Feasibility and Acceptability of the Novel Tu'Washindi Intervention to Increase PrEP Use among Adolescent Girls and Young Women in Siaya County, Kenya.

The Tu'Washindi intervention addressed intimate partner violence (IPV) and relationship dynamics to increase PrEP use among adolescent girls and young women (AGYW) in Siaya County, Kenya. We evaluated feasibility and acceptability in a cluster-randomized trial in six DREAMS Safe Spaces. The multilevel intervention, delivered over 6 months, included three components delivered by DREAMS staff with support from the study team: an 8-session structured support club; community sensitization of male partners; and a couples PrEP education and health fair ("Buddy Day"). Feasibility and acceptability assessments included implementation process measures, questionnaires, and focus group discussions with AGYWs and post-intervention questionnaires with intervention providers. The study included 103 AGYWs aged 17 to 24 (N = 49 intervention), with 97% retention. Median age was 22, 54% were married, and 84% were mothers. At enrollment, 45% used PrEP and 61% reported lifetime IPV. All intervention participants attended at least one support club session (mean = 5.2 of 8) and 90% attended Buddy Day. At 6 months, most participants perceived Tu'Washindi to be effective: all agreed (with 54% reporting "strongly agree") that the intervention improved partner communication and 60% agreed they were better able to gain partner support for their PrEP use. Providers believed the intervention resonated with community values. Tu'Washindi was highly acceptable and feasible and it was perceived by AGYW participants and providers as being effective in improving partner relationships and supporting PrEP use.

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

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

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

INTRODUCTION: Oral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa, a priority population for epidemic control. However, intimate partner violence (IPV) and low relationship power can create significant challenges to PrEP use. The Tu'Washindi intervention aimed to increase PrEP use by addressing relationship- and violence-related barriers among AGYW enrolled in the DREAMS Initiative in Siaya County, Kenya. METHODS: Our multi-level, community-based intervention was piloted in a cluster-randomized controlled trial conducted at six DREAMS sites from April to December 2019 (NCT03938818). Three intervention components were delivered over 6 months: an eight-session empowerment-based support club, community sensitization targeted towards male partners and a couples' PrEP education event. Participants were ages 17-24, HIV negative and either eligible for, or already taking, PrEP. Over 6 months of follow-up, we assessed IPV (months 3 and 6) and PrEP uptake and continuation (month 6) through interviewer-administered questionnaires; PrEP adherence was assessed with Wisepill electronic monitoring devices. These outcomes were compared using adjusted Poisson and negative binomial regression models. RESULTS: We enrolled 103 AGYW with median age of 22 years (IQR 20-23); one-third were currently taking PrEP and 45% reported IPV in the past 3 months. Retention was 97% at month 6. Compared to the control arm, intervention arm participants were more likely to initiate PrEP, if not already using it at enrolment (52% vs. 24%, aRR 2.28, 95% CI 1.19-4.38, p = 0.01), and those taking PrEP had more days with device openings (25% of days vs. 13%, aRR 1.94, 95% CI 1.16-3.25, p = 0.01). Twenty percent of participants reported IPV during follow-up. There were trends towards fewer IPV events (aIRR 0.66, 95% CI 0.27-1.62, p = 0.37) and fewer events resulting in injury (aIRR 0.21, 95% CI 0.04-1.02, p = 0.05) in the intervention versus control arm. CONCLUSIONS: Tu'Washindi shows promise in promoting PrEP uptake and adherence among AGYW without concomitant increases in IPV; however, adherence was still suboptimal. Further research is needed to determine whether these gains translate to increases in the proportion of AGYW with protective levels of PrEP adherence and to evaluate the potential for the intervention to reduce IPV risk.

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

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

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

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

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

Introduction: Women in sub-Saharan Africa (SSA) experience disproportionately high rates of HIV infection and unintended pregnancy compared to their age-matched counterparts in other regions of the world. Multipurpose prevention technologies (MPTs) that offer protection against HIV and unintended pregnancy in a single product stand to address these dual sexual and reproductive health needs simultaneously. The aim of this scoping review is to identify factors that are important for optimizing the likelihood of MPT adoption by end users in SSA. Methods: Study inclusion criteria included MPT research (HIV and pregnancy prevention dual indication) published or presented in English from 2000 to 2022 and conducted in SSA amongst end-users (women aged 15-44), male partners, health care providers, and community stakeholders. References were identified by searching peer reviewed literature, grey literature, conference presentations (2015-2022), grant databases, and outreach to MPT subject matter experts. Of 115 references identified, 37 references met inclusion criteria and were extracted for analysis. A narrative synthesis approach was used to summarize findings within and across MPT products. Results: Studies were identified from six countries in SSA and a substantial proportion included a South African (n = 27) and/or Kenyan (n = 16) study site. Most studies utilized a qualitative study design (n = 22) and evaluated MPT acceptability and preferences by presenting hypothetical products through images or a list of product attributes (n = 21). The vaginal ring (n = 20), oral tablet (n = 20), and injection (n = 15) were examined most frequently. Across studies, there was high acceptability and demand for an HIV and pregnancy prevention MPT. End users valued choice in prevention product type as well as discreetness and long-acting options. Provider counseling and community sensitization were reported as essential for future introduction of novel MPT delivery forms. Conclusion: Recognizing the heterogeneity of women's preferences and changing reproductive and sexual health needs over the life course, choice is important in the delivery of pregnancy and HIV prevention products as well as amongst MPT products with distinct product profiles. End user research with active MPTs, vs. hypothetical or placebo MPTs, is necessary to advance understanding of end-user preferences and acceptability of future products.

