Predictors of Willingness to Diffuse PrEP Information within Ego-Centric Networks of Women Who Inject Drugs.

Little is known about how social networks among women who inject drugs (WWID) can be leveraged to increase awareness about pre-exposure prophylaxis (PrEP). We tested the hypothesis that interpersonal characteristics influence willingness of WWID to communicate PrEP information with peers. Forty WWID ≥ 18 years completed social network surveys. Participants named on average 9.3 (SD = 3.3) network members, resulting in 375 unique relationships. WWID were willing to share PrEP information with 83% of network members. Participants had higher odds of willingness to share information within relationships when the network member was female, homeless and perceived to be at risk for HIV. Among relationships with family members and transactional sex clients, stronger emotional closeness was associated with higher odds of willingness to share information. Peer interventions where WWID share PrEP information with peers may be an efficient approach to increase PrEP awareness among this vulnerable population.

Individual Versus Team-Based Financial Incentives to Increase Physical Activity: A Randomized, Controlled Trial.

BACKGROUND: More than half of adults in the United States do not attain the minimum recommended level of physical activity to achieve health benefits. The optimal design of financial incentives to promote physical activity is unknown. OBJECTIVE: To compare the effectiveness of individual versus team-based financial incentives to increase physical activity. DESIGN: Randomized, controlled trial comparing three interventions to control. PARTICIPANTS: Three hundred and four adult employees from an organization in Philadelphia formed 76 four-member teams. INTERVENTIONS: All participants received daily feedback on performance towards achieving a daily 7000 step goal during the intervention (weeks 1- 13) and follow-up (weeks 14- 26) periods. The control arm received no other intervention. In the three financial incentive arms, drawings were held in which one team was selected as the winner every other day during the 13-week intervention. A participant on a winning team was eligible as follows: $50 if he or she met the goal (individual incentive), $50 only if all four team members met the goal (team incentive), or $20 if he or she met the goal individually and $10 more for each of three teammates that also met the goal (combined incentive). MAIN MEASURES: Mean proportion of participant-days achieving the 7000 step goal during the intervention. KEY RESULTS: Compared to the control group during the intervention period, the mean proportion achieving the 7000 step goal was significantly greater for the combined incentive (0.35 vs. 0.18, difference: 0.17, 95 % confidence interval [CI]: 0.07-0.28, p <0.001) but not for the individual incentive (0.25 vs 0.18, difference: 0.08, 95 % CI: -0.02-0.18, p = 0.13) or the team incentive (0.17 vs 0.18, difference: -0.003, 95 % CI: -0.11-0.10, p = 0.96). The combined incentive arm participants also achieved the goal at significantly greater rates than the team incentive (0.35 vs. 0.17, difference: 0.18, 95 % CI: 0.08-0.28, p < 0.001), but not the individual incentive (0.35 vs. 0.25, difference: 0.10, 95 % CI: -0.001-0.19, p = 0.05). Only the combined incentive had greater mean daily steps than control (difference: 1446, 95 % CI: 448-2444, p ≤ 0.005). There were no significant differences between arms during the follow-up period (weeks 14- 26). CONCLUSIONS: Financial incentives rewarded for a combination of individual and team performance were most effective for increasing physical activity. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02001194.

Mediation Analysis of the Efficacy of the Eban HIV/STD Risk-Reduction Intervention for African American HIV Serodiscordant Couples.

Targeting couples is a promising behavioral HIV risk-reduction strategy, but the mechanisms underlying the effects of such interventions are unknown. We report secondary analyses testing whether Social-Cognitive-Theory variables mediated the Eban HIV-risk-reduction intervention's effects on condom-use outcomes. In a multisite randomized controlled trial conducted in four US cities, 535 African American HIV-serodiscordant couples were randomized to the Eban HIV risk-reduction intervention or attention-matched control intervention. Outcomes were proportion condom-protected sex, consistent condom use, and frequency of unprotected sex measured pre-, immediately post-, and 6 and 12 months post-intervention. Potential mediators included Social-Cognitive-Theory variables: outcome expectancies and self-efficacy. Mediation analyses using the product-of-coefficients approach in a generalized-estimating-equations framework revealed that condom-use outcome expectancy, partner-reaction outcome expectancy, intention, self-efficacy, and safer-sex communication improved post-intervention and mediated intervention-induced improvements in condom-use outcomes. These findings underscore the importance of targeting outcome expectancies, self-efficacy, and safer-sex communication in couples-level HIV risk-reduction interventions.

