Community recommendations for promoting HIV testing to Black young men who have sex with men in the southern United States.

BACKGROUND: Considering the need to increase HIV testing among racial minority youth in the southern United States, we conducted an exploratory study in Alabama to elucidate recommendations on improving testing rates among Black young men who have sex with men (BYMSM). METHODS: We conducted in-depth interviews and focus groups with BYMSM and prevention and outreach workers. Data collection occurred online and in person between 2020-2022. RESULTS: Our sample included data from n = 56 BYMSM and n = 12 prevention and outreach workers. BYMSMs' mean age = 24 years. Among prevention and outreach workers, 58% identified as male with mean age = 39 years; 83% identified as Black. Transcripts were coded thematically; five concurrent themes emerged from both BYMSM and prevention and outreach workers: promoting testing at younger ages, need for visibility and outreach, connecting through shared experiences, value of nonjudgmental approaches, and need to increase HIV knowledge in BYMSM. CONCLUSIONS: Findings suggest that cultivating trust is salient to promoting HIV testing in BYMSM. To end the epidemic in the southern United States, a region that is heavily rural with high rates of HIV, it may be necessary to begin prevention conversations at younger ages and equip prevention and outreach workers with communication skills that leverage de-stigmatizing approaches.

HIV and intersectional stigma among people living with HIV and healthcare workers and antiretroviral therapy adherence in the Dominican Republic.

BACKGROUND: HIV-related stigma, discrimination, and social marginalization undermines optimal HIV care outcomes. More research examining the impact of HIV-related stigma, discrimination, other interlocking forms of oppression, and antiretroviral therapy (ART) adherence is needed to optimize HIV treatment programming. This study uses data from two clinics in the Dominican Republic to examine client and healthcare worker (HCW) perceptions of HIV and intersectional stigmas among people living with HIV. METHODS: Surveys exploring demographics, HIV-related stigma, various dimensions of discrimination (race/ethnicity, HIV status, sexual orientation), healthcare engagement, and medication adherence were collected from 148 clients and 131 HCWs. Analysis of variance was conducted to examine differences in stigma by clinic and logistic regressions were used to determine predictors of optimal client medication adherence. RESULTS: Perceived discrimination in healthcare facilities due to clients' sexual orientation retained significance in crude and multivariable logistic regression models and was negatively associated with ART adherence (aOR:0.79; 95% CI:0.66, 0.95). DISCUSSION: Findings highlight the importance of implementing strategies to address stigma, discrimination, and social marginalization, particularly within healthcare facilities.

Study protocol for transforming health equity research in integrated primary care: Antiracism as a disruptive innovation.

Among the consequences of systemic racism in health care are significant health disparities among Black/African American individuals with comorbid physical and mental health conditions. Despite decades of studies acknowledging health disparities based on race, significant change has not occurred. There are shockingly few evidence-based antiracism interventions. New paradigms are needed to intervene on, and not just document, racism in health care systems. We are developing a transformative paradigm for new antiracism interventions for primary care settings that integrate mental and physical health care. The paradigm is the first of its kind to integrate community-based participatory research and systems science, within an established model of early phase translation to rigorously define new antiracism interventions. This protocol will use a novel application of systems sciences by combining the qualitative systems sciences methods (group model building; GMB) with quantitative methods (simulation modeling) to develop a comprehensive and community-engaged view of both the drivers of racism and the potential impact of antiracism interventions. Community participants from two integrated primary health care systems will engage in group GMB workshops with researchers to 1) Describe and map the complex dynamic systems driving racism in health care practices, 2) Identify leverage points for disruptive antiracism interventions, policies and practices, and 3) Review and prioritize a list of possible intervention strategies. Advisory committees will provide feedback on the design of GMB procedures, screen potential intervention components for impact, feasibility, and acceptability, and identify gaps for further exploration. Simulation models will be generated based on contextual factors and provider/patient characteristics. Using Item Response Theory, we will initiate the process of developing core measures for assessing the effectiveness of interventions at the organizational-systems and provider levels to be tested under a variety of conditions. While we focus on Black/African Americans, we hope that the resulting transformative paradigm can be applied to improve health equity among other marginalized groups.

Optimizing Individual HIV Testing and Counseling for Emerging Adult Sexual Minority Men (Aged 18 to 24) in Relationships: A Pilot Randomized Controlled Trial of Adjunct Communication Components.

