Social networks of people with serious mental illness who smoke: potential role in a smoking cessation intervention.

BACKGROUND: Smoking is a major contributor to morbidity and mortality among individuals with serious mental illness (SMI) and social networks may play an important role in smoking behaviors. AIMS: Our objectives were to (1) describe the network characteristics of adults with SMI who smoke tobacco (2) explore whether network attributes were associated with nicotine dependence. METHODS: We performed a secondary analysis of baseline data from a tobacco smoking cessation intervention trial among 192 participants with SMI. A subgroup (n = 75) completed questions on the characteristics of their social network members. The network characteristics included network composition (e.g. proportion who smoke) and network structure (e.g. density of connections between members). We used multilevel models to examine associations with nicotine dependence. RESULTS: Participant characteristics included: a mean age 50 years, 49% women, 48% Black, and 41% primary diagnosis of schizophrenia/schizoaffective disorder. The median personal network proportion of active smokers was 22%, active quitters 0%, and non-smokers 53%. The density of ties between actively smoking network members was greater than between non-smoking members (55% vs 43%, p = .02). Proportion of network smokers was not associated with nicotine dependence. CONCLUSIONS: We identified potential social network challenges and assets to smoking cessation and implications for network interventions among individuals with SMI.

Syphilis Diagnosis After a Chlamydia, Gonorrhea, or HIV Diagnosis Among Reproductive-Aged Women in Baltimore, MD.

BACKGROUND: Syphilis incidence is increasing among reproductive-aged women, and previous sexually transmitted infections (STIs) are a risk factor for subsequent STIs. This study aimed to determine syphilis incidence after a chlamydia, gonorrhea, or HIV diagnosis, and identify characteristics associated with higher syphilis incidence rates among reproductive-aged women in 1 mid-Atlantic city. METHODS: A retrospective cohort of 85,113 chlamydia, gonorrhea, and HIV diagnoses occurring between 2009 and 2021 and among women aged 13 to 50 years was constructed using public health surveillance data. Cumulative incidence curves were estimated to examine time to early syphilis (i.e., primary, secondary, or early latent) diagnosis, and multivariable analyses determined incidence rate ratios by age (<25 vs. ≥25 years) and number of prior STI diagnoses (0 vs. ≥1) during the study period, stratified by STI. RESULTS: There were 85,113 reportable STI diagnoses and 646 syphilis diagnoses in the cohort. Approximately 1 of 150 chlamydia, 1 of 100 gonorrhea, and 1 of 50 HIV diagnoses were followed by a syphilis diagnosis within 5 years. Cumulative incidence of syphilis differed significantly by STI diagnosis ( P < 0.001). In multivariable analysis, syphilis incidence rates were higher among women diagnosed with ≥1 (vs. 0) prior STI regardless of STI type ( P < 0.05) and among women ≥25 (vs. <25) years old diagnosed with gonorrhea ( P < 0.05). CONCLUSIONS: There were significant differences in syphilis incidence by prior STI type, number of STIs, and age. Our data support targeted screening for syphilis among women with a history of STIs, parwomen with ≥1 prior STI diagnosis, and older women diagnosed with gonorrhea.

Correction: Desires for Individual- and Interpersonal-Level Patient Portal Use for HIV Prevention Among Urban Sexual Minority Men: Cross-sectional Study.

[This corrects the article DOI: 10.2196/43550.].

Desires for Individual- and Interpersonal-Level Patient Portal Use for HIV Prevention Among Urban Sexual Minority Men: Cross-sectional Study.