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

BACKGROUND: The field of violence prevention research is unequivocal that interventions must target contextual factors, like social norms, to reduce gender-based violence. Limited research, however, on the social norms contributing to intimate partner violence or reproductive coercion exists. One of the driving factors is lack of measurement tools to accurately assess social norms. METHODS: Using an item response modelling approach, this study psychometrically assesses the reliability and validity of a social norms measure of the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy with data from a population-based sample of married adolescent girls (ages 13-18) and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019. RESULTS: A two-dimensional Partial Credit Model for polytomous items was fit, showing evidence of reliability and validity. Higher scores on the "challenging husband authority" dimension were statistically associated with husband perpetration of intimate partner violence. CONCLUSIONS: This brief scale is a short (5 items), practical measure with strong reliability and validity evidence. This scale can help identify populations with high-need for social norms-focused IPV prevention and to help measure the impact of such efforts.

Long-term prevention of gender-based violence, like intimate partner violence and reproductive coercion, requires efforts to change the social environment that facilitates violence against women, yet limited research is available on how to change social environments. One reason is that there are few tools to accurately measure social environments, including social norms, which are the unspoken rules about what behavior is acceptable and what behavior is not. The present research assessed a new social norms measurement tool on the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy using data from a population-based sample of married adolescents and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019. We found that this scale had strong reliability and validity, and that the group of questions about challenging husband authority were related to husband perpetration of intimate partner violence against his wife. This brief scale is a short (5 questions), practical measure with strong reliability and validity evidence that can help identify populations with high-need for social norms-focused prevention and to help measure the impact of such efforts. This evidence strengthens the current set of measurement tools on social norms available to researchers and practitioners.

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

BACKGROUND: Adverse Childhood Experiences (ACEs) are a measure of childhood toxic stress that have a dose-dependent relationship with many adult health outcomes. While ACEs have been validated across diverse populations to measure neglect, abuse, and family dysfunction, they do not specifically assess trauma related to racism/xenophobia and immigration. 54% of Latinx youth in the United States are immigrants or children of immigrants and a large group with potentially unmeasured trauma. This study looks beyond ACEs to identify adverse and protective factors for healthy development among Latinx youth in an agricultural community through the perspectives of their mothers. METHODS: Twenty mothers of adolescent participants in A Crecer: the Salinas Teen Health Study (a prospective cohort study of 599 adolescents) completed semi-structured interviews in Spanish. Interviews focused on mothers' perspectives on community resources, parenting strategies, parenting support systems, and their future aspirations for their children. Four coders completed iterative rounds of thematic coding drawing from published ACEs frameworks (original ACEs, community ACEs) and immigrant specific adverse events arising from the data. RESULTS: Mothers in this study reported adverse experiences captured within community-level ACEs but also distinct experiences related to intergenerational trauma and immigrant-related adversities. The most cited community-level ACEs were housing instability and community violence. Immigrant related adversities included experiences of systemic racism with loss of resources, political instability limiting structural resources, and language-limited accessibility. These were exacerbated by the loss of family supports due to immigration related family-child separation including deportations and staggered parent-child migration. Having experienced intergenerational trauma and systemic oppression, mothers discussed their strategies for building family unity, instilling resilience in their children, and improving socioeconomic opportunities for their family. CONCLUSIONS: Latina mothers shared the impacts of immigrant-related experiences on systemic inequities in the United States which are currently missing from the ACEs framework. Immigrant specific adverse events include language-limited accessibility, or family-child separations, and policies impacting structural resources for immigrant families. Mothers highlighted their capacity to build resilience in their children and buffer impacts of systemic racism. Community-tailored interventions can build on this foundation to reduce health disparities and promote health equity in this population.

