Ending HIV Transmission in Australia: Expanding PrEP to Cisgender Women: A Scoping Review.

Pre-exposure prophylaxis (PrEP) availability through the Pharmaceutical Benefits Scheme provides real potential for the elimination of HIV transmission in Australia, as evidenced by a rapid decline in HIV incidence among gay and bisexual men (GBM). However, HIV elimination will not be possible without also extending PrEP to other populations, including cisgender women. We conducted a scoping review to examine the extent to which PrEP access for cisgender women has been considered in Australia. A comprehensive search across five databases, grey literature, and hand search of references was conducted. A single reviewer conducted title and abstract screening and two reviewers completed full-text screening and data extraction. Nineteen documents were included in the final review and included both peer-reviewed journal articles and guidelines and strategies. Focused discussion of cisgender women's use of PrEP was largely missing from the literature and, although their use of PrEP is supported in some relevant guidelines, little has been done to actively develop strategies to inform cisgender women about PrEP as a precursor to prescribing for HIV prevention. Healthcare providers' narrow view of PrEP as being the domain of GBM further limits cisgender women's potential access. If HIV elimination in Australia is to be a reality, we need to develop mechanisms to specifically engage with cisgender women about PrEP.

In-person versus electronic screening for social risks among carers of pediatric inpatients: A mixed methods randomized trial.

We aimed to compare disclosure of social risks according to self-report on an iPad versus face-to-face questions from a health professional and to explore carers' experiences of screening. This two-arm, parallel group, randomized trial was conducted from January 19, 2021, to December 17, 2021, in a public hospital pediatric ward serving a disadvantaged area of an Australian capital city. Carers of children aged ≤ 5 years admitted to the Children's Ward were eligible. The primary outcome was disclosure of social risks. The screener included nine items on food security, household utilities, transport, employment, personal and neighborhood safety, social support, housing and homelessness. Disclosure of social risks was similar between the self-completion (n = 193) and assisted-completion (n = 193) groups for all 9 items, ranging 4.1% higher for worrying about money for food (95% CI - 11.4, 3.1%) among the assisted-completion group, to 5.7% (-1.6, 13.0%) higher for unemployment among the self-completion group. In qualitative interviews, participants were positive about screening for social risks in the hospital ward setting and the majority indicated a preference for self-completion.  Conclusion: Differences in the disclosure of social risks according to self- versus assisted-completion were small, suggesting that either method could be used. Most carers expressed a preference for self- completion, which is therefore recommended as the ideal mode for such data collection for Australian pediatric inpatient settings.  Trial registration: Australia New Zealand Clinical Trial Registry ( www.anzctry.org.au ; #ACTRN12620001326987; date of registration 8 December 2020). What is Known: • Most evidence on screening of social risks in pediatric inpatient settings is from the USA. • Little is known about disclosure of social risks in countries with universal health care and social welfare. What is New: • Disclosure of social risks was similar for electronic compared with face-to-face screening. • Carers preferred electronic completion over face-to-face completion.

Provider views of pre-exposure prophylaxis (PrEP) for cisgender women - where do women fit in HIV elimination in Australia?

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) in Australia has largely been targeted at gay, bisexual and other men who have sex with men. In the context of HIV elimination, the aim of this qualitative study was to explore PrEP prescribing for Australian cisgender women from the provider's perspective. METHODS: Semi-structured interviews were held with Australian prescribers in 2022. Participants were recruited through relevant clinical services, newsletter distribution and snowball sampling. Interviews were audio-recorded, transcribed and analysed thematically. RESULTS: Seventeen prescribers participated, of whom 9 were sexual health physicians and 10 worked in New South Wales. All reported limited clinical experience prescribing PrEP for women. Potential enablers to PrEP prescribing to women included education for women and clinicians, easily identifiable risk factors, individualised risk assessment and expansion of existing services. Barriers were limited PrEP awareness among women and prescribers, difficulties with risk assessment and consult and service limitations. The type of service recommended for PrEP provision varied among participants. CONCLUSIONS: Clinician experience of PrEP prescribing to Australian cisgender women is limited, with substantial barriers to access perceived by prescribers. Targeted education to PrEP prescribers, updated national PrEP guidelines to include women as a distinct group and further research regarding women's preferred model of PrEP access are required. Clarity of clinical ownership over PrEP implementation for women and, more broadly, women's sexual health, is essential in order to achieve HIV elimination in Australia.