BACKGROUND: Gay, bisexual, and other sexual minority men have expressed the acceptability of patient portals as tools for supporting HIV prevention behaviors, including facilitating disclosure of HIV and other sexually transmitted infection (STI/HIV) laboratory test results to sex partners. However, these studies, in which Black or African American sexual minority men were undersampled, failed to determine the relationship of reported history of discussing HIV results with sex partners and anticipated willingness to disclose web-based STI/HIV test results using a patient portal. OBJECTIVE: Among a sample of predominantly Black sexual minority men, this study aimed to (1) determine preferences for patient portal use for HIV prevention and (2) test the associations between reported history of discussing HIV results and anticipated willingness to disclose web-based STI/HIV test results with most recent main and nonmain partners using patient portals. METHODS: Data come from audio-computer self-assisted interview survey data collected during the 3-month visit of a longitudinal cohort study. Univariate analysis assessed patient portal preferences by measuring the valuation rankings of several portal features. Multiple Poisson regression models with robust error variance determined the associations between history of discussing HIV results and willingness to disclose those results using web-based portals by partner type, and to examine criterion validity of the enhancing dyadic communication (EDC) scale to anticipated willingness. RESULTS: Of the 245 participants, 71% (n=174) were Black and 22% (n=53) were White. Most participants indicated a willingness to share web-based STI/HIV test results with their most recent main partner. Slightly fewer, nonetheless a majority, indicated a willingness to share web-based test results with their most recent nonmain partner. All but 2 patient portal features were valued as high or moderately high priority by >80% of participants. Specifically, tools to help manage HIV (n=183, 75%) and information about pre- and postexposure prophylaxis (both 71%, n=173 and n=175, respectively) were the top-valuated features to include in patient portals for HIV prevention. Discussing HIV test results was significantly associated with increased prevalence of willingness to disclose web-based test results with main (adjusted prevalence ratio [aPR] 1.46, 95% CI 1.21-1.75) and nonmain partners (aPR 1.54, 95% CI 1.23-1.93). CONCLUSIONS: Our findings indicate what features Black sexual minority men envision may be included in the patient portal's design to optimize HIV prevention, further supporting the criterion validity of the EDC scale. Efforts should be made to support Black sexual minority men's willingness to disclose STI/HIV testing history and status with partners overall as it is associated significantly with a willingness to disclose testing results digitally via patient portals. Future studies should consider discussion behaviors regarding past HIV test results with partners when tailoring interventions that leverage patient portals in disclosure events.

Enacted Sexual Minority Stigma, Psychological Distress, and Sexual and Drug Risk Behaviors Among Urban Men Who Have Sex with Men (MSM).

Urban Black men who have sex with men (MSM) bear a disproportionate burden of HIV and syphilis in the U.S. Experiences of enacted sexual minority stigma and psychological distress among these men may be associated with HIV/STI sexual and drug risk behaviors. The objective was to determine the associations between enacted sexual minority stigma, psychological distress, and sexual and drug risk behaviors. In an urban prospective cohort study, survey measures assessed past 3-month exposure to enacted sexual minority stigma, psychological distress, and sexual and drug risk behaviors. Multivariable logistic regression models were utilized for hypothesis testing. The Black MSM (N = 140) reported the following: 22.1% experiences of enacted sexual minority stigma, 39% high levels of psychological distress, 48.6% > 1 sex partner, 8.6% transactional sex, and 6% injection drug use (IDU). In models adjusted for age and education, enacted sexual minority stigma significantly increased the odds of reporting > 1 sex partner, transactional sex, and IDU. Adjusting additionally for homelessness, the association between enacted sexual minority stigma and transactional sex remained significant. Adding psychological distress to this model showed a significant association between psychological distress and transactional sex, while the association was no longer significant for transactional sex. These findings highlight some of the complex psycho-social relationships that may be associated with sexual and drug risk behaviors among Black MSM placing them at increased risk for HIV and syphilis.