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

BACKGROUND: Input from end-users during preclinical phases can support market fit for new HIV prevention technologies. With several long-acting pre-exposure prophylaxis (PrEP) implants in development, we aimed to understand young women's preferences for PrEP implants to inform optimal design. METHODS: We developed a discrete choice experiment and surveyed 800 young women in Harare, Zimbabwe and Tshwane, South Africa between September-November 2020. Women aged 18-30 years who were nulliparous, postpartum, or exchanged sex for money, goods or shelter in prior year were eligible; quotas were set for each subgroup. The DCE asked participants to choose between two hypothetical implants for HIV prevention in a series of nine questions. Implants were described by: size, number of rods and insertion sites, duration (6-months, 1-year, 2-years), flexibility, and biodegradability. Random-parameters logit models estimated preference weights. RESULTS: Median age was 24 years (interquartile range 21-27). By design, 36% had used contraceptive implants. Duration of protection was most important feature, with strong preference for a 2-year over 6-month implant. In Zimbabwe, the number of rods/insertion sites was second most important and half as important as duration. Nonetheless, to achieve an implant lasting 2-years, 74% were estimated to accept two rods, one in each arm. In South Africa, preference was for longer, flexible implants that required removal, although each of these attributes were one-third as important as duration. On average, biodegradability and size did not influence Zimbabwean women's choices. Contraceptive implant experience and parity did not influence relative importance of attributes. CONCLUSIONS: While duration of protection was a prominent attribute shaping women's choices for PrEP implants, other characteristics related to discreetness were relevant. Optimizing for longest dosing while also ensuring minimal detection of implant placement seemed most attractive to potential users.

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

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

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

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

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

INTRODUCTION: Young women in sub-Saharan Africa account for two-thirds of all new HIV infections and face high rates of unintended pregnancy. Multipurpose prevention technologies (MPTs) are promising products under development that are designed to simultaneously prevent HIV and unintended pregnancy. Since MPTs will be used in the context of sexual relationships, ensuring acceptability and use requires understanding the role of male partners in MPT use decision-making. METHODS: This paper draws on qualitative data from 39 couples enrolled in the Microbicide Trials Network (MTN) 045 study, conducted in 2019-2020. Partners completed a discrete choice experiment (DCE), first separately and then jointly, to measure preferences for future MPT attributes and then completed a qualitative interview. We also draw on quantitative data from interviewer observation about who dominated the decision-making process during the joint DCE. Content analysis was used to examine (1) how couples made decisions on existing non-MPT HIV and pregnancy prevention products; (2) how couples made decisions on future ideal-MPT product during the DCE; and (3) how these decision-making processes varied by decision-making dominance (10 male, 10 female and 19 equal) and interview type (19 joint and 20 separate). RESULTS: Existing non-MPT product decisions focused on trust between partners and product attributes, while future ideal-MPT product decisions exclusively focused on product attributes. Across existing and future products, preferences for product attributes varied by gender. Male partners were most concerned with limiting side effects impacting sexual pleasure, female partners were most concerned with limiting side effects causing physical symptoms and both were concerned with the return to fertility. Across all dominance and interview types, couples reported making decisions together and female partners were often able to negotiate with male partners for their preferred product or set of product attributes. CONCLUSIONS: Research activities in this study provided an opportunity for couples to openly present their product attribute preferences to their partner, learn about their partner's attribute preferences, negotiate for their ideal set of attributes and ultimately choose attributes that benefited the couple without disempowering the female partner. Future research should focus on the utility of couple-based decision-making aids or similar tools for facilitating joint MPT decision-making.

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

INTRODUCTION: High social-emotional functioning, including emotion regulation and nonviolent conflict resolution, constitute developmental competencies of adolescence that promote health and well-being. We used prospective longitudinal data from a predominantly Latinx population to understand how family context and social environment risk factors for violence related to patterns of social-emotional functioning during the transition between middle school and high school. METHODS: We prospectively interviewed 599 8th graders every 6 months for 2 years. We used trajectory models to explore longitudinal patterns of emotion regulation and nonviolent problem solving and multinomial regression to distinguish how these groups were associated with family context, partner and peer gang involvement, and neighborhood social disorder. RESULTS: Youth reporting lower neighborhood disorder in 8th grade were more likely to be in the high emotion regulation trajectory group. Youth without exposure to gangs through peers and partners in 8th grade were more likely to be in the high nonviolent problem-solving skills trajectory group. Family cohesion was associated with being in the high trajectory groups for both emotional regulation and problem-solving skills. CONCLUSION: Emotion regulation and nonviolent problem-solving skills had different associations with the social environment risk factors for violence examined, indicating that mechanisms of influence and strategies for intervention may vary. The association between problem-solving skills and exposure to gangs through peers and partners shows that social norms may be important targets of change. Additionally, interventions with parents that build family cohesion during adolescence may buffer environmental exposures that shape adolescents' ability to practice protective social-emotional behaviors.