The majority of new HIV infections in the US occur among sexual minority men (SMM) with older adolescent and emerging adult SMM at the highest risk. Those in relationships face unique HIV prevention challenges. Existing sexual HIV transmission risk interventions for male couples often encounter implementation challenges and engaging younger SMM early in relationships may be particularly difficult. This pilot randomized controlled trial evaluated the acceptibility and feasibility of We Test HIV testing - a behavioral health intervention tailored for younger SMM in realtionships - and generated preliminary estimates of effect size. The intervention comprises two adjunct moduls - video-based communication skills training as well as communication goal setting and planning - delivered in conjunction with routine HIV testing and counseling in individual or dyadic formats. A sample of 69 SMM aged 17 to 24 were recruited online. Following baseline assessment, youth were randomized to receive either the experimental, We Test, intervention or routine HIV testing (the control condition). Follow-up assessments were completed 3 and 6 months post-baseline. Results suggested the study was feasible and the individually delivered format was acceptible. We Test HIV testing was associated with significant improvements in communication skills. In addition, youth who remained in a relationship experienced an increase in communal coping to reduce HIV infection risk and relationship power. While groups did not differ with respect to condomless anal sex with casual partners, these psycho-social constructs (communication, communal coping with HIV prevention, and relationship power) may serve as mediators of intervention effects on sexual risk reduction in a larger study.

Regulatory Issues in Electronic Health Records for Adolescent HIV Research: Strategies and Lessons Learned.

BACKGROUND: Electronic health records (EHRs) are a cost-effective approach to provide the necessary foundations for clinical trial research. The ability to use EHRs in real-world clinical settings allows for pragmatic approaches to intervention studies with the emerging adult HIV population within these settings; however, the regulatory components related to the use of EHR data in multisite clinical trials poses unique challenges that researchers may find themselves unprepared to address, which may result in delays in study implementation and adversely impact study timelines, and risk noncompliance with established guidance. OBJECTIVE: As part of the larger Adolescent Trials Network (ATN) for HIV/AIDS Interventions Protocol 162b (ATN 162b) study that evaluated clinical-level outcomes of an intervention including HIV treatment and pre-exposure prophylaxis services to improve retention within the emerging adult HIV population, the objective of this study is to highlight the regulatory process and challenges in the implementation of a multisite pragmatic trial using EHRs to assist future researchers conducting similar studies in navigating the often time-consuming regulatory process and ensure compliance with adherence to study timelines and compliance with institutional and sponsor guidelines. METHODS: Eight sites were engaged in research activities, with 4 sites selected from participant recruitment venues as part of the ATN, who participated in the intervention and data extraction activities, and an additional 4 sites were engaged in data management and analysis. The ATN 162b protocol team worked with site personnel to establish the necessary regulatory infrastructure to collect EHR data to evaluate retention in care and viral suppression, as well as para-data on the intervention component to assess the feasibility and acceptability of the mobile health intervention. Methods to develop this infrastructure included site-specific training activities and the development of both institutional reliance and data use agreements. RESULTS: Due to variations in site-specific activities, and the associated regulatory implications, the study team used a phased approach with the data extraction sites as phase 1 and intervention sites as phase 2. This phased approach was intended to address the unique regulatory needs of all participating sites to ensure that all sites were properly onboarded and all regulatory components were in place. Across all sites, the regulatory process spanned 6 months for the 4 data extraction and intervention sites, and up to 10 months for the data management and analysis sites. CONCLUSIONS: The process for engaging in multisite clinical trial studies using EHR data is a multistep, collaborative effort that requires proper advanced planning from the proposal stage to adequately implement the necessary training and infrastructure. Planning, training, and understanding the various regulatory aspects, including the necessity of data use agreements, reliance agreements, external institutional review board review, and engagement with clinical sites, are foremost considerations to ensure successful implementation and adherence to pragmatic trial timelines and outcomes.

Integration of an Electronic Screening, Brief Intervention, and Referral to Treatment Program Into an HIV Testing Program to Reduce Substance Use and HIV Risk Behavior Among Men Who Have Sex With Men: Protocol for Intervention Development and a Pilot Randomized Controlled Trial.

BACKGROUND: Men who have sex with men (MSM) are disproportionally affected by HIV and drug and alcohol use; however, few effective HIV prevention interventions for MSM who use substances exist. Screening, Brief Intervention, and Referral to Treatment is an early intervention for non-treatment-seeking individuals with problematic substance use and for timely referral to treatment for those with substance use disorders. Electronic screening and brief interventions (e-SBIs) reduce implementation challenges. An e-SBI tailored for MSM at the time of HIV testing might be particularly opportune to strengthen their motivation to reduce substance use and HIV risk behavior. OBJECTIVE: This study aims to develop a tailored e-SBI program to reduce substance use and HIV risk behavior among MSM seeking HIV testing at Nexo Asociación Civil, our community partners in Argentina (primary); assess the feasibility and acceptability of integrating the e-SBI into the Nexo HIV testing program (primary); assess the feasibility and acceptability of implementing an adapted Men's Health Project (MHP) at Nexo (secondary); and finally, explore preliminary findings on substance use and sexual risk reduction outcomes (exploratory). METHODS: This mixed methods study has 2 stages. During stage 1 (development), we will use the User Centered Rapid App Design process consisting of focus groups (n=16), individual interviews (n=24), and a pilot deployment of the e-SBI (n=50) to iteratively develop the e-SBI. Quantitative and qualitative assessments at each step will inform the revision of the e-SBI. Furthermore, we will use the assessment, decision, administration, production, topic experts, integration, training, testing framework to adapt MHP. During stage 2 (pilot randomized controlled trial [RCT]), we will randomize 200 MSM coming to Nexo for HIV testing. They will complete a baseline assessment and then their assigned intervention (e-SBI vs screening only) and will be followed-up for 6 months. We will also conduct in-depth interviews with up to 45 participants: 15 participants from either study condition who entered or completed MHP or other substance abuse treatment and 15 from each arm who met the criteria for MHP but did not request it. RESULTS: The study began recruitment in October 2022, and the stage-1 pilot study is near completion. Preliminary findings from stage 1 show high e-SBI acceptability. Data analysis of the stage-1 pilot is now beginning. The stage-2 pilot RCT will be launched in March 2024, with all data collection completed by May 2025. CONCLUSIONS: This study will allow us to assess the acceptability and feasibility of e-SBI implementation during HIV testing encounters. We will also build the necessary research infrastructure for a subsequent RCT to assess the efficacy of e-SBIs in reducing substance use and HIV sexual risk behavior among MSM in this setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT05542914; https://tinyurl.com/yyjj64dm. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/56683.