RESUMEN: Hombres urbanos de raza Negra que tienen sexo con hombres (HSH) sobrellevan una carga desproporcionada de VIH y sífilis en los EE.UU. Experiencias de estigma efectivo de minoría sexual y angustia psicológica entre estos hombres pudiese ser asociado con conductas sexuales de riesgo VIH/ITS y drogas. El objetivo era determinar las asociaciones entre un estigma efectivo de minoría sexual, angustia psicológica, y comportamientos sexuales y de riesgo de drogas. En un estudio de cohortes prospectivo urbano, las medidas de la encuesta evaluada en los últimos tres meses de exposición al estigma efectivo, angustia psicológica, y sus conductas sexuales y comportamientos riesgoso de drogas. Modelos de regresión logística multivariante se utilizaron para la prueba de hipótesis. Los HSH de raza negra (N = 140) reportaron lo siguiente: 22.1% experiencias de estigma efectivo, 39% niveles altos de angustia psicológica, 48.6% y > 1 pareja sexual, 8.6% sexo transaccional, y 6% uso de drogas inyectables (UDI). En modelos ajustados a edad y educación, un estigma efectivo de minoría sexual aumentó de manera significante las probabilidades de reportar y > 1 pareja sexual, sexo transaccional, y UDI. Ajustando adicionalmente para personas sin vivienda, la asociación entre estigma efectivo de minoría sexual y sexo transaccional permaneció significante. La adición de angustia psicológica al modelo mostró una asociación significativa entre angustia psicológica y sexo transaccional, mientras que la asociación ya no era significativa para el sexo transaccional. Estos resultados destacan algunas de las complejas relaciones psicosociales que pudiesen estar asociadas con conductas sexuales y de riesgo de drogas entre HSH de raza negra, poniéndolos a mayor riesgo de contraer VIH y sífilis.

Improving Research Dissemination to Black Sexual Minority Men: Development of a Community-Led and Theory-Based Dissemination Plan.

Background. Although research dissemination to participants and community stakeholders is a fundamental component of translational research, it rarely occurs. The objective of this study was to create a community-led, theory-based dissemination plan to engage local Black sexual minority men in an active dissemination process throughout a sexual health research study. Method. Seven focus groups (N = 38) were conducted with Black, cisgender sexual minority men aged 18 to 45 years. Findings were analyzed through thematic content analysis guided by McGuire's persuasive communication theory. Findings were used to draft a dissemination plan, which was then reviewed and edited by the study's community advisory board (CAB). The plan continues to be updated in response to community needs through CAB discussions. Results. Participants preferred messages concerning syphilis and other health concerns as well as information on local resources. Preferred sources included researchers working with trusted community organizations and leaders. Preferred channels included community events and social media, implemented with consistency. CAB feedback included expanding the target audience of dissemination efforts as well as the development of ideas for channels (i.e., events) and sources (i.e., community organizations and leaders). Additional revisions occurred in response to the COVID-19 pandemic. Conclusion. Given the continued lack of research dissemination to participant and community stakeholders, the process of developing a community-led, theory-based dissemination plan may benefit and help guide researchers to adopt this practice. It is critical that participant and community stakeholder dissemination become more highly prioritized as we strive for public health improvements and the elimination of health disparities.

Factors Associated With Syphilis Transmission and Acquisition Among Men Who Have Sex With Men: Protocol for a Multisite Egocentric Network Study.

BACKGROUND: In the United States, the rates of primary and secondary syphilis have increased more rapidly among men who have sex with men (MSM) than among any other subpopulation. Rising syphilis rates among MSM reflect changes in both individual behaviors and the role of sexual networks (eg, persons linked directly or indirectly by sexual contact) in the spread of the infection. Decades of research examined how sexual networks influence sexually transmitted infections (STIs) among MSM; however, few longitudinal data sources focusing on syphilis have collected network characteristics. The Centers for Disease Control and Prevention, in collaboration with 3 sites, enrolled a prospective cohort of MSM in 3 US cities to longitudinally study sexual behaviors and STIs, including HIV, for up to 24 months. OBJECTIVE: The Network Epidemiology of Syphilis Transmission (NEST) study aimed to collect data on the factors related to syphilis transmission and acquisition among MSM. METHODS: The NEST study was a prospective cohort study that enrolled 748 MSM in Baltimore, Maryland; Chicago, Illinois; and Columbus, Ohio. NEST recruitment used a combination of convenience sampling, venue-based recruitment, and respondent-driven sampling approaches. At quarterly visits, participants completed a behavioral questionnaire and were tested for syphilis, HIV, gonorrhea, and chlamydia. The participants also provided a list of their sexual partners and described their 3 most recent partners in greater detail. RESULTS: The NEST participants were enrolled in the study from July 2018 to December 2021. At baseline, the mean age of the participants was 31.5 (SD 9.1) years. More than half (396/727. 54.5%) of the participants were non-Hispanic Black, 29.8% (217/727) were non-Hispanic White, and 8.8% (64/727) were Hispanic or Latino. Multiple recruitment strategies across the 3 study locations, including respondent-driven sampling, clinic referrals, flyers, and social media advertisements, strengthened NEST participation. Upon the completion of follow-up visits in March 2022, the mean number of visits per participant was 5.1 (SD 3.2; range 1-9) in Baltimore, 2.2 (SD 1.6; range 1-8) in Chicago, and 7.2 (SD 2.9; range 1-9) in Columbus. Using a community-based participatory research approach, site-specific staff were able to draw upon collaborations with local communities to address stigma concerning STIs, particularly syphilis, among potential NEST participants. Community-led efforts also provided a forum for staff to describe the NEST study objectives and plans for research dissemination to the target audience. Strategies to bolster data collection during the COVID-19 pandemic included telehealth visits (all sites) and adaptation to self-collection of STI specimens (Baltimore only). CONCLUSIONS: Data from NEST will be used to address important questions regarding individual and partnership-based sexual risk behaviors among MSM, with the goal of informing interventions to prevent syphilis in high-burden areas. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/40095.