Integrating HIV Preexposure Prophylaxis With Community-Based Syringe Services for Women Who Inject Drugs: Results From the Project SHE Demonstration Study.

INTRODUCTION: To guide future preexposure prophylaxis (PrEP) implementation for women who inject drugs (WWID), a population increasingly represented in new HIV cases in the United States, we present results from a demonstration project integrated within a syringe services program (SSP) in Philadelphia, PA. METHODS: WWID ≥18 years were educated about and offered 24 weeks of daily PrEP. Participants completed surveys and clinical assessments at baseline and at weeks 1, 3, 12, and 24. We used descriptive statistics to estimate feasibility/acceptability, engagement in the care cascade, HIV/sexually transmitted diseases (STI) and pregnancy, issues of safety/tolerability, and preferences/satisfaction with PrEP services. Multivariable logistic regression with generalized estimating equations was used to identify factors associated with PrEP uptake and retention. RESULTS: We recruited 136 WWID. Of those, 95 were included in the final sample, and 63 accepted a PrEP prescription at week 1. Uptake was associated with greater baseline frequency of SSP access [adjusted odds ratio (aOR) = 1.85; 95% confidence interval (CI): 1.24 to 2.77], inconsistent condom use (aOR = 3.38; 95% CI: 1.07 to 10.7), and experiencing sexual assault (aOR = 5.89; 95% CI: 1.02, 33.9). Of these 95, 42 (44.2%) were retained at week 24. Retention was higher among women who reported more frequent baseline SSP access (aOR = 1.46; 95% CI: 1.04 to 2.24). Self-reported adherence was high but discordant with urine-based quantification of tenofovir. Baseline STI prevalence was 17.9%; there were 2 HIV seroconversions and 1 pregnancy. Safety/tolerability issues were uncommon, and acceptability/satisfaction was high. CONCLUSIONS: Integrating PrEP with SSP services is feasible and acceptable for WWID. This suggests that daily PrEP is a viable prevention tool for this vulnerable population.

Framing Social Comparison Feedback With Financial Incentives for Physical Activity Promotion: A Randomized Trial.

BACKGROUND: Social comparison feedback is often used in physical activity interventions but the optimal design of feedback is unknown. METHODS: This 4-arm, randomized trial consisted of a 13-week intervention period and 13-week follow-up period. During the intervention, 4-person teams were entered into a weekly lottery valued at about $1.40/day and contingent on the team averaging ≥7000 steps per day. Social comparison feedback on performance was delivered weekly for 26 weeks, and varied by reference point (50th vs 75th percentile) and forgiveness in use of activity data (all 7 d or best 5 of 7 d). The primary outcome was the mean proportion of participant-days achieving the 7000-step goal. RESULTS: During the intervention period, the unadjusted mean proportion of participant-days that the goal was achieved was 0.47 (95% confidence interval [CI]: 0.38 to 0.56) in the 50th percentile arm, 0.38 (95% CI: 0.30 to 0.37) in the 75th percentile arm, 0.40 (95% CI: 0.31 to 0.49) in the 50th percentile with forgiveness arm, and 0.47 (95% CI: 0.38 to 0.55) in the 75th percentile with forgiveness arm. In adjusted models during the intervention and follow-up periods, there were no significant differences between arms. CONCLUSIONS: Changing social comparison feedback did not impact physical activity.

Early abortion in family medicine: clinical outcomes.

PURPOSE: Clinical innovations have made it more feasible to incorporate early abortion into family medicine, yet the outcomes of early abortion procedures in this setting have not been well studied. We wished to assess the outcomes of first-trimester medication and aspiration abortion procedures by family physicians. METHODS: Prospective observational cohort study conducted from August 2001 to February 2005 of 2,550 women who sought pregnancy termination in 4 clinical practices of family medicine departments and 1 private office/training site. RESULTS: The rate of successful uncomplicated procedures for medication was 96.5% (95.5%-97.1% [corrected] confidence interval [CI], 95.5%-97.0%) and for aspiration was 99.9% (CI, 99.3%-1). Adverse events and complications of medication abortions were failed procedure (ongoing pregnancy; n = 19, 1.45%); incomplete abortion (n = 16, 1.22%); hemorrhage (n = 9, 0.69%); and patient request for aspiration (n = 1, 0.08%). One (0.08%) missed ectopic pregnancy was seen among patients receiving medication. Four types of adverse outcomes were encountered with aspiration: incomplete abortion requiring re-aspiration (n = 21, 1.83%); hemorrhage during the procedure (n = 4, 0.35%); missed ectopic pregnancy (n = 3, 0.26%); and minor endometritis (n = 1, 0.09%). Missed ectopic pregnancies were successfully treated in the inpatient setting without mortality (overall hospitalization rate of 0.16 of 100). All other complications were managed within outpatient family medicine sites. Rates of complication did not vary by experience of physician or by site of care (residency vs private practice). CONCLUSIONS: Complications of medication and aspiration procedures occurred at a low rate, and most were minor and managed without incident.