Study protocol for clinical trial of the FIT Families multicomponent obesity intervention for African American adolescents and their caregivers: Next step from the ORBIT initiative.

INTRODUCTION: This study will test the effectiveness of FIT Families (FIT), a multicomponent family-based behavioural intervention, against a credible attention control condition, Home-Based Family Support (HBFS). This protocol paper describes the design of a randomised clinical trial testing the efficacy of the FIT intervention. The protocol will assess the efficacy of FIT to improve health status in African American adolescents with obesity (AAAO) and their primary caregivers on primary (percent body fat) and secondary (physical activity, metabolic control, weight loss) outcomes and its cost-effectiveness. METHODS: 180 youth/caregiver dyads are randomised into FIT or HBFS, stratified by age, gender and baseline per cent overweight. The proposed study follows a two condition (FIT, HBFS) by four assessment time points. Tests will be conducted to identify potential relationship of baseline demographic and clinical variables to our dependent variables and see whether they are balanced between groups. It is hypothesised that youth/caregiver dyads randomised to FIT will show significantly greater reductions in percent body fat over a 12-month follow-up period compared with AAAO receiving HBFS. Preliminary findings are expected by November 2023. ETHICS: This protocol received IRB approval from the Medical University of South Carolina (Pro00106021; see 'MUSC IRB 106021 Main Approval.doxc' in online supplemental materials). DISSEMINATION: Dissemination activities will include summary documents designed for distribution to the broader medical community/family audience and submission of manuscripts, based on study results, to relevant peer-reviewed scientific high-impact journals. TRIAL REGISTRATION NUMBER: NCT04974554.

Building an HIV Learning Health Care Community for Youth in Florida: Opportunities and Challenges.

In Florida, 33% of new HIV infections among men and 21% of new infections among women are among those younger than 29 years of age. We describe the development of a Learning Health Care Community for youth (Y-LHCC) in Orange County, FL. Its core implementation team (iTeam) was composed of representatives from community agencies and academics, whose work was informed by data from the Florida Department of Health (FDOH) and regional research, in-depth interviews (IDIs) with agency representatives, and a pilot implementation of Tailored Motivational Interviewing (TMI) to improve service provision. IDIs revealed limited programming specifically for youth, significant structural challenges providing them with PrEP, and differences in use of evidence-based behavioral interventions to improve HIV services. FDOH provided data on new HIV infections, linkage to care, viral suppression, and PrEP coverage, however, limitations such as minimal data on PrEP referrals and use, agency level data, and inability to generate data quarterly (which would facilitate program improvement) were encountered. Thirty staff members from five agencies serving youth in Orange County participated in TMI training. About half the agency staff (n = 16) completed at least three of the four online training sessions. MI skills improved from pre- (n = 28; M = 1.96) to post TMI training (n = 11; M = 2.48, SD = 0.57); (t(37) = - 3.14, p = 0.0033). The iTeam held seven remote meetings and two in-person half-day meetings at the end of the study, during which they reassessed areas of focus for improving youth services. They also reiterated their commitment to continuing to meet beyond the study period and to engage other agencies in the newly established coalition. Findings highlight the potential of creating a Y-LHCC in Florida as well as some of the challenges that will need to be overcome to achieve ending the HIV Epidemic goals for young people in the region.

