Poliovirus outbreak in New York State, August 2022: qualitative assessment of immediate public health responses and priorities for improving vaccine coverage.

In 2022, a case of paralysis was reported in an unvaccinated adult in Rockland County (RC), New York. Genetically linked detections of vaccine-derived poliovirus type 2 (VDPV2) were reported in multiple New York counties, England, Israel, and Canada. The aims of this qualitative study were to: i) review immediate public health responses in New York to assess the challenges in addressing gaps in vaccination coverage; ii) inform a longer-term strategy to improving vaccination coverage in under-vaccinated communities, and iii) collect data to support comparative evaluations of transnational poliovirus outbreaks. Twenty-three semi-structured interviews were conducted with public health professionals, healthcare professionals, and community partners. Results indicate that i) addressing suboptimal vaccination coverage in RC remains a significant challenge after recent disease outbreaks; ii) the poliovirus outbreak was not unexpected and effort should be invested to engage mothers, the key decision-makers on childhood vaccination; iii) healthcare providers (especially paediatricians) received technical support during the outbreak, and may require resources and guidance to effectively contribute to longer-term vaccine engagement strategies; vi) data systems strengthening is required to help track under-vaccinated children. Public health departments should prioritize long-term investments in appropriate communication strategies, countering misinformation, and promoting the importance of the routine immunization schedule.

Operationalizing the Centers for Disease Control and Prevention's Vaccinate With Confidence Framework During the COVID-19 Emergency Response in the United States.

In December 2020, 11 months after identifying the first laboratory-confirmed case of COVID-19 in the United States, the U.S. Food and Drug Administration authorized emergency use of two COVID-19 vaccines. To prepare the public for a large-scale vaccination campaign and build confidence in COVID-19 vaccines, the U.S. Centers for Disease Control and Prevention (CDC) funded more than 200 partners and developed a national Vaccinate with Confidence (VwC) COVID-19 framework to support Americans in their decision to get vaccinated. The evolving nature of the pandemic and highly variable confidence in vaccines across populations has resulted in many unique complexities and challenges to reaching universally high vaccination coverage. Here, we describe how 23 professional health associations and national partner organizations, focused solely on building vaccine confidence, operationalized CDC's VwC COVID-19 framework from February 2021 to March 2022. Capturing how partners deployed and adapted their activities to meet a shifting pandemic landscape, which began with high demand for vaccines that waned over time, is an important first step to understanding how this new strategy was utilized and could be implemented for future surges in COVID-19 cases and other routine immunization efforts. Going forward, evaluation of partner activities should be prioritized to capture learnings and assess VwC program effectiveness.

Effectiveness of HIV Stigma Interventions for Men who have Sex with Men (MSM) With and Without HIV in the United States: A Systematic Review and Meta-Analyses.

Stigma may contribute to HIV disparities for men who have sex with men (MSM). This systematic review quantified the effects of HIV stigma interventions for MSM on stigma and sex risk. We conducted a systematic search to identify US-based studies published between 2000 and June 2019 focused on HIV and MSM, and either measured stigma pre-post or included a stigma intervention component. Twenty-nine articles, representing 26 unique studies met inclusion criteria. Random effect models showed no intervention effect for reducing stigma and a non-significant increase in HIV testing. Significant decreases in condomless sex with males, condomless sex with females, and substance-influenced sex were found. Few intervention studies measured stigma pre-post. Findings suggest that including a stigma reduction component in interventions can improve HIV testing and reduce sex risk for MSM. Developing interventions to address stigma may be important in decreasing HIV infection among MSM and ending the HIV epidemic.

Patterns in COVID-19 Vaccination Coverage, by Social Vulnerability and Urbanicity - United States, December 14, 2020-May 1, 2021.