Effect of a Behavioral Intervention on Perpetrating and Experiencing Forced Sex Among South African Adolescents: A Secondary Analysis of a Cluster Randomized Trial.

Importance: Scant research has investigated interventions to reduce forced sexual intercourse among adolescents. The need for such interventions is especially great in South Africa, which has some of the highest rates of sexual assault in the world. Objectives: To determine whether an HIV/sexually transmitted disease risk-reduction intervention that reduced sexual risk behavior and sexually transmitted disease prevalence also reduced the perpetration and experience of forced sex among South African adolescents. Design, Setting, and Participants: A cluster randomized clinical trial, at schools located in a township and a semirural area, Eastern Cape Province, South Africa. Matched pairs of schools were randomly selected (9 of 17); of 1118 students in sixth grade at these 18 schools who had parent or guardian consent, 1057 (94%) were enrolled, and those not reporting forced sex perpetration before the intervention were included in the analyses (n = 1052). Post hoc secondary analysis of a cluster randomized clinical trial was performed, with baseline and 3-, 6-, 12-, 42-, and 54-month postintervention assessments between October 4, 2004, and June 30, 2010. Generalized estimating equation Poisson regression analyses adjusting for gender and clustering within schools were conducted between August 23, 2017, and April 30, 2018. Recruiters and data collectors, but not intervention facilitators, were blind to the participants' intervention assignment. Interventions: Theory-based, culturally adapted, 6-session HIV/sexually transmitted disease risk-reduction intervention (Let Us Protect Our Future intervention) and attention-matched, chronic disease prevention control intervention implemented by specially trained man and woman cofacilitators from the community. Main Outcomes and Measures: Study outcomes for this secondary analysis (planned after the data were collected) are self-reports of perpetrating and experiencing forced vaginal intercourse. Results: Participants included 1052 adolescents (557 girls [53%]; mean [SD] age, 12.4 [1.2] years) reporting not perpetrating forced sex at baseline. Fewer intervention than control participants reported forced sex perpetration postintervention compared with the control group at 3 months (9 of 561 [2%] vs 20 of 491 [4%]; risk ratio [RR], 0.978; 95% CI, 0.959-0.997), 6 months (17 of 561 [3%] vs 35 of 491 [7%]; RR, 0.964; 95% CI, 0.941-0.988), 12 months (21 of 561 [4%] vs 42 of 491 [9%]; RR, 0.959; 95% CI, 0.934-0.985), 42 months (41 of 561 [7%] vs 56 of 491 [11%]; RR, 0.967; 95% CI, 0.937-0.998), and 54 months (52 of 561 [9%] vs 68 of 491 [14%]; RR, 0.964; 95% CI, 0.932-0.997). Conclusions and Relevance: In settings with high rates of sexual assault, the use of theory-based culturally adapted interventions with early adolescents may reduce rates of perpetrating and experiencing forced sex. Trial Registration: ClinicalTrials.gov Identifier: NCT00559403.

A Randomized, Controlled Trial of Lottery-Based Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults.

PURPOSE: To evaluate the effect of lottery-based financial incentives in increasing physical activity. DESIGN: Randomized, controlled trial. SETTING: University of Pennsylvania Employees. PARTICIPANTS: A total of 209 adults with body mass index ≥27. INTERVENTIONS: All participants used smartphones to track activity, were given a goal of 7000 steps per day, and received daily feedback on performance for 26 weeks. Participants randomly assigned to 1 of the 3 intervention arms received a financial incentive for 13 weeks and then were followed for 13 weeks without incentives. Daily lottery incentives were designed as a "higher frequency, smaller reward" (1 in 4 chance of winning $5), "jackpot" (1 in 400 chance of winning $500), or "combined lottery" (18% chance of $5 and 1% chance of $50). MEASURES: Mean proportion of participant days step goals were achieved. ANALYSIS: Multivariate regression. RESULTS: During the intervention, the unadjusted mean proportion of participant days that goal was achieved was 0.26 in the control arm, 0.32 in the higher frequency, smaller reward lottery arm, 0.29 in the jackpot arm, and 0.38 in the combined lottery arm. In adjusted models, only the combined lottery arm was significantly greater than control ( P = .01). The jackpot arm had a significant decline of 0.13 ( P < .001) compared to control. There were no significant differences during follow-up. CONCLUSIONS: Combined lottery incentives were most effective in increasing physical activity.