RESUMEN: En Florida, el 33% y 21% de las nuevas infecciones del VIH entre hombres y mujeres, respectivamente, fueron entre personas menores de 29 años de edad. Describimos el desarrollo de una Comunidad de Aprendizaje de Atención Médica para jóvenes (Y-LHCC) en el Condado de Orange, FL. Su equipo central de implementación (iTeam) estuvo compuesto de representantes de agencias comunitarias y académicos, cuyo trabajo se basó en datos del Departamento de Salud de Florida (FDOH) e investigaciones regionales, entrevistas en profundidad con representantes de agencias y un programa piloto de implementación de la Entrevista Motivacional a la Medida (TMI) para mejorar la prestación de servicios. Las entrevistas revelaron poca programación específica para los jóvenes, desafíos estructurales significativos para proporcionarles PrEP, y diferencias en el uso de intervenciones conductuales basadas en evidencia para mejorar los servicios de VIH. El FDOH proporcionó datos sobre nuevas infecciones por el VIH, vinculación con la atención médica, supresión viral y cobertura de PrEP. Sin embargo, se encontraron limitaciones en la data, tales como datos limitados sobre derivaciones u uso de PrEP, falta de datos a nivel de agencia, e incapacidad para generar datos trimestrales (lo que facilitaría la mejora de programas en la agencia). Treinta miembros del personal de cinco agencias que atienden a jóvenes en el Condado de Orange participaron en la capacitación de TMI. Aproximadamente la mitad del personal de la agencia (n = 16) completó al menos tres de las cuatro sesiones de capacitación remota. Las habilidades de MI mejoraron desde antes (n = 28; M = 1.96, SD = .042) hasta después del entrenamiento de TMI (n = 11; M = 2.48, SD = 0.57); (t(37) = − 3.14, p = 0.0033). El iTeam realizó siete reuniones remotas y dos reuniones en persona de medio día al final del estudio, durante las cuales reevaluaron las áreas de enfoque para mejorar los servicios para jóvenes. También reiteraron su compromiso de continuar reuniéndose más allá del período de estudio y de involucrar a otras agencias en la coalición recién establecida. Los hallazgos destacan el potencial de crear un Y-LHCC en Florida, así como algunos de los desafíos que deberán superarse para lograr los objetivos de terminar con la epidemia de VIH para los jóvenes de la región.

Digital Adaptive Behavioral Interventions to Improve HIV Prevention and Care: Innovations in Intervention Approach and Experimental Design.

PURPOSE OF REVIEW: Recent advances in digital technologies can be leveraged to adapt HIV prevention and treatment services to the rapidly changing needs of individuals in everyday life. However, to fully take advantage of these technologies, it is critical to effectively integrate them with human-delivered components. Here, we introduce a new experimental approach for optimizing the integration and adaptation of digital and human-delivered behavioral intervention components for HIV prevention and treatment. RECENT FINDINGS: Typically, human-delivered components can be adapted on a relatively slow timescale (e.g., every few months or weeks), while digital components can be adapted much faster (e.g., every few days or hours). Thus, the systematic integration of these components requires an experimental approach that involves sequential randomizations on multiple timescales. Selecting an experimental approach should be motivated by the type of adaptive intervention investigators would like to develop, and the scientific questions they have about its construction.

Influence of provider openness and leadership behaviors on adherence to motivational interviewing training implementation strategies: Considerations for evidence-based practice delivery.

Background: Adherence to intervention training implementation strategies is at the foundation of fidelity; however, few studies have linked training adherence to trainee attitudes and leadership behaviors to identify what practically matters for the adoption and dissemination of evidence-based practices. Through the conduct of this hybrid type 3 effectiveness-implementation cluster randomized controlled trial, we collected Exploration, Preparation, Implementation, and Sustainment (EPIS) data and merged it with tailored motivational interviewing training adherence data, to elucidate the relationship between provider attitudes toward evidence-based practices, leadership behaviors, and training implementation strategy (e.g., workshop attendance and participation in one-on-one coaching) adherence. Method: Our sample included data from providers who completed baseline (pre-intervention) surveys that captured inner and outer contexts affecting implementation and participated in tailored motivational interviewing training, producing a dataset that included training implementation strategies adherence and barriers and facilitators to implementation (N = 77). Leadership was assessed by two scales: the director leadership scale and implementation leadership scale. Attitudes were measured with the evidence-based practice attitude scale (EBPAS-50). Adherence to training implementation strategies was modeled as a continuous outcome with a Gaussian distribution. Analyses were conducted in SPSS. Results: Of the nine general attitudes toward evidence-based practice, openness was associated with training adherence (estimate [EST] = 0.096, p < .001; 95% CI = [0.040, 0.151]). Provider general (EST = 0.054, 95% CI = [0.007, 0.102]) and motivational interviewing-specific (EST = 0.044, 95% CI = [0.002, 0.086]) leadership behaviors were positively associated with training adherence (p < .05). Of the four motivational interviewing-specific leadership domains, knowledge and perseverant were associated with training adherence (p < .05). As these leadership behaviors increased, knowledge (EST = 0.042, 95% CI = [0.001, 0.083]) and perseverant (EST = 0.039, 95% CI = [0.004, 0.075]), so did provider adherence to training implementation strategies. Conclusions: As implementation science places more emphasis on assessing readiness prior to delivering evidence-based practices by evaluating organizational climate, funding streams, and change culture, consideration should also be given to metrics of leadership. A potential mechanism to overcome resistance is via the implementation of training strategies focused on addressing leadership prior to conducting training for the evidence-based practice of interest.