Psychological distress and adherence to anti-retroviral therapy or pre-exposure prophylaxis regimens among Urban Black gay and bisexual men (MSM).

BACKGROUND: Urban Black gay, and bisexual men (MSM) bear a disproportionate burden of HIV in the U.S. Mental health is a barrier to adherence to both antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP). The objective was to determine the association between psychological distress and ART or PrEP adherence among urban Black MSM. METHODS: Using data from a four-year prospective cohort study, adherence to ART was defined as > 95% and PrEP was defined as > 80% of doses taken in the past 30 days. Psychological distress measures included difficulty sleeping; feeling anxious; suicidality; feeling sad or depressed; feeling sick, ill, or not well in the past 3 months; high (vs. low) overall psychological distress was classified as above the median value. Associations were examined using Chi-square, Fisher's exact tests, and logistic regression. RESULTS: Among 165 Black MSM, 44.2% (73) reported high psychological distress. 65.3% (47/72) of participants living with HIV and 39.8% (37/93) of HIV negative participants were ART or PrEP adherent, respectively. Education was significantly associated with PrEP adherence (p = 0.038). Non-injection drug use in the past 3 months (p = 0.008), difficulty sleeping (p = 0.010), feeling anxious (p = 0.003), and feeling sad or depressed (p < 0.001), and overall psychological distress (p < 0.001) were significantly associated with ART adherence. High psychological distress was significantly associated with a reduced odds of ART adherence (aOR 0.23; 95% CI = 0.08-0.70) adjusting for age and non-injection drug use. CONCLUSIONS: Increased psychological distress was significantly associated with ART nonadherence and may represent an important barrier to viral suppression.

Sexually Transmitted Infection Transmission Dynamics During the Coronavirus Disease 2019 (COVID-19) Pandemic Among Urban Gay, Bisexual, and Other Men Who Have Sex With Men.

BACKGROUND: The impact of coronavirus disease 2019 (COVID-19) mitigation measures on sexually transmitted infection (STI) transmission and racial disparities remains unknown. Our objectives were to compare sex and drug risk behaviors, access to sexual health services, and STI positivity overall and by race during the COVID-19 pandemic compared with pre-pandemic among urban sexual minority men (MSM). METHODS: Sexually active MSM aged 18-45 years were administered a behavioral survey and STI testing every 3-months. Participants who completed at least 1 during-pandemic (April 2020-December 2020) and 1 pre-pandemic study visit (before 13 March 2020) that occurred less than 6 months apart were included. Regression models were used to compare during- and pre-pandemic visit outcomes. RESULTS: Overall, among 231 MSM, reports of more than 3 sex partners declined(pandemic-1: adjusted prevalence ratio 0.68; 95% confidence interval: .54-.86; pandemic-2: 0.65, .51-.84; pandemic-3: 0.57, .43-.75), substance use decreased (pandemic-1: 0.75, .61-.75; pandemic-2: 0.62, .50-.78; pandemic-3: 0.61, .47-.80), and human immunodeficiency virus/preexposure prophylaxis care engagement (pandemic-1: 1.20, 1.07-1.34; pandemic-2: 1.24, 1.11-1.39; pandemic-3: 1.30, 1.16-1.47) increased. STI testing decreased (pandemic-1: 0.68, .57-.81; pandemic-2: 0.78, .67-.92), then rebounded (pandemic-3: 1.01, .87-1.18). Nei-ther Chlamydia (pandemic-2: 1.62, .75-3.46; pandemic-3: 1.13, .24-1.27) nor gonorrhea (pandemic-2: 0.87, .46 1.62; pandemic-3: 0.56, .24-1.27) positivity significantly changed during vs pre-pandemic. Trends were mostly similar among Black vs. non-Black MSM. CONCLUSIONS: We observed sustained decreases in STI risk behaviors but minimal change in STI positivity during compared with pre-pandemic. Our findings underscore the need for novel STI prevention strategies that can be delivered without in-person interactions.

