1973 (46·2%) of the 4268 female sex workers surveyed were living with HIV; of these, 863 (93·5%; RDS-adjusted) of 931 women in the intervention group and 927 (88·8%) of 1042 in the usual care group were virologically suppressed. 287 (22·4%) of 1200 HIV-negative women in the intervention group and 194 (15·7%) of 1096 in the usual care group reported currently taking PrEP, of whom only two (0·4%) of 569 had protective tenofovir diphosphate concentrations in dried blood spots (>700 fmol/dried blood punch). There was no effect of the intervention on the primary endpoint of risk of both HIV transmission and acquisition (intervention group n=1156/2131, RDS-adjusted proportion 55·3%; usual care group n=1104/2137, RDS-adjusted proportion 52·7%; age-adjusted risk difference -0·9%, 95% CI -5·7% to 3·9%, p=0·70). For the secondary outcomes, the proportion of women living with HIV at risk of transmission was low and significantly reduced in the intervention group (n=63/931, RDS-adjusted proportion 5·8%) compared with the usual care group (103/1041, 10·4%), with an age-adjusted risk difference of -5·5% (95% CI -8·2% to -2·9%, p=0·0003). Risk of acquisition among HIV-negative women was similar in the intervention (n=1093/1200, RDS-adjusted proportion 92·1%) and the usual care group (1001/1096, 92·2%), with an age-adjusted risk difference of -0·6% (95% CI -4·6 to 3·4, p=0·74). There was no overall benefit of the intervention on combined risk of transmission or acquisition. Viral load suppression in women living with HIV was high and appeared to be further improved by AMETHIST, suggesting potential for impressive uptake and adherence to ART in vulnerable and mobile populations. Sustaining treatment and reinvigorating prevention remain crucial. The Wellcome Trust and the Bill & Melinda Gates Foundation. For the Shona and Ndebele translations of the abstract see Supplementary Materials section.

The HIV prevention decision-making cascade: Integrating behavioural insights into HIV prevention efforts

The syndemic of HIV, sexually transmitted infections (STIs), and early pregnancy remain a key challenge to global public health. Decision-making around sexual and reproductive health (SRH) behaviours is critical to ensuring the uptake of biomedical technologies. Drawing from behavioural science theories, we propose a novel conceptual framework—the Decision Cascade—to describe the decision-making process that a user will go through as they navigate these decisions. Analogous to the HIV prevention and treatment cascade, this model describes key steps individuals go through when deciding to use HIV prevention technologies. Each step (being cued/triggered to act, reacting to the behaviour, evaluating the behaviour, assessing the feasibility of acting and the timing and final execution of the action), is influenced by a myriad of individual and socio-cultural factors, shaping the ultimate decision and behaviour outcome in a continual cycle. This framework has applications beyond HIV prevention, extending to other SRH technologies and treatments. By prioritizing human-centered design and understanding user decision-making intricacies, interventions can enhance effectiveness and address the complexities of SRH service uptake across diverse populations. The Decision Cascade framework offers a comprehensive lens to inform intervention design, emphasizing the need for nuanced approaches that resonate with the realities of decision-makers. Adopting such approaches is essential to achieving meaningful impact in HIV prevention and broader SRH initiatives.

Gender Norms and Structural Barriers to Use of HIV Prevention in Unmarried and Married Young Women in Manicaland, Zimbabwe: An HIV Prevention Cascade Analysis