Researchers and practitioners, who aim to improve the uptake of evidence-based practices, continue to seek ways in which to improve provider participation in training implementation strategies. The persistent challenge in addressing provider disengagement, while linking this disinterest to poor patient outcomes, has been ascertaining how to quantify relevant delivery considerations, for example, provider attitudes and leadership behaviors that may influence commitment to learning or apathy to behavior change, concurrently with training adherence. Through the conduct of this study, we collected both types of data: (1) provider attitudes and leadership behaviors and (2) training adherence outcomes. We found that provider openness, general leadership behaviors, and motivational interviewing-specific leadership behaviors were associated with adherence to training implementation strategies. As more emphasis is placed on assessing clinic readiness prior to adopting new evidence-based practices, a discussion on including metrics of provider attitudes to evidence-based practice, innovation, and the specific intervention is warranted, alongside consideration for how implementation training strategies focused on addressing leadership can bolster change-supportive behaviors prior to delivery of innovations.

Maintaining Program Fidelity in a Changing World: National Implementation of a School-Based HIV Prevention Program.

Large-scale, evidence-based interventions face challenges to program fidelity of implementation. We developed implementation strategies to support teachers implementing an evidence-based HIV prevention program in schools, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT) in The Bahamas. We examined the effects of these implementation strategies on teachers' implementation in the subsequent year after the initial implementation during the COVID-19 pandemic. Data were collected from 79 Grade 6 teachers in 24 government elementary schools. Teachers completed training workshops and a pre-implementation questionnaire to record their characteristics and perceptions that might affect their program fidelity. School coordinators and peer mentors provided teachers with monitoring, feedback, and mentoring. In Year 1, teachers on average taught 79.3% of the sessions and 80.8% of core activities; teachers in Year 2 covered 84.2% of sessions and 72.9% of the core activities. Teachers with "good" or "excellent" school coordinators in the second year taught significantly more sessions on average (7.8 vs. 7.0, t = 2.04, P < 0.05) and more core activities (26.3 vs. 23.0, t = 2.41, P < 0.05) than teachers with "satisfactory" coordinators. Teachers who had a "good" or "satisfactory" mentor taught more sessions than teachers who did not have a mentor (7.9 vs. 7.3; t = 2.22; P = 0.03). Two-level mixed-effects model analysis indicated that teachers' program fidelity in Year 1, confidence in the execution of core activities, and school coordinators' performance were significantly associated with Year 2 implementation dose. Implementation of FOYC + CImPACT was significantly associated with improved student outcomes. Teachers maintained high fidelity to a comprehensive HIV prevention program over 2 years during the COVID-19 pandemic. Future program implementers should consider additional implementation support to improve the implementation of school-based programs.

Interventions Across the Translational Research Spectrum: Addressing Disparities Among Racial and Ethnic Minoritized Youth with Type 1 Diabetes.

Racial and ethnic minoritized youth with type 1 diabetes (T1D) are at elevated risk for health disparities. Few intervention studies have been conducted for these youth and evidence to support best practices to address their needs is lacking. Existing evidence supports the use of brief trials of diabetes technology with structured support from clinic staff, culturally tailored interventions such as language-congruent clinical care, and use of community health workers as promising directions to improve health outcomes. Clinicians and researchers should work collaboratively with community members to improve the quality of T1D intervention science for racial and ethnic minoritized youth.

Opening the Black Box of Family-Based Treatments: An Artificial Intelligence Framework to Examine Therapeutic Alliance and Therapist Empathy.

The evidence-based treatment (EBT) movement has primarily focused on core intervention content or treatment fidelity and has largely ignored practitioner skills to manage interpersonal process issues that emerge during treatment, especially with difficult-to-treat adolescents (delinquent, substance-using, medical non-adherence) and those of color. A chief complaint of "real world" practitioners about manualized treatments is the lack of correspondence between following a manual and managing microsocial interpersonal processes (e.g. negative affect) that arise in treating "real world clients." Although family-based EBTs share core similarities (e.g. focus on family interactions, emphasis on practitioner engagement, family involvement), most of these treatments do not have an evidence base regarding common implementation and treatment process problems that practitioners experience in delivering particular models, especially in mid-treatment when demands on families to change their behavior is greatest in treatment - a lack that characterizes the field as a whole. Failure to effectively address common interpersonal processes with difficult-to-treat families likely undermines treatment fidelity and sustained use of EBTs, treatment outcome, and contributes to treatment dropout and treatment nonadherence. Recent advancements in wearables, sensing technologies, multivariate time-series analyses, and machine learning allow scientists to make significant advancements in the study of psychotherapy processes by looking "under the skin" of the provider-client interpersonal interactions that define therapeutic alliance, empathy, and empathic accuracy, along with the predictive validity of these therapy processes (therapeutic alliance, therapist empathy) to treatment outcome. Moreover, assessment of these processes can be extended to develop procedures for training providers to manage difficult interpersonal processes while maintaining a physiological profile that is consistent with astute skills in psychotherapeutic processes. This paper argues for opening the "black box" of therapy to advance the science of evidence-based psychotherapy by examining the clinical interior of evidence-based treatments to develop the next generation of audit- and feedback- (i.e., systemic review of professional performance) supervision systems.