Disparities in vaccination coverage by social vulnerability, defined as social and structural factors associated with adverse health outcomes, were noted during the first 2.5 months of the U.S. COVID-19 vaccination campaign, which began during mid-December 2020 (1). As vaccine eligibility and availability continue to expand, assuring equitable coverage for disproportionately affected communities remains a priority. CDC examined COVID-19 vaccine administration and 2018 CDC social vulnerability index (SVI) data to ascertain whether inequities in COVID-19 vaccination coverage with respect to county-level SVI have persisted, overall and by urbanicity. Vaccination coverage was defined as the number of persons aged ≥18 years (adults) who had received ≥1 dose of any Food and Drug Administration (FDA)-authorized COVID-19 vaccine divided by the total adult population in a specified SVI category.† SVI was examined overall and by its four themes (socioeconomic status, household composition and disability, racial/ethnic minority status and language, and housing type and transportation). Counties were categorized into SVI quartiles, in which quartile 1 (Q1) represented the lowest level of vulnerability and quartile 4 (Q4), the highest. Trends in vaccination coverage were assessed by SVI quartile and urbanicity, which was categorized as large central metropolitan, large fringe metropolitan (areas surrounding large cities, e.g., suburban), medium and small metropolitan, and nonmetropolitan counties.§ During December 14, 2020-May 1, 2021, disparities in vaccination coverage by SVI increased, especially in large fringe metropolitan (e.g., suburban) and nonmetropolitan counties. By May 1, 2021, vaccination coverage was lower among adults living in counties with the highest overall SVI; differences were most pronounced in large fringe metropolitan (Q4 coverage = 45.0% versus Q1 coverage = 61.7%) and nonmetropolitan (Q4 = 40.6% versus Q1 = 52.9%) counties. Vaccination coverage disparities were largest for two SVI themes: socioeconomic status (Q4 = 44.3% versus Q1 = 61.0%) and household composition and disability (Q4 = 42.0% versus Q1 = 60.1%). Outreach efforts, including expanding public health messaging tailored to local populations and increasing vaccination access, could help increase vaccination coverage in high-SVI counties.

Observed reactions among patients attending HIV treatment facilities to a brief video intervention on treatment initiation and adherence.

Entertainment-education can affect positive behavior change. Taking Care of Me is an effective, video-based intervention designed to improve patients' continuum of HIV care outcomes. The study's aim was to refine the pre-final video at points where patients stopped watching and missed embedded health messages. We evaluated the video using systematic unobtrusive observations triangulated with electronic medical record (EMR) data. We conducted observations in three HIV treatment facilities' waiting rooms in the southern US in 2016. Using a web-based data collection instrument, one observer spent 8 h at each facility observing patients' engagement with the video. We mapped the embedded messages in each scene and identified the messages that patients missed when they stopped watching. We compared missed messages to treatment initiation, medication adherence, and retention in care data abstracted from each clinic's EMR system. We were able to identify specific scenes where low levels of engagement corresponded to lower than expected retention in care outcomes and edit these scenes to improve engagement. Identifying and editing video scenes to increase viewership potentially could enhance intervention efficacy. Our methods could be used to assess and refine other video-based interventions being developed in resource limited settings.

Improving the HIV Prevention Landscape to Reduce Disparities for Black MSM in the South.

Black men who have sex with men (MSM) in the South have the highest rates of HIV diagnosis in the country adding to the persistent racial disparities in HIV experienced by this population. The current HIV prevention and care landscape is heavily driven by individual-level clinical and biomedical approaches that have shown progress in reducing HIV diagnoses, but yield less than adequate results in reducing the HIV racial disparities for Black MSM in the South. In efforts to enhance focus on reducing the racial HIV disparities and more completely address the needs of Black MSM in the South, we offer insight on comprehensive approaches that can complement our current HIV prevention and care portfolio. There are five domains we discuss which include: (1) leveraging and integrating resources; (2) building upon existing program models designed to reduce disparities; (3) workforce development and cultural sensitivity; (4) social determinants of health data utilization; and 5) policy considerations. We