Background Gender norms against adolescent girls and young women (AGYW)’s having pre-marital sex and using condoms in marriage are included as barriers to motivation to use condoms in HIV prevention cascades. Representative survey data on gender norms are needed to test this assumption. Methods General-population survey participants in Manicaland, Zimbabwe (ages≥15, N=9803) were asked if they agreed/disagreed with statements on gender norms. AGYW at risk of HIV infection were asked whether community views discouraged condom use. Multivariable logistic regression was used to measure variations in community members’ views and associations between AGYW’s perceiving negative gender norms and condom HIV prevention cascades. Results 57% of men and 70% of women disagreed that ‘If I have a teenage daughter and she has sex before marriage, I would be ok with this’; and 41% of men and 57% of women disagreed that ‘If I have a teenage daughter, I would tell her about condoms’. 32% and 69% of sexually-active HIV-negative unmarried AGYW, respectively, said negative community views were important in decisions to use condoms and their friends were not using condoms. In each case, those who agreed had lower motivation to use condoms. Fewer of those with friends not using condoms reported using condoms themselves (39% vs. 68%; p&lt;0.001). 21% of men and 32.5% of women found condom use in marriage acceptable. 74% and 93% of married AGYW at risk, respectively, said negative community views influenced their decisions to use condoms and their friends did not use condoms. Fewer married AGYW reporting friends not using condoms were motivated to use condoms but there was no difference in reported condom use (4.1% vs. 6.9%; p=0.48). Conclusions Negative gender norms can form a barrier to motivation to use condoms in unmarried and married AGYW at risk of HIV infection, and, for unmarried AGYW, to condom use.

HIV Information Avoidance, HIV Stigma, and Medical Mistrust among Black Sexual Minority Men in the Southern United States: Associations with HIV Testing.

Uptake of HIV testing is a critical step in the HIV prevention and treatment care cascade. Barriers to HIV testing, however, remain and innovative research in this area is warranted to improve uptake of testing. As such, we investigated the role of HIV information avoidance - a novel construct potentially related to HIV testing. We analyzed this construct in relation to other factors known to impact HIV testing, namely HIV stigma and medical mistrust. Multiple linear regression analyses indicated that HIV information avoidance was negatively associated with HIV testing, while medical mistrust was positively associated with HIV testing. HIV testing stigma was not associated with HIV testing. This work contributes to the developing literature on HIV information avoidance and its relationships with HIV stigma and HIV testing uptake. Further, these findings can inform HIV testing interventions which often do not focus on HIV information avoidance. Future research on the mechanisms of information avoidance that are amenable to intervention, and the temporal ordering of the relationship between information avoidance and HIV testing is warranted.

Factors Associated with COVID-19 Vaccine Uptake among Schoolgoing Adolescent Girls and Young Women in South Africa.

(1) Background: By October 2022, vaccination rates with at least one dose of a COVID-19 vaccine were low among adolescent girls aged 12-17 (38%) and young women aged 18-34 (45%) in South Africa. This study aimed to measure and identify barriers to and facilitators of motivation to take up, access to, and uptake of COVID-19 vaccines among schoolgoing adolescent girls and young women in two districts in South Africa. (2) Methods: Using the theory of the HIV prevention cascade, we conceptualised the relationship between motivation, access, and uptake of COVID-19 vaccines, and associated barriers. Potential barriers and facilitators were identified using bivariate and multivariable Poisson regression. (3) Results: Among all 2375 participants, access was high (69%), but motivation (49%) and vaccination with at least one COVID-19 vaccine (45%) were lower. Fear of injections was a barrier to vaccine uptake (aRR 0.85 95% CI 0.82-0.88), while being tested for COVID-19 (aRR 2.10 95% CI 1.85-2.38) and believing that the COVID-19 vaccine was safe (aRR 1.31 95% CI 1.18-1.44) and would prevent you from getting very sick (aRR 1.11 95% CI 1.04-1.19) were facilitators. (4) Conclusions: The controversy about the value of vaccinating adolescents and the delay in vaccine rollout for adolescents and young adults may have contributed to fears about the safety and efficacy of COVID-19 vaccines, as well as a lack of motivation to get vaccinated.