Sexual health in a new cultural context: a resource for international students in regional Australia.

A large number of international students enrol in Australian higher education and contribute to Australia's multicultural population. Diverse cultural backgrounds and life experiences impact international students' knowledge of sexual health and healthy relationships. Along with unfamiliarity of the Australian healthcare system, this may place international students at risk of poor sexual health. We explored the sexual health priorities of international students with 12 male and 16 female international students aged between 18 and 49 years, for the development of a sexual health and relationship information resource for international students. Interviews were recorded, transcribed verbatim and coded thematically in Nvivo 12. Students noted that cultural norms about sex inhibited their ability to access information and they had concerns about their relationship behaviours within the Australian cultural context. Some participants noted challenges with accessing information and care and were enthusiastic about increasing international student access to reliable information and access to services. Based on the findings from these interviews, we developed a resource specifically for international students and evaluated its design and content through three focus group discussions with international students. This evaluation data informed refinements made to the resource. The resource Kit contains sexual health and relationship information and provides links to reputable online sexual health information. The Kit has been widely distributed to international students and is currently being further evaluated for use and acceptability.

Social capital and wellbeing among Australian adults' during the COVID-19 pandemic: a qualitative study.

BACKGROUND: COVID-19 has created global disruption, with governments across the world taking rapid action to limit the spread of the virus. Physical distancing and lockdowns abruptly changed living conditions for many, posing specific challenges of social isolation and lack of connectedness due to being physically and socially isolated from family and friends. Social capital is the bonding of individuals within a society that facilitates and shapes social interactions. The aim of this study was to qualitatively explore the impact that existing social capital has on Australians' experience of lockdowns during the COVID-19 pandemic and the effect this has had on their wellbeing and quality of life. METHODS: Participants from various socioeconomic areas within Australia were purposively selected to participate in semi-structured interviews conducted via videoconferencing or telephone. Inductive thematic analysis of the data was undertaken. RESULTS: A total of 20 participants were interviewed ranging in age from 21 to 65 years, including 50% (n = 10) females, 40% (n = 8) males, 5% (n = 1) non-binary and 5% (n = 1) transgender. Three main themes emerged from the analysis of the data: No person is an island; Social engagement; and Loneliness and isolation. Individuals who resided in low socioeconomic areas, those who lived alone and had reduced social support expressed feelings of poorer wellbeing. CONCLUSIONS: This study describes the lived-experiences of the influence of the COVID-19 pandemic on Australians' social capital and wellbeing. The findings highlight the need for interventions to increase social support, social cohesion, and social connectedness, especially among Australians from low socioeconomic areas, to enhance their overall wellbeing.

The impact of conditional cash transfers for HIV prevention on peer relationships: perspectives from female recipients and non-recipients in HPTN 068.

CCTs are currently being explored for HIV prevention among adolescent girls and young women (AGYW) in Southern Africa. However, little is known about how CCT geared towards adolescents' influence peer relationships, despite evidence that peer relationships form a critical part of development in adolescence. This article presents findings from a qualitative study that explored CCT recipients' and non-recipients' perspectives on the impact of CCTs paid to AGYW on peer relationships.HPTN 068 was a randomised controlled trial that assessed whether providing CCT to AGYW and their households reduces AGYW's risk of acquiring HIV. As part of this trial, we conducted interviews and focus group discussions with sub-samples of AGYW (n = 39), who were both cash recipients and non-recipients. Through content analysis, we explored ways in which the CCT positively or negatively impacted on peer relationships.From the recipients' viewpoint, the CCT improved their social standing within their peer groups. It facilitated peer identity and promoted social connectedness among AGYW receiving the CCT. Receipt of the CCT enabled AGYW to resemble and behave like their peers who had money, allowing their poverty to become "invisible". The CCT facilitated social interactions, information sharing, and instrumental social support among AGYW. CCT recipients experienced an increase in their social capital, evident in their ability to network, share, and reciprocate with others. However, the CCT also evoked negative emotions such as jealousy, anxiety, and resentment among non-recipients and led to a deterioration of personal relationships.CCTs have enormous benefits for AGYW, but they may also have a negative impact on peer relationships. The implementation of HIV prevention interventions focused on structural drivers needs to be conscious of these dynamics and ensure that the negative consequences do not outweigh benefits.