HIV Transmission Potential and Sex Partner Concurrency: Evidence for Racial Disparities in HIV Risk Among Gay and Bisexual Men (MSM).

We determined whether racial disparities in HIV infection among gay and bisexual men (MSM) may be partially explained by racial differences in the HIV transmission potential (i.e. mixing of people living with HIV and people not living with HIV or of unknown HIV serostatus) and density (i.e. sex partner concurrency) of sexual networks. Data included a behavioral survey, testing for HIV, and an egocentric sexual network survey. Mixed effects logistic regressions were used for hypothesis testing. Black (vs. non-Black) MSM were more likely to not know their partner's HIV serostatus (21.8% vs. 9.6%). Similar proportions reported sex partner concurrency (67.1% vs. 68.0%). In adjusted analyses, among Black MSM, sex partner concurrency significantly increased the odds of an HIV transmission potential partnership (TPP), and this association was not significant among non-Black indexes. The association between an HIV TPP and sex partner concurrency may help explain persistent racial disparities in HIV prevalence.

RESUMEN: Determinamos si las disparidades raciales en infecciones del VIH entre hombres homosexuales y bisexuales (hombres que tienen sexo con hombres) puede ser parcialmente explicado por diferencias raciales en el potencial de transmisión del VIH (es decir, mezcla de personas viviendo con VIH y personas que no viven con VIH o cuyo estado serológico del VIH es desconocido) y densidad (es decir, concurrencia de pareja sexual) de redes sexuales. Los datos incluyeron una encuesta de comportamiento, pruebas para el VIH y una encuesta de redes sexuales egocéntrica. Regresiones logísticas de efectos mixtos fueron usados para la prueba de hipótesis. HSH negros (vs. HSH no-negros) eran más propensos a no saber el estado serológico del VIH de su pareja (21.8% vs. 9.6%). Proporciones similares reportaron concurrencia de pareja sexual (67.1% vs. 68.0%). En análisis ajustados, entre HSH negros, la concurrencia de pareja sexual aumentó significativamente las probabilidades de una asociación potencial de transmisión del VIH (TPP por sus siglas en inglés), y esta asociación no fue significativa entre índices de no-negros. La asociación entre una TPP VIH y concurrencia de pareja sexual puede ayudar a explicar disparidades raciales persistentes en la prevalencia del VIH.

Acceptability and Feasibility of Geographically Explicit Ecological Momentary Assessment Among Men Who Have Sex with Men.

Syphilis among men who have sex with men (MSM) has increased greatly in the past twenty years in the U.S. Geographically explicit ecological momentary assessment (GEMA), in which behaviors are geotagged and contextualized in time and space, may contribute to a greater understanding of transmission risk. The objective was to determine the acceptability and feasibility of GEMA for assessing HIV and syphilis transmission risk behaviors among a sample of MSM. Participants responded to a brief survey five times a day for two weeks. Feasibility was measured by participant recruitment, enrollment, prompts received and answered, geotagged prompts, and technical interference with data collection. Acceptability was measured by ratings of enjoyment and willingness for future participation. Summaries of five behavioral measures from the brief survey were calculated. Among the 83 participants contacted, 67.5% (56) expressed interest, 98% (55) were scheduled, and 81.8% (45) were enrolled. Participants answered 78.3% (2,277) of prompts received and 87.7% (1,998) of answered prompts were geotagged. Overall, 70.5% (31) enjoyed participating and 91.1% (41) were willing to participate in the future. Among prompts answered, missingness was low for five behavioral measures (range 0.2% (4) to 0.7% (16)). Feasibility and acceptability were high and missingness was low on behavioral measures in this MSM study population. Most participants reported that they would participate again. Future work should focus on whether GEMA improves our understanding of syphilis and HIV transmission risk.