Cultural interventions addressing disparities in the HIV prevention and treatment cascade among Black/African Americans: a scoping review

Culture is an important determinant of HIV risk and protective behaviors; yet, we know little about how it is integrated in HIV interventions. This scoping review characterizes the integration of culture in HIV prevention and treatment interventions focused on Black/African Americans. We searched MEDLINE, PsycINFO, CINAHL, and Google Scholar for peer-reviewed manuscripts published between July 1, 2011, and June 28, 2021. Twenty-five interventions were identified, with 96% focused on prevention. Most (40%) targeted men who have sex with men or transgender women. Only three were grounded in cultural theory. Although all interventions were labeled “culturally based,” only two explicitly defined culture. Moreover, there was much diversity regarding the ways in which interventions integrated cultural elements, with some conflating race/ethnicity with culture. To improve uptake and HIV-related outcomes, interventions integrating culture are greatly needed. Additionally, HIV interventions purporting to be “culturally based” must include basic information to support rigor and reproducibility.

Drivers of uptake of HIV testing services, a snapshot of barriers and facilitators among adolescent boys and young men in Lusaka: a qualitative study

BackgroundStriking gender and rural–urban disparities highlight the need to redesign HIV services to improve HIV testing and linkage by adolescent boys and young men (ABYM) in sub-Saharan African cities.PurposeWe sought...

The Impacts of HIV-Related Service Interruptions During the COVID-19 Pandemic: Protocol of a Mixed Methodology Longitudinal Study.

The global COVID-19 pandemic has imposed unprecedented pressure on health systems and has interrupted public health efforts for other major health conditions, including HIV. It is critical to comprehensively understand how the pandemic has affected the delivery and utilization of HIV-related services and what are the effective strategies that may mitigate the negative impacts of COVID-19 and resultant interruptions. The current study thus aims to comprehensively investigate HIV service interruptions during the pandemic following a socioecological model, to assess their impacts on various outcomes of the HIV prevention and treatment cascade and to identify resilience resources for buffering impacts of interruptions on HIV treatment cascade outcomes. We will assess HIV service interruptions in South Carolina (SC) since 2020 using operational report data from Ryan White HIV clinics and HIV service utilization data (including telehealth use) based on statewide electronic health records (EHR) and cellphone-based place visitation data. We will further explore how HIV service interruptions affect HIV prevention and treatment cascade outcomes at appropriate geospatial units based on the integration of multi-type, multi-source datasets (e.g., EHR, geospatial data). Finally, we will identify institutional-, community-, and structural-level factors (e.g., resilience resources) that may mitigate the adverse impacts of HIV service interruptions based on the triangulation of quantitative (i.e., EHR data, geospatial data, online survey data) and qualitative (i.e., in-depth interviews with clinic leaders, healthcare providers, people living with HIV, and HIV clinic operational reports) data regarding health system infrastructure, social capital, and organizational preparedness. Our proposed research can lead to a better understanding of complicated HIV service interruptions in SC and resilience factors that can mitigate the negative effects of such interruptions on various HIV treatment cascade outcomes. The multilevel resilience resources identified through data triangulation will assist SC health departments and communities in developing strategic plans in response to this evolving pandemic and other future public health emergencies (e.g., monkeypox, disasters caused by climate change). The research findings can also inform public health policymaking and the practices of other Deep South states with similar sociocultural contexts in developing resilient healthcare systems and communities and advancing epidemic preparedness.

Applying the HIV Prevention Cascade to an Evaluation of a Large-Scale Combination HIV Prevention Programme for Adolescent Girls and Young Women in South Africa