Food pedagogy-key elements for urban health and sustainability: A scoping review.

Food-related issues are on the rise in urban areas around the world. Issues include unhealthy food habits and eating practices, disconnection from food and culture, social isolation and environmental unsustainability. There has been increasing consideration of pedagogical approaches, or food pedagogies, to address these challenges. This paper aims to identify the key elements and influences over food-related activities within food pedagogies that strive to improve urban health and sustainability. A scoping literature review was conducted using five electronic databases. Of the 271 abstracts identified, thirty-five articles met the inclusion criteria. The review identified four key elements: 'Everyday food experiences', 'Social relations', 'Culture', and 'Sustainable lifestyles' and two main influences: 'Professionals involved with food-related activities' and 'Spaces of learning/experiencing food-related activities'. The key elements and influences embrace pedagogical and practical attributes of food pedagogies that address the complex food-related issues. However, limited published research examines food pedagogies or attempts to develop an agreed, theoretically informed framework. This review provides understanding of important knowledge and practical implications of food pedagogies for multiple stakeholders involved in food-related activities, useful to the development of food education programs and food policies or initiatives for societal health and sustainability in urban areas.

"The sky is the limit; I am going there": experiences of hope among young women receiving a conditional cash transfer in rural South Africa.

Young women in South Africa face elevated risk of HIV infection compared to male peers. Cash transfers may mitigate their risk for HIV; however, there is limited understanding of mechanisms of impact. We explored hope as one potential mechanism. Longitudinal qualitative analysis was used to explore how cash transfer recipients in the HPTN 068 study conceptualised hope and how the intervention influenced their hope over time. We found the intervention increased confidence, alleviated financial stressors and instilled in young women the belief that a better life, defined as being educated, independent and supportive to family, was attainable. Findings support hope as a critical outcome of cash transfer and other economic strengthening interventions.

Association between economic wellbeing and ethnicity, socioeconomic status, and remoteness during the COVID-19 pandemic.

OBJECTIVE: The aim of this study is to explore the association between economic wellbeing and ethnicity, socioeconomic status, and remoteness during the COVID-19 pandemic. DESIGN: A cross-sectional study via SurveyMonkey was conducted in Australia between August 2020 and October 2020. Descriptive and inferential statistics were used to analyze the data. RESULTS: A total of 1211 individuals responded to the survey. Income loss was significantly associated with those from low socioeconomic status (OR = 1.65; 95% CI 1.01-2.68). Access of superannuation was significantly associated with those in outer regional (OR = 3.61; 95% CI 0.81-16.03) and low socioeconomic status (OR = 2.72; 95% CI 1.34-5.53). Financial inability to pay for services was significantly associated with living in remote areas (OR = 2.26; 95% CI 0.88-5.80). CONCLUSIONS: The economic wellbeing of people who identify as Aboriginal and Torres Strait Islander, live in regional or remote areas, and reside in low socioeconomic areas have been substantially impacted during the pandemic. Findings call for policies to address the underlying social determinants of health.

The social determinants of health and health outcomes among adults during the COVID-19 pandemic: A systematic review.