Adapting Effective mHealth Interventions to Improve Uptake and Adherence to HIV Pre-Exposure Prophylaxis Among Thai Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial.

BACKGROUND: Young men who have sex with men (YMSM) are the fastest-growing HIV-positive population worldwide. Thailand has the highest adult HIV seroprevalence in Asia; over 25% of men having sex with men in Bangkok are HIV positive. Pre-exposure prophylaxis (PrEP) is an efficacious HIV prevention strategy recommended for all at-risk individuals. PrEP is highly effective when taken as prescribed, but PrEP utilization rate has been low, and adherence is often inadequate. OBJECTIVE: We propose to develop and pilot a multicomponent, technology-based intervention to promote motivation to begin PrEP ("uptake") and sustained adherence to PrEP among HIV-negative Thai YMSM. We will adapt an existing 2-session technology-delivered, motivational interviewing-based intervention to focus on PrEP use in YMSM in Thailand. The resulting intervention is called the Motivational Enhancement System for PrEP Uptake and Adherence (MES-PrEP). We will also develop motivational text messaging (MTM) to send two-way motivational messages to promote PrEP use. METHODS: The proposed study includes 3 phases. Phase 1 includes in-depth interviews with HIV-negative Thai YMSM and providers to explore barriers and facilitators of PrEP initiation and adherence, aiming to inform intervention content. Phase 2 consists of adapting and beta-testing MES-PrEP and MTM for functionality and feasibility using a youth advisory board of Thai YMSM. In Phase 3, we will conduct a pilot randomized controlled trial to evaluate the feasibility, acceptability, and preliminary efficacy of MES-PrEP and MTM to increase PrEP uptake and adherence among Thai YMSM. A total of 60 HIV-negative Thai YMSM who have not started PrEP and 60 YMSM who are on PrEP but not adherent to it will be randomized 2:1 to receive MES-PrEP and MTM (n=40) or standard PrEP counseling (n=20). The feasibility and acceptability of the intervention will be assessed through usage patterns and the System Usability Scale. The preliminary impact will be assessed by evaluating the proportion of PrEP initiation and level of adherence to PrEP. Participants will complete the assessments at baseline and at 1-, 3-, and 6-month postintervention. Biomarkers of adherence to PrEP and biomarkers of HIV and sexually transmitted infections will be collected. RESULTS: Recruitment for this study began in January 2022 for phase 1. Qualitative interviews were completed with 30 YMSM and 5 clinical providers in May 2022. Phase 3, the pilot feasibility and acceptability trial, began in July 2023. Upon project completion, we shall have developed a highly innovative mobile health intervention to support YMSM using PrEP, which will be ready for testing in a larger efficacy trial. CONCLUSIONS: This study addresses a critical problem (ie, high HIV incidence and low PrEP use) among Thai YMSM. We are developing 2 potentially synergistic technology-based, theory-driven interventions aimed at maximizing PrEP use. The proposed project has the potential to make significant contributions to advancing HIV prevention research and implementation science. TRIAL REGISTRATION: ClinicalTrials.gov NCT05243030; https://clinicaltrials.gov/ct2/show/NCT05243030. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46435.

Effects of Teacher Training and Continued Support on the Delivery of an Evidence-Based HIV Prevention Program: Findings From a National Implementation Study in the Bahamas.

BACKGROUND: Few studies have investigated the effects of teacher training and continued support on teachers' delivery of evidence-based HIV prevention programs. We examined these factors in a national implementation study of an evidence-based HIV risk reduction intervention for adolescents in the sixth grade in the Bahamas. METHODS: Data were collected from 126 grade 6 teachers and 3,118 students in 58 government elementary schools in the Bahamas in 2019-2021. This is a Hybrid Type III implementation study guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) model. Teachers attended 2-day training workshops. Trained school coordinators and peer mentors provided biweekly monitoring and mentorship. We used mixed-effects models to assess the effects of teacher training and continued support on implementation fidelity. RESULTS: Teachers who received training in-person or both in-person and online taught the most core activities (27.0 and 27.2 of 35), versus only online training (21.9) and no training (14.9) (F = 15.27, p < .001). Teachers with an "excellent" or "very good" school coordinator taught more core activities than those with a "satisfactory" coordinator or no coordinator (29.2 vs. 27.8 vs. 19.3 vs. 14.8, F = 29.20, p < .001). Teachers with a "very good" mentor taught more core activities and sessions than those with a "satisfactory" mentor or no mentor (30.4 vs. 25.0 vs. 23.1; F = 7.20; p < .01). Teacher training, implementation monitoring, peer mentoring, teachers' self-efficacy, and school-level support were associated with implementation fidelity, which in turn was associated with improved student outcomes (HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection). CONCLUSION: Teachers receiving in-person training and those having higher-rated school coordinator and mentor support taught a larger number of HIV prevention core activities. Effective teacher training, implementation monitoring, and peer mentoring are critical for improving implementation fidelity and student outcomes.