Adolescent girls and young women (AGYW) in South Africa are at a three times higher risk of acquiring HIV than their male counterparts. The HIV prevention cascade is a tool which can be used to measure coverage of HIV prevention services, although there is limited empirical evidence to demonstrate its application in low-resourced settings. The unifying framework is a conceptualisation of the HIV prevention cascade which theorises that both motivation and access are required for an individual to effectively use an HIV prevention method. We applied this framework to data from a random sample of 127,951 beneficiaries of a combination HIV prevention programme for AGYW aged 15–24 in South Africa to measure the steps to, and identify key barriers to, effective use of male condoms and oral pre-exposure prophylaxis (PrEP) among this vulnerable population. Barriers to each step were analysed using univariate and multivariable logistic regression. Among self-reported HIV-negative AGYW who had sex in the past 6 months, effective use of condoms (15.2%), access to PrEP (39.1%) and use of PrEP (3.8%) were low. AGYW were: less likely to be motivated to use condoms if they believed that they had a faithful partner (aOR 0.44, 95% CI 0.22–0.90) or disliked condoms (aOR 0.26, 95% CI 0.11–0.57), less likely to access condoms if the place where AGYW accessed them was far away (aOR 0.25, 95% CI 0.10–0.64), more likely to effectively use condoms if they received counselling on how to use them (aOR 2.24, 95% CI 1.05–4.76), less likely to be motivated to use PrEP if they did not believe PrEP was efficacious (aOR 0.35, 95% CI 0.17–0.72), more likely to be motivated if they felt confident that they could use PrEP, and more likely to have access to PrEP if they had ever been offered PrEP (aOR 2.94, 95% CI 1.19–7.22). This combination HIV prevention programme and similar programmes should focus on risk-reduction counselling interventions for AGYW and their male partners to improve effective use of condoms and ensure easy access to condoms and PrEP by making them available in youth-friendly spaces. Our findings demonstrate that the application of HIV prevention cascades can inform AGYW HIV prevention programming in low-resourced settings.

Strengthening the HIV prevention cascade to maximise epidemiological impact in eastern Zimbabwe: a modelling study

HIV prevention cascades provide a systematic understanding of barriers to prevention. In this study we used mathematical modelling to understand the consequences of these barriers and how the cascade could be strengthened to maximise epidemiological impact, providing potentially important insights for programmes. We used an individual-based model of HIV transmission (PopART-IBM), calibrated to data from the Manicaland cohort from eastern Zimbabwe. HIV prevention cascade estimates from this cohort were used as probabilities for indicators in the model representing an individual's motivation, access, and capacity to effectively use pre-exposure prophylaxis, voluntary male medical circumcision, and condoms. We examined how current barriers affect the number and distribution of HIV infections compared with a no-barrier scenario. Using assumptions about how interventions could strengthen the HIV prevention cascade, we estimated the reduction in HIV infections over a 10-year period through addressing different elements of the cascade. 21 200 new potentially avertable HIV infections will occur over the next 10 years due to existing HIV prevention cascade barriers, 74·2% of the 28 500 new infections that would occur with existing barriers in a population of approximately 1·2 million adults. Removing these barriers would reduce HIV incidence below the benchmarks for epidemic elimination. Addressing all cascade steps in one priority population is substantially more effective than addressing one step across all populations. Interventions exist in eastern Zimbabwe to reduce HIV towards elimination, but barriers of motivation, access, and effective use prevent their full effect being realised. Interventions need to be multilayered and address all steps along the HIV prevention cascade. Models incorporating the HIV prevention cascade can help to identify the main barriers to greater effectiveness. National Institutes of Mental Health, Bill & Melinda Gates Foundation, and Medical Research Council Centre for Global Infectious Disease Analysis funding from the UK Medical Research Council and UK Foreign, Commonwealth & Development Office (FCDO).

HIV prevalence, risk behaviour, and treatment and prevention cascade outcomes among cisgender men, transgender women, and transgender men who sell sex in Zimbabwe: a cross-sectional analysis of programme data