OBJECTIVE: To synthesize the best available evidence on the relationship between the social determinants of health and health outcomes among adults during the COVID-19 pandemic. INTRODUCTION: COVID-19 has created widespread global transmission. Rapid increase in individuals infected with COVID-19 prompted significant public health responses from governments globally. However, the social and economic impact on communities may leave some individuals more susceptible to the detrimental effects. METHODS: A three-step search strategy was used to find published and unpublished papers. Databases searched included: MEDLINE, CINAHL, EMBASE, and Google Scholar. All identified citations were uploaded into Endnote X9, with duplicates removed. Methodological quality of eligible papers was assessed by two reviewers, with meta-synthesis conducted in accordance with JBI methodology. RESULTS: Fifteen papers were included. Three synthesized-conclusions were established (a) Vulnerable populations groups, particularly those from a racial minority and those with low incomes, are more susceptible and have been disproportionately affected by COVID-19 including mortality; (b) Gender inequalities and family violence have been exacerbated by COVID-19, leading to diminished wellbeing among women; and (c) COVID-19 is exacerbating existing social determinants of health through loss of employment/income, disparities in social class leading to lack of access to health care, housing instability, homelessness, and difficulties in physical distancing. CONCLUSION: Reflection on social and health policies implemented are necessary to ensure that the COVID-19 pandemic does not exacerbate health inequalities into the future.

Perceptions of Aboriginal and Torres Strait Islander Australians toward cardiovascular primary prevention programs: A qualitative systematic review.

OBJECTIVE: To synthesize the best available qualitative evidence on the perceptions of Aboriginal and Torres Strait Islander Australians (hereafter, respectfully referred to as Indigenous Australians) toward participation in cardiovascular primary prevention programs. BACKGROUND: In 2017, cardiovascular disease was the leading cause of premature mortality in Indigenous Australians, accounting for 11.5% of all deaths. Health risk behaviors such as smoking, physical inactivity, poor nutrition, and obesity largely contribute to this burden of disease. METHODS: A search using MEDLINE, CINAHL, EMBASE, PubMed, Google Scholar, MedNar, ProQuest and Index to Theses for published and unpublished studies was conducted in January 2020. The methodological quality of the included studies was independently assessed by two reviewers using the Joanna Briggs Institute (JBI) critical appraisal tool. Data extraction and meta-aggregation were conducted in accordance with JBI methodology. RESULTS: Eleven studies were included. Three synthesized findings were developed (a) social and community support affect participants' experiences of prevention programs; (b) structural drivers and social determinants influence Indigenous Australians experiences and participation in prevention programs and health risk behavioral change; and (c) a personal desire to change behaviors and participate in prevention programs requires development of knowledge regarding healthy lifestyles and creation of new social norms. CONCLUSIONS: Indigenous Australians participation in primary prevention for cardiovascular risk factors and adoption of a healthy lifestyle are influenced by social support, social determinants, and personal desire. Future programs need to tackle the structural drivers and facilitate a supportive environment to assist in health risk behavior change.

Depression and Incident HIV in Adolescent Girls and Young Women in HIV Prevention Trials Network 068: Targets for Prevention and Mediating Factors.

The human immunodeficiency virus (HIV) epidemic among adolescent girls and young women (AGYW) in sub-Saharan Africa is a critical public health problem. We assessed whether depressive symptoms in AGYW were longitudinally associated with incident HIV, and identified potential social and behavioral mediators. Data came from a randomized trial of a cash transfer conditional on school attendance among AGYW (ages 13-21 years) in rural Mpumalanga Province, South Africa, during 2011-2017. We estimated the relationship between depressive symptoms and cumulative HIV incidence using a linear probability model, and we assessed mediation using inverse odds ratio weighting. Inference was calculated using the nonparametric bootstrap. AGYW with depressive symptoms had higher cumulative incidence of HIV compared with those without (risk difference = 3.5, 95% confidence interval (CI): 0.1, 7.0). The strongest individual mediators of this association were parental monitoring and involvement (indirect effect = 1.6, 95% CI: 0.0, 3.3) and reporting a partner would hit her if she asked him to wear a condom (indirect effect = 1.5, 95% CI: -0.3, 3.3). All mediators jointly explained two-thirds (indirect effect = 2.4, 95% CI: 0.2, 4.5) of the association between depressive symptoms and HIV incidence. Interventions addressing mental health might reduce risk of acquiring HIV among AGYW.