Couples' Preferences for "2 in 1" Multipurpose Prevention Technologies to Prevent Both HIV and Pregnancy: Results of a Discrete Choice Experiment in Uganda and Zimbabwe.

End-user input early in biomedical product development may optimize design to support high uptake and adherence. We interviewed 400 couples (800 total participants) in Uganda and Zimbabwe to assess their preferences for multipurpose prevention technologies (MPTs) for HIV and pregnancy prevention. Using a discrete choice experiment, couples made a series of choices between hypothetical MPTs, including oral tablets and vaginal rings, inserts, and films and completed an interviewer-administered questionnaire assessing sociodemographic and behavioral measures. Most couples preferred presented MPTs over male condoms. Couples' MPT choices in both countries were influenced most by the combination of product form and dosing frequency, with monthly dosing preferred over daily. Analysis highlighted differences by country as to which side effects were most important: Ugandan couples placed greater importance on effects on the vaginal environment during sex, whereas Zimbabwean couples placed more importance on changes to menstruation and other side effects (headache, cramps). Couples' preferences signaled an openness to new product forms and more frequent dosing if preferred characteristics of other attributes were achieved.

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

BACKGROUND: Male partner awareness and acceptance of microbicide and family planning product use has been shown to increase women's own acceptance and adherence of a product. However, little is known about preferences regarding potential Multipurpose Prevention Technology (MPT) product delivery forms. As part of the TRIO study, men's reactions to their female partner's TRIO product use and comparisons of men's and women's views of TRIO product attributes and use acceptability were explored to better understand product preferences. METHODS: Women in TRIO used three placebo products that represented potential MPTs: daily oral tablets, monthly vaginal rings, and monthly dual injections. Male partners (N = 39) and women (N = 88) completed in-depth interviews on their own and their partner's experiences with these products. Qualitative coding and analyses followed a conceptual model of HIV prevention product acceptability, and here, we explored themes of disclosure, trust and infidelity as they informed barriers and facilitators to product use. RESULTS: Men expressed a desire to know of their partner's product use decisions and be informed and educated on the products to better support their partners, in some cases, expressing a high level of concern regarding maximizing the ease of product adherence for their partner. They also wanted to understand the effects of products on sexual encounters with their partner, but in some cases, wanted more knowledge in order to control their partner's product use decisions. Similarly to women, men found long-acting, discreet products that have little to no effect on sexual encounters or libido the most acceptable for their female partners' use. Product use was most acceptable to men if they were informed of use without inadvertent discovery. CONCLUSIONS: Men's product attribute preferences often aligned with women's opinions of the same products. To support women's correct use of MPTs, further research is needed to determine the best strategy for achieving male partner acceptance and support of product use, particularly for less familiar delivery forms, such as the vaginal ring.

Early Sexual Debut and Neighborhood Social Environment in Latinx Youth.

OBJECTIVES: To examine whether social aspects of the neighborhood environment are associated with early sexual initiation in a California agricultural community of predominantly Latinx adolescents. METHODS: In a prospective cohort study of 599 eighth graders recruited from middle schools in Salinas, California (2015-2019), participants completed five interviews over 2 years. Social environment measures included neighborhood social dynamics (neighborhood disorder, social cohesion, and social network gang exposure); experiences of discrimination; and school connectedness. We estimated associations between baseline social environment and early sexual initiation (<15 years) using Poisson regression with robust standard errors. We compared contraceptive self-efficacy and attitudes by sexual initiation status using ANOVA. RESULTS: Most youth were Latinx (94%) and age 13 (70%) at enrollment; 53% were female and 49% had a parent employed in agriculture. Additionally, 14% reported first vaginal sex before age 15. Neighborhood disorder (relative risk [RR], 1.13; 95% confidence interval [CI], 1.05-1.21), social network gang exposure (RR, 2.23; 95% CI, 1.49-3.33), and experiences of discrimination (RR, 1.67 [1-2 events versus none], 95% CI, 1.09-2.55; RR, 2.33 [3+ events versus none], 95% CI, 1.07-4.64) were associated with early sexual initiation. School connectedness was protective (RR, 0.44, 95% CI, 0.29-0.69). Youth who initiated sex before age 15 had more negative birth control attitudes and expressed lower motivation to use contraceptives. CONCLUSIONS: Findings underscore opportunities to promote early adolescent sexual health through strengthening supportive and safe neighborhood environments with the promise of addressing disparities in unintended pregnancy and sexually transmitted infection rates in later adolescence.

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

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

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

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

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

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

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

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