There is a paucity of evidence on HIV vulnerabilities and service engagements among people who sell sex in sub-Saharan Africa and identify as cisgender men, transgender women, or transgender men. We aimed to describe sexual risk behaviours, HIV prevalence, and access to HIV services among cisgender men, transgender women, and transgender men who sell sex in Zimbabwe. We did a cross-sectional analysis of routine programme data that were collected between July 1, 2018, and June 30, 2020, from cisgender men who sell sex, transgender women who sell sex, and transgender men who sell sex, as part of accessing sexual and reproductive health and HIV services provided through the Sisters with a Voice programme, at 31 sites across Zimbabwe. All people who sell sex reached by the programme had routine data collected, including routine HIV testing, and were referred using a network of peer educators. Sexual risk behaviours, HIV prevalence, and HIV services uptake during the period from July, 2018, to June, 2020, were analysed through descriptive statistics by gender group. A total of 1003 people who sell sex were included in our analysis: 423 (42·2%) cisgender men, 343 (34·2%) transgender women, and 237 (23·6%) transgender men. Age-standardised HIV prevalence estimates were 26·2% (95% CI 22·0-30·7) among cisgender men, 39·4% (34·1-44·9) among transgender women, and 38·4% (32·1-45·0) among transgender men. Among people living with HIV, 66·0% (95% CI 55·7-75·3) of cisgender men, 74·8% (65·8-82·4) of transgender women, and 70·2% (59·3-79·7) of transgender men knew their HIV status, and 15·5% (8·9-24·2), 15·7% (9·5-23·6), and 11·9% (5·9-20·8) were on antiretroviral therapy, respectively. Self-reported condom use was consistently low across gender groups, ranging from 26% (95% CI 22-32) for anal sex among transgender women to 32% (27-37) for vaginal sex among cisgender men. These unique data show that people who sell sex and identify as cisgender men, transgender women, or transgender men in sub-Saharan Africa have high HIV prevalences and risk of infection, with alarmingly low access to HIV prevention, testing, and treatment services. There is an urgent need for people-centred HIV interventions for these high-risk groups and for more inclusive HIV policies and research to ensure we truly attain universal access for all. Aidsfonds Netherlands.

Impact of Social Media Use on HIV Testing and Related Mediator among Men Who Have Sex with Men in Shandong Province, China

In China, HIV testing is the important first step of HIV prevention and treatment cascades but is not widely adopted by men who have sex with men (MSM). However, social media has been increasingly used to promote and improve HIV testing. This study aimed to assess the impact of social media use on HIV testing and explore the mediator in the relationship between social media and HIV testing. The authors conducted a cross-sectional study among 935 MSM participants in 11 cities in Shandong Province from 14 September to 6 December 2020. Multivariable regression was conducted to assess the relationship between social media use and HIV testing uptake, and mediation analysis was used to assess the mediation effect of HIV testing self-efficacy in the relationship between social media use and HIV testing. The present study findings showed that social media use was related to HIV testing (aOR = 3.024, 95% CI: 1.869, 4.892) and HIV self-testing uptake (aOR = 1.894, 95% CI: 1.228, 2.922), but was not related to HIV facility-based testing (aOR = 1.709, 95% CI: 0.806, 3.625, p = 0.162). A mediation effect of HIV testing self-efficacy was found between social media use and HIV testing (indirect effect: 0.13, 95% CI: 0.01, 0.29), facility-based testing (indirect effect: 0.05, 95% CI: 0.003, 0.16), and self-testing uptake (indirect effect: 0.07, 95% CI: 0.01, 0.16). Social media could be an effective tool to improve HIV testing, and healthcare providers should pay more attention to HIV testing self-efficacy in HIV testing promotion.

Ethical Issues in the Use of Smartphone Apps for HIV Prevention in Malaysia: Focus Group Study With Men Who Have Sex With Men.

The use of smartphone apps can improve the HIV prevention cascade for key populations such as men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, mobile health app-based strategies have the potential to open new frontiers for HIV prevention. However, little guidance is available to inform researchers about the ethical concerns that are unique to the development and implementation of app-based HIV prevention programs. This study aimed to fill this gap by characterizing the attitudes and concerns of Malaysian MSM regarding HIV prevention mobile apps, particularly regarding the ethical aspects surrounding their use. We conducted web-based focus group discussions with 23 MSM between August and September 2021. Using in-depth semistructured interviews, participants were asked about the risks and ethical issues they perceived to be associated with using mobile apps for HIV prevention. Each session was digitally recorded and transcribed. Transcripts were inductively coded using the Dedoose software (SocioCultural Research Consultants) and analyzed to identify and interpret emerging themes. Although participants were highly willing to use app-based strategies for HIV prevention, they raised several ethical concerns related to their use. Prominent concerns raised by participants included privacy and confidentiality concerns, including fear of third-party access to personal health information (eg, friends or family and government agencies), issues around personal health data storage and management, equity and equitable access, informed consent, and regulation. The study's findings highlight the role of ethical concerns related to the use of app-based HIV prevention programs. Given the ever-growing nature of such technological platforms that are intermixed with a complex ethical-legal landscape, mobile health platforms must be safe and secure to minimize unintended harm, safeguard user privacy and confidentiality, and obtain public trust and uptake.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Research in the AHISA Network