Methamphetamine Use, Syphilis, and Specific Online Sex Partner Meeting Venues Are Associated With HIV Status Among Urban Black Gay and Bisexual Men Who Have Sex Men.

BACKGROUND: In the context of increasing syphilis rates, particularly among Black men who have sex men (MSM), the objectives were to determine the associations between methamphetamine (meth) use and syphilis and HIV positivity, and to identify sex partner meeting venues as potential intervention access points among Black MSM in a mid-Atlantic US city. METHODS: This study is an ongoing longitudinal cohort study. Participants were recruited from clinical and nonclinical settings and included sexually active MSM aged 18 to 45 years. The baseline visit included a behavioral survey and testing for syphilis, HIV, gonorrhea, and chlamydia. Logistic regression analyses were used for hypothesis testing. RESULTS: Among 359 MSM completing baseline, 74.4% (268) Black MSM were included; 31% (84) were aged 24 to 29 years, 43.7% (117) reported unprotected anal intercourse at last sex, and 15.3% (41) reported meth use in the past 3 months. Sixteen percent (43) had syphilis, 46.6% (125) were living with HIV, and 19.0% (51) had gonorrhea and/or chlamydia. Meth use was associated with sexual and drug risk behaviors and HIV, but not syphilis. In adjusted analyses, meth use increased the odds of HIV positivity by 6.43 (95% confidence interval, 2.30-17.98) and syphilis positivity by 2.57 (95% confidence interval, 1.23-5.37). Four online sex partner meeting venues were associated with meth use and HIV, whereas syphilis was associated with one. CONCLUSIONS: Among Black MSM, meth use and syphilis positivity were associated with more than 6-fold and almost 3-fold increased adjusted odds of HIV positivity, respectively. Four specific sex partner meeting venues may be important access points for HIV/sexually transmitted infection and substance use prevention.

Socioeconomic Factors Associated With an Intention to Work While Sick From COVID-19.

OBJECTIVE: We sought to understand barriers to staying home from work when sick from COVID-19 (COVID-19 presenteeism) to understand COVID-19 health disparities and transmission and guide workplace and social policy. METHODS: We used logistic regression models to assess which socioeconomic factors were associated with intended COVID-19 presenteeism among an online study population working outside their home in March 2020 (N = 220). RESULTS: Overall, 34.5% of participants reported intended COVID-19 presenteeism. Younger individuals and individuals making over $90,000 per year were less likely to report COVID-19 presenteeism. Individuals who were worried about having enough food had 3-fold higher odds of intended COVID-19 presenteeism. CONCLUSION: Current policies around food access, paid sick leave, and other workplace protections need to be expanded and made more accessible to reduce health disparities as well as the transmission of COVID-19 and other infections.

Recommendations From Black Sexual Minority Men: Building Trust to Improve Engagement and Impact of HIV/STI Research.

As demonstrated by the consistently documented disproportionately high rates of HIV and STIs (sexually transmitted infections) among Black sexual minority men (BSMM), current efforts to develop responsive interventions to reduce HIV and other STIs within this population have not been sufficient. It is therefore critical that public health researchers reflect meaningfully on the ways in which they investigate HIV and STIs. Engagement with BSMM is crucial in addressing the disproportionately high rates of HIV and STIs experienced, and thus the goal of the current research was to identify community-developed strategies that may enhance community engagement in research with BSMM. Seven focus groups (N = 38) were held with cisgender BSMM ages 18 to 45 years in Baltimore, Maryland to explore how to better engage this population and improve HIV and STI research. Data analysis of the text was conducted using an iterative, thematic constant comparison process informed by grounded theory. Four distinct themes related to trust-building within the broader community emerged: (1) authentic engagement with the community, (2) increased transparency of the research process, (3) capacity building of research staff from the community, and (4) a balance of research and action. Strategies for researchers to build community trust were identified that are related to, but slightly distinct from, common discussions in the community engaged research literature that are centered more specifically on trust-building within community-academic partnerships. Engagement with BSMM is crucial in addressing HIV and STI health disparities. It is critical that community engagement also be a priority to policy makers, research institutions, and funding institutions.