Self-Esteem as an Indicator of Transactional Sex Among Young Women in Rural South Africa (HPTN 068).

Transactional sex (TS) has been shown to contribute to the HIV epidemic in sub-Saharan Africa. Previous research has yet to identify psychosocial factors that make young women vulnerable to engaging in TS. This analysis examined the association between self-esteem and TS among young women in rural South Africa. A post hoc analysis of post-intervention survey data from HPTN 068 was conducted. Log-binomial regression was used to compute a prevalence ratio measure of association. Among 1942 young women, the prevalence of TS among those with lower self-esteem was 4.7 times the prevalence of TS among those with higher self-esteem (p < 0.001). Findings provide support for the association between lower self-esteem and TS in this context and may inform intervention development.

Fostering gender equality and alternatives to violence: perspectives on a gender-transformative community mobilisation programme in rural South Africa.

Gender-based violence and violence against children are significant problems in South Africa. Community mobilisation and gender-transformative programming are promising approaches to address and reduce violence. A quantitative evaluation of One Man Can, a gender-transformative community mobilisation programme in South Africa, found mixed results in increasing gender-equitable behaviours and reducing violence. To better understand these findings, we analyse longitudinal qualitative data from community mobilisers, community members and community action teams, exploring individual and community-level factors that facilitate and hinder change. Interviews and focus groups were transcribed and analysed. Participants self-reported changes in their gender-equitable attitudes and use of violence as a result of participation in the programme, although some participants also reported opposition to shifting to a more gender-equitable culture. Facilitators to change included the internalisation of gender-transformative messaging and supportive social networks, which was buoyed by a shared vocabulary in their community generated by One Man Can. Because the programme targeted a critical mass of community members with gender-transformative programming, mobilisers and community action teams were held accountable by community members to model non-violent behaviour. Results reinforce the importance of addressing facilitators and barriers to change at both individual and community levels.

The effects of a cash transfer intervention on sexual partnerships and HIV in the HPTN 068 study in South Africa.

Evidence on cash transfer interventions for HIV prevention in adolescent girls and young women is unclear and indicates that they may not work uniformly in all settings. Qualitative interviews were conducted with 22 girls and young women post-intervention to determine how a cash transfer study (HPTN 068) in South Africa was perceived to influence sexual behaviours and to explore mechanisms for these changes. Participants described how the intervention motivated them to increase condom use, have fewer partners, end risky relationships and access HIV testing services at local primary health clinics. Changes were attributed to receipt of the cash transfer, in addition to HIV testing and sexual health information. Processes of change included improved communication with partners and increased negotiation power in sexual decision-making. Economic empowerment interventions increase confidence in negotiating behaviours with sexual partners and are complementary to sexual health information and health services that provide young women with a foundation on which to make informed decisions about how to protect themselves.

Characteristics Associated With Human Immunodeficiency Virus Transmission Networks Involving Adolescent Girls and Young Women in Human Immunodeficiency Virus Prevention Trials Network 068 Study.

We combined behavioral survey data from the human immunodeficiency virus (HIV) Prevention Trials Network 068 study with phylogenetic information to determine if cluster membership was associated with characteristics of young women and their partners. Clusters were more likely to involve young women from specific villages and schools, indicating some localized transmission.Supplemental digital content is available in the text.

Friendships Among Young South African Women, Sexual Behaviours and Connections to Sexual Partners (HPTN 068).