Cardiovascular Risk Assessment Among Adolescents and Youths Living With HIV: Evaluation of Electronic Health Record Findings and Implications.

BACKGROUND: The HIV epidemic remains a major public health concern, particularly among youths living with HIV. While the availability of antiretroviral therapy has significantly improved the health outcomes of people living with HIV, there is growing evidence that youths living with HIV may be at increased risk of cardiovascular disease. However, the underlying mechanisms linking HIV and cardiovascular disease among youths living with HIV remain poorly understood. One potential explanation is that HIV-related biomarkers, including detectable viral load (VL) and low cluster of differentiation 4 (CD4) lymphocyte counts, may contribute to increased cardiovascular risk. Despite the potential importance of these biomarkers, the relationship between HIV-related biomarkers and cardiovascular risk among youths living with HIV has been understudied. OBJECTIVE: To address this gap, we examined whether detectable VL and low CD4 lymphocyte counts, both of which are indications of unsuppressed HIV, were associated with cardiovascular risk among youths living with HIV. METHODS: We analyzed electronic health record data from 7 adolescent HIV clinics in the United States (813 youths living with HIV). We used multivariable linear regression to examine the relationship between detectable VL and CD4 lymphocyte counts of ≤200 and cardiovascular risk scores, which were adapted from the gender-specific Framingham algorithm. RESULTS: In our study, nearly half of the participants (366/766, 47.8%) had detectable VL, indicating unsuppressed HIV, while 8.6% (51/593) of them had CD4 lymphocyte counts of ≤200, suggesting weakened immune function. We found that those with CD4 lymphocyte counts of ≤200 had significantly higher cardiovascular risk, as assessed by Cardiac Risk Score2, than those with CD4 lymphocyte counts of >200 (P=.002). After adjusting for demographic and clinical factors, we found that for every 1000-point increase in VL copies/mL, the probability of having cardiovascular risk (Cardiac Risk Score2) increased by 38%. When measuring the strength of this connection, we observed a minor effect of VL on increased cardiovascular risk (ß=.134, SE 0.014; P=.006). We obtained similar results with Cardiac Risk Score1, but the effect of CD4 lymphocyte counts of ≤200 was no longer significant. Overall, our findings suggest that detectable VL is associated with increased cardiovascular risk among youths living with HIV, and that CD4 lymphocyte counts may play a role in this relationship as well. CONCLUSIONS: Our study highlights a significant association between unsuppressed HIV, indicated by detectable VL, and increased cardiovascular risk in youths living with HIV. These findings emphasize the importance of implementing interventions that address both VL suppression and cardiovascular risk reduction in this population. By tailoring interventions to meet the unique needs of youths, we can promote overall well-being throughout the HIV care continuum and across the life span. Ultimately, these efforts have the potential to improve the health outcomes and quality of life of youths living with HIV. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/11185.

Mechanisms of Successful Implementation of Tailored Motivational Interviewing in a Multisite Study of Youth HIV Clinics in the United States.

BACKGROUND: A recent implementation science stepped-wedge trial of motivational interviewing (MI) in adolescent HIV clinics indicated variable degrees of implementation success. The present mixed-methods study analyzed trajectories of postimplementation MI competence scores and compared postimplementation qualitative interviews among the clinics with the highest levels of provider competency and the lowest levels of competency to further understand mechanisms of successful implementation. SETTING: Ten HIV clinics in the Adolescent Trials Network for HIV/AIDS Interventions. METHODS: This study used a sequential explanatory mixed-methods design. Continuous MI competency data from the parent study were structured with repeated measurements nested within providers nested within 10 sites. A mixed-effects regression model rank ordered the clinics by competence scores. Key stakeholders (N = 77) at the 10 randomized clinics completed a 1-hour qualitative interview at 12-month follow-up (immediately postimplementation). Using the phases of reflexive thematic analysis, interviews from the 3 highest competence clinics and the 3 lowest competence clinics were pragmatically analyzed. RESULTS: Thematic analysis suggested 3 central themes that influenced successful evidence-based practice (EBP) implementation. Organizational culture included the leadership, collective effort, and resources that influenced how the organization at large responded to the implementation intervention. Staff attitudes encapsulated individual providers' mindsets and attitudes about MI and the implementation intervention. EBP integration reflected the perception and use of MI by individuals and the organization as a whole. These themes and their subthemes are interconnected and exerted an influence on each other through the implementation process. CONCLUSIONS: Findings suggest additional implementation strategies to improve implementation of EBPs. Such mixed-methods research is critical to understanding the mechanisms of successful implementation of EBP and improving future implementation strategies.