Overlapping Transmission Networks of Early Syphilis and/or Newly HIV Diagnosed Gay, Bisexual and Other Men Who Have Sex with Men (MSM): Opportunities for Optimizing Public Health Interventions.

Syphilis and HIV among gay, bisexual and other men who have sex with men (MSM) are syndemic suggesting current prevention strategies are not effective. Sex partner meeting places and their networks may yield effective and optimal interventions. From 2009 to 2017, 57 unique venues were reported by > 1 MSM and 7.0% (n = 4), 21.1% (n = 12) and 71.9% (n = 41) were classified as syphilis, HIV or co-diagnosed venues, respectively. Forty-nine venues were connected in one main network component with four online, co-diagnosis venues representing 51.6% of reports and the highest degree and eigenvector centralities. In a sub-analysis during a local syphilis epidemic, the proportion of venues connected in the main component increased 38.7% (61.5% to 86.4%); suggesting increasing overlap in syphilis and HIV transmission and density of the venue network structure over time. This network analysis may identify the optimal set of venues for tailored interventions. It also suggests increasing difficulty of interrupting network transmission through fragmentation.

Promoting Tuberculosis Preventive Therapy for People Living with HIV in South Africa: Interventions Hindered by Complicated Clinical Guidelines and Imbalanced Patient-Provider Dynamics.

Isoniazid preventive therapy (IPT) reduces the risk of active tuberculosis among people living with HIV, but implementation of IPT in South Africa and elsewhere remains slow. The objective of this study was to examine both nurse perceptions of clinical mentorship and patient perceptions of in-queue health education for promoting IPT uptake in Potchefstroom, South Africa. We measured adoption, fidelity, acceptability, and sustainability of the interventions using both quantitative and qualitative methods. Adoption, fidelity, and acceptability of the interventions were moderately high. However, nurses believed they could not sustain their increased prescriptions of IPT, and though many patients intended to ask nurses about IPT, few did. Most patients attributed their behavior to an imbalance of patient-provider power. National IPT guidelines should be unambiguous and easily implemented after minimal training on patient eligibility and appropriate medication durations, nurse-patient dynamics should empower the patient, and district-level support and monitoring should be implemented.

Formative research for an mHealth program to improve the HIV care continuum in South Africa.

In South Africa, high attrition rates throughout the care continuum present major barriers to controlling the HIV epidemic. Mobile health (mHealth) interventions may provide innovative opportunities for efficient healthcare delivery and improving retention in care. In this formative research, we interviewed 11 patients and 28 healthcare providers in North West Province, South Africa, to identify perceived benefits, concerns and suggestions for a future mHealth program to deliver HIV Viral Load and CD4 Count test results directly to patients via mobile phone. Thematic analysis found that reduced workload for providers, reduced wait times for patients, potential expanded uses and patient empowerment were the main perceived benefits of an mHealth program. Perceived concerns included privacy, disseminating distressing results through text messages and patients' inability to interpret results. Participants felt that an mHealth program should complement face-to-face interactions and educational information to interpret results is needed. Providers identified logistical considerations and suggested protocols be developed. An mHealth program to deliver HIV test results directly to patients could mitigate multiple barriers to care but needs to be tested for efficacy. Concerns identified by patients and providers must be addressed in designing the program to successfully integrate with health facility workflow and ensure its sustainability.

Human Immunodeficiency Virus Diagnosis After a Syphilis, Gonorrhea, or Repeat Diagnosis Among Males Including non-Men Who Have Sex With Men: What Is the Incidence?