Members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) network conduct research aiming to close gaps between what is known to be impactful across the HIV prevention and treatment cascade, and services delivered to optimize outcomes for adolescents/young adults (AYA) in high HIV-prevalence settings. The COVID-19 pandemic introduced new challenges which threaten to exacerbate care and access disparities. We report results of a survey among AHISA teams with active AYA HIV research programs in African countries to determine how the pandemic has impacted their efforts. Results highlighted the detrimental impact of the pandemic on research efforts and the expanded need for implementation research to help provide evidence-based, context-specific pandemic recovery support. Key lessons learned included the viability of remote service delivery strategies and other innovations, the need for adaptive systems that respond to evolving contextual needs, and the need for organized documentation plans, within empathic and flexible environments.

Correlates of HIV Testing across the lifespan - adolescence through later adulthood - among sexual minority men in the US who are not on PrEP.

Regular HIV testing is an essential component of the HIV prevention and care cascade. Sexual minority males (SMM) account for most new HIV infections in the US and testing rates among SMM vary substantially across the lifespan. Research has largely overlooked the developmental context of HIV testing. The current study compared correlates of HIV testing among adolescents (aged 13-17; n = 1,641), emerging adults (aged 18-29; n = 50,483), early adults (aged 30-39; n = 25,830), middle adults (aged 40-64; n = 25,326), and late adults (65 and older; n = 1,452) who were recruited online. Overall, HIV testing rates were lowest among adolescent SMM. Having condomless anal sex in the past 3-months was a consistentpredictor of HIV testing across all age cohorts.The association between relationship status and frequency of HIV testing varied across ages. Being in a non-monogamous relationship (versus single) was associated with more frequent HIV testing among adolescent and emerging adult SMM , while being in a monogamous relationship (versus single) was associated with lower odds of HIV testing among early, middle, and late adults.

HIV prevention metrics: lessons to be learned from contraception.

IntroductionAs the range of effective HIV prevention options, including multiple biomedical tools, increases, there are many challenges to measuring HIV prevention efforts. In part, there is the challenge of varying prevention needs, between individuals as well as within individuals over time. The field of contraception faces many similar challenges, such as the range of prevention methods and changing contraceptive needs, and has developed many metrics for assessing contraceptive use at the program level, using frameworks that move beyond the HIV prevention cascade. We explore these similarities and differences between these two prevention fields and then discuss how each of these contraceptive metrics could be adapted to assessing HIV prevention.DiscussionWe examined measures of initiation, coverage and persistence. Among measures of initiation, HIV Prevention–Post Testing would be a useful corollary to Contraceptive Use–Post Partum for a subset of the population. As a measure of coverage, both Net Prevention Coverage and HIV Protection Index (modelled off the Contraception Protection Index) may be useful. Finally, as a measure of persistence, Person‐Years of HIV Protection could be adapted from Couple‐Years Protection. As in contraception, most programs will not reach 100% on HIV prevention metrics but these metrics are highly useful for making comparisons.ConclusionsWhile we may not be able to perfectly capture the true population of who would benefit from HIV prevention, by building off the work of the contraceptive field to use and refine these metrics, we can assess and compare HIV prevention over time and across programs. Furthermore, these metrics can help us reach global targets, such as the 2025 UNAIDS Goals, and reduce HIV incidence.