Improving Adherence to a Mediterranean Ketogenic Nutrition Program for High-Risk Older Adults: A Pilot Randomized Trial.

(1) Background: Mediterranean ketogenic nutrition (MKN) may directly target multiple neurobiological mechanisms associated with dementia risk in older adults. Despite its promise, this type of nutrition can be challenging to learn and adhere to in a healthy manner. Our team used the National Institutes of Health Obesity Related Behavioral Intervention Trials (NIH ORBIT) model to develop and pilot a program to help older adults with memory concerns use MKN. (2) Methods: Using a two-arm, randomized design, we evaluated an MKN Adherence (MKNA) program compared to an MKN education (MKNE) program (N = 58). The primary difference between study arms involved the use of motivational interviewing (MI) strategies and behavior change techniques (BCT) only in the MKNA arm. Participants were included if they evidenced subjective memory concerns or objective memory impairment on the Montreal Cognitive Assessment (Score 19 ≤ 26). Primary outcomes examined included feasibility, acceptability, adherence, and clinical outcomes associated with the program. (3) Results: Overall, there was relatively high program completion in both groups, with 79% of participants completing the 6-week program. The recruitment protocol required adjustment but was successful in reaching the target sample size. Retention (82%) and session attendance (91%) were higher in the MKNA arm compared to the MKNE (retention = 72%; attendance = 77%). Overall, most participants in both groups rated the program as "excellent" using the client satisfaction questionnaire. Participants in the MKNA arm evidenced higher objective and self-reported adherence to MKN during the 6-week program. Further, there was some evidence of clinical benefits of the program, although these effects diminished as adherence decreased in the 3 months follow-up. (4) Discussion: This pilot trial demonstrated that the MKN program incorporating MI and BCT strategies may better engage and retain participants than a nutrition education program alone, although participants in both groups reported high satisfaction.

Weight Discrimination and Health Risk Behavior in Racial, Ethnic, and Sexual Minority Adults.

BACKGROUND: People with obesity face significant discrimination due to their weight. Exposure to such discrimination is associated with poor health outcomes. Little is known about pathways that explain that association, and even less is known about those pathways in racial, ethnic, and sexual minorities. Health risk behaviors may serve as one such pathway. PURPOSE: We examined associations between weight discrimination and health risk behaviors and assessed whether associations are moderated by gender, race, ethnicity, or sexual orientation. METHODS: Quota sampling was used to oversample Black (36%), Latino (36%), and sexual minority (29%) adults (n = 2,632) who completed an online survey. Using regression analysis, health risk behaviors (maladaptive eating behaviors, physical inactivity, sitting, smoking, alcohol use, and sleep disturbance) were predicted from previous experience with weight discrimination while controlling for demographic characteristics, BMI, and depressive symptoms. Additional analyses tested for interactions between weight discrimination and key demographic variables (i.e., gender, race, ethnicity, and sexual minority status). RESULTS: Weight discrimination was associated with greater emotional eating, binge eating, unhealthy weight control behaviors, cigarette smoking, problematic alcohol use, and sleep disturbance. Gender moderated the association between weight discrimination and binge eating, alcohol use, and physical activity, with stronger effects observed in men than women. Exploratory analyses provided limited evidence for differential effects of weight discrimination across specific combinations of intersecting identities. CONCLUSIONS: Weight discrimination was associated with engagement in unhealthy behaviors and relationships were largely similar across diverse demographic groups. Health risk behaviors may represent a key pathway through which weight discrimination harms health.

People with high body weight remain one of the most stigmatized groups in the USA and face significant discrimination due to their weight. Experiencing weight discrimination is associated with poor health, yet little is known about the underlying pathways that explain this association and even less is known about those pathways in socially marginalized groups. We investigated unhealthy behavior as a possible a pathway by assessing associations between weight discrimination and several health risk behaviors and identifying whether those associations vary by gender, race, ethnicity, or sexual orientation. A diverse sample of 2,632 U.S. adults completed an online survey. Previous experience with weight discrimination was found to be associated with greater emotional eating, binge eating, unhealthy weight control behaviors, cigarette smoking, problematic alcohol use, and poor sleep. The association between weight discrimination and binge eating, alcohol use, and physical activity was stronger in men than in women, yet exploratory analyses provided limited evidence for differential effects of weight discrimination across specific combinations of intersecting identities. Weight discrimination was associated with engagement in unhealthy behaviors and associations were largely similar across participants from diverse demographic groups. Health risk behaviors may represent a key pathway through which weight discrimination harms health.