BACKGROUND: The release of the first drug for human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) in 2012 marked the beginning of a new era of HIV prevention. Although PrEP is highly efficacious, identifying and ultimately increasing uptake among the highest risk male subgroups remains a challenge. METHODS: Public health surveillance data from 2009 to 2016 was used to evaluate the risk of an HIV diagnosis after a syphilis (ie, primary, secondary, or early latent), gonorrhea, and repeat diagnoses among urban males, including men who have sex with men (MSM) and non-MSM in Baltimore City. RESULTS: Of the 1531 males with 898 syphilis diagnoses and 1243 gonorrhea diagnoses, 6.8% (n = 104) were subsequently diagnosed with HIV. Within 2 years, 1 in 10 syphilis or gonorrhea diagnoses were followed by an HIV diagnosis among MSM, and 1 in 50 syphilis or gonorrhea diagnoses were followed by an HIV diagnosis among non-MSM. Among non-MSM with gonorrhea, the rate of HIV incidence was 5.36 (95% confidence interval, 2.37-12.14) times higher in those with (vs. without) a subsequent syphilis diagnosis or gonorrhea diagnosis. CONCLUSIONS: Local health care providers should offer PrEP to MSM diagnosed with syphilis or gonorrhea and to non-MSM with a previous gonorrhea diagnosis at time of a syphilis or gonorrhea diagnosis. The high proportion and short time to an HIV diagnosis among MSM after a syphilis or gonorrhea diagnosis suggest immediate PrEP initiation.

Are the London Declaration's 2020 goals sufficient to control Chagas disease?: Modeling scenarios for the Yucatan Peninsula.

BACKGROUND: The 2020 Sustainable Development goals call for 100% certified interruption or control of the three main forms of Chagas disease transmission in Latin America. However, how much will achieving these goals to varying degrees control Chagas disease; what is the potential impact of missing these goals and if they are achieved, what may be left? METHODS: We developed a compartmental simulation model that represents the triatomine, human host, and non-human host populations and vector-borne, congenital, and transfusional T. cruzi transmission between them in the domestic and peridomestic settings to evaluate the impact of limiting transmission in a 2,000 person virtual village in Yucatan, Mexico. RESULTS: Interruption of domestic vectorial transmission had the largest impact on T. cruzi transmission and prevalence in all populations. Most of the gains were achieved within the first few years. Controlling vectorial transmission resulted in a 46.1-83.0% relative reduction in the number of new acute Chagas cases for a 50-100% interruption in domestic vector-host contact. Only controlling congenital transmission led to a 2.4-8.1% (30-100% interruption) relative reduction in the total number of new acute cases and reducing only transfusional transmission led to a 0.1-0.3% (30-100% reduction). Stopping all three forms of transmission resulted in 0.5 total transmission events over five years (compared to 5.0 with no interruption); interrupting all forms by 30% resulted in 3.4 events over five years per 2,000 persons. CONCLUSIONS: While reducing domestic vectorial, congenital, and transfusional transmission can successfully reduce transmission to humans (up to 82% in one year), achieving the 2020 goals would still result in 0.5 new acute cases per 2,000 over five years. Even if the goals are missed, major gains can be achieved within the first few years. Interrupting transmission should be combined with other efforts such as a vaccine or improved access to care, especially for the population of already infected individuals.

A systems approach to vaccine decision making.

Vaccines reside in a complex multiscale system that includes biological, clinical, behavioral, social, operational, environmental, and economical relationships. Not accounting for these systems when making decisions about vaccines can result in changes that have little effect rather than solutions, lead to unsustainable solutions, miss indirect (e.g., secondary, tertiary, and beyond) effects, cause unintended consequences, and lead to wasted time, effort, and resources. Mathematical and computational modeling can help better understand and address complex systems by representing all or most of the components, relationships, and processes. Such models can serve as "virtual laboratories" to examine how a system operates and test the effects of different changes within the system. Here are ten lessons learned from using computational models to bring more of a systems approach to vaccine decision making: (i) traditional single measure approaches may overlook opportunities; (ii) there is complex interplay among many vaccine, population, and disease characteristics; (iii) accounting for perspective can identify synergies; (iv) the distribution system should not be overlooked; (v) target population choice can have secondary and tertiary effects; (vi) potentially overlooked characteristics can be important; (vii) characteristics of one vaccine can affect other vaccines; (viii) the broader impact of vaccines is complex; (ix) vaccine administration extends beyond the provider level; and (x) the value of vaccines is dynamic.