Friends could be influential on young women's sexual health via influences on sexual behaviours and as connections to sexual partners, but are understudied in sub-Saharan Africa. We cross-sectionally surveyed 2326 13-20 year-old young women eligible for grades 8-11 in rural South Africa about their sexual behaviour and up to three sexual partners. Participants each described five specific but unidentified friends and the relationships between them in an 'egocentric' network analysis design. We used logistic regression to investigate associations between friendship characteristics and participants' reports of ever having had sex (n = 2326) and recent condom use (n = 457). We used linear regression with random effects by participant to investigate friendship characteristics and age differences with sexual partners (n = 633 participants, 1051 partners). We found that it was common for friends to introduce young women to those who later became sexual partners, and having older friends was associated with having older sexual partners, (increase of 0.37 years per friend at least 1 year older, 95% CI 0.21-0.52, adjusted). Young women were more likely to report ever having had sex when more friends were perceived to be sexually active (adjusted OR 1.85, 95% CI 1.72-2.01 per friend) and when they discussed sex, condoms and HIV with friends. Perception of friends' condom use was not associated with participants' reported condom use. While this study is preliminary and unique in this population and further research should be conducted, social connections between friends and sexual partners and perceptions of friend sexual behaviours could be considered in the design of sexual health interventions for young women in South Africa.

Cash Transfers, Young Women's Economic Well-Being, and HIV Risk: Evidence from HPTN 068.

Despite the large interest in economic interventions to reduce HIV risk, little research has been done to show whether there are economic gains of these interventions for younger women and what intermediary role economic resources play in changing participants' sexual behavior. This paper contributes to this gap by examining the impacts of a conditional cash transfer (CCT) for young women in South Africa on young women's economic resources and the extent to which they play a role in young women's health and behavior. We used data from HIV Prevention Trials Network 068 study, which provided transfers to young women (in addition to their parents) conditional on the young woman attending at least 80% of school days in the previous month. We found that the CCT increased young women's economic wellbeing in terms of having savings, spending money, being unindebted, and food secure. We also investigated heterogeneous effects of the program by household economic status at baseline because the program was not specifically poverty targeted and found that the results were driven by young women from the poorest families. From these results, we examined heterogeneity by baseline poverty for other outcomes related to HIV risk including sexual behavior and psychosocial well-being. We found psychosocial well-being benefits in young women from the poorest families and that economic wellbeing gains explained much these impacts.

Hope, the Household Environment, and Sexual Risk Behaviors Among Young Women in Rural South Africa (HPTN 068).

We assessed the psychological trait of hope as an explanatory mediator in the relationship between the home environment and sexual risk behaviors among 2533 young women in rural South Africa. Hope mediated the relationship between average household age and sexual debut (mediated effect = - 0.003, p < 0.05), and between household consumption and sexual debut (mediated effect = - 0.019, p < 0.05). Both higher average household age (ß = 0.01; 95% CI 0.00, 0.01) and greater household consumption (ß = 0.05; 95% CI 0.02, 0.08) were marginally associated with higher hope. In turn, greater hope was associated with lower odds of sexual debut (aOR = 0.62; 95% CI 0.52, 0.74). These results provide important preliminary evidence of the role of the home environment in shaping protective psychological assets and healthy sexual behaviors. Continued exploration of the relationship between hope and the home environment may help to explain why young women in this context have a disproportionate risk for HIV.

Gender Norms, Gender Role Conflict/Stress and HIV Risk Behaviors Among Men in Mpumalanga, South Africa.

Men's gender role conflict and stress (GRC/S), the psychological strain they experience around fulfilling expectations of themselves as men, has been largely unexplored in HIV prevention research. We examined associations between both men's gender norms and GRC/S and three HIV risk behaviors using data from a population-based survey of 579 18-35 year-old men in rural northeast South Africa. Prevalence of sexual partner concurrency and intimate partner violence (IPV) perpetration in the last 12 months were 38.0 and 13.4%, respectively; 19.9% abused alcohol. More inequitable gender norms and higher GRC/S were each significantly associated with an increased odds of concurrency (p = 0.01; p < 0.01, respectively), IPV perpetration (p = 0.03; p < 0.01), and alcohol abuse (p = 0.02; p < 0.001), controlling for demographic characteristics. Ancillary analyses demonstrated significant positive associations between: concurrency and the GRC/S sub-dimension subordination to women; IPV perpetration and restrictive emotionality; and alcohol abuse and success, power, competition. Programs to transform gender norms should be coupled with effective strategies to prevent and reduce men's GRC/S.