A Randomized Trial of Social Comparison Feedback and Financial Incentives to Increase Physical Activity.

PURPOSE: To compare the effectiveness of different combinations of social comparison feedback and financial incentives to increase physical activity. DESIGN: Randomized trial (Clinicaltrials.gov number, NCT02030080). SETTING: Philadelphia, Pennsylvania. PARTICIPANTS: Two hundred eighty-six adults. INTERVENTIONS: Twenty-six weeks of weekly feedback on team performance compared to the 50th percentile (n = 100) or the 75th percentile (n = 64) and 13 weeks of weekly lottery-based financial incentive plus feedback on team performance compared to the 50th percentile (n = 80) or the 75th percentile (n = 44) followed by 13 weeks of only performance feedback. MEASURES: Mean proportion of participant-days achieving the 7000-step goal during the 13-week intervention. ANALYSIS: Generalized linear mixed models adjusting for repeated measures and clustering by team. RESULTS: Compared to the 75th percentile without incentives during the intervention period, the mean proportion achieving the 7000-step goal was significantly greater for the 50th percentile with incentives group (0.45 vs 0.27, difference: 0.18, 95% confidence interval [CI]: 0.04 to 0.32; P = .012) but not for the 75th percentile with incentives group (0.38 vs 0.27, difference: 0.11, 95% CI: -0.05 to 0.27; P = .19) or the 50th percentile without incentives group (0.30 vs 0.27, difference: 0.03, 95% CI: -0.10 to 0.16; P = .67). CONCLUSION: Social comparison to the 50th percentile with financial incentives was most effective for increasing physical activity.

A mixed-methods randomized controlled trial of financial incentives and peer networks to promote walking among older adults.

BACKGROUND: Financial incentives and peer networks could be delivered through eHealth technologies to encourage older adults to walk more. METHODS: We conducted a 24-week randomized trial in which 92 older adults with a computer and Internet access received a pedometer, daily walking goals, and weekly feedback on goal achievement. Participants were randomized to weekly feedback only (Comparison), entry into a lottery with potential to earn up to $200 each week walking goals were met (Financial Incentive), linkage to four other participants through an online message board (Peer Network), or both interventions (Combined). Main outcomes were the proportion of days walking goals were met during the 16-week intervention and 8-week follow-up. We conducted a content analysis of messages posted by Peer Network and Combined arm participants. RESULTS: During the 16-week intervention, there were no differences in the proportion of days walking goals were met in the Financial Incentive (39.7%; p = .78), Peer Network (24.9%; p = .08), and Combined (36.0%; p = .77) arms compared with the Comparison arm (36.0%). During 8 weeks of follow-up, the proportion of days walking goals were met was lower in the Peer Network arm (18.7%; p = .025) but not in the Financial Incentive (29.3%; p = .50) or Combined (24.8%; p = .37) arms, relative to the Comparison arm (34.5%). Messages posted by participants focused on barriers to walking and provision of social support. CONCLUSIONS: Financial incentives and peer networks delivered through eHealth technologies did not result in older adults walking more.

Cancer information seeking preferences and experiences: disparities between Asian Americans and Whites in the Health Information National Trends Survey (HINTS).

Little is known about cancer information needs and seeking patterns in the rapidly growing Asian American population. The purpose of this study is to characterize cancer information seeking behaviors and preferences in Asian Americans and to examine their cancer-related knowledge and risk perceptions. Data from the nationally representative Health Information National Trends Survey (HINTS) database were analyzed to compare non-Hispanic Asians and Whites. Asians had lower awareness of the National Institutes of Health and American Cancer Society, were less likely to think that not smoking or quitting smoking would reduce cancer risk, were less knowledgeable about colon cancer screening, and considered their personal cancer risk to be low. Asians and Whites had similar media usage rates. They also had similar rates of preference for cancer information from various sources, although Asians were significantly more likely to prefer print materials. The level of trust of cancer information from doctors was high overall. This study is limited by under-representation of some demographic subpopulations, future surveys should oversample Asians and strive to include higher-risk Asians (e.g., elderly, poorly educated, immigrants, and those with limited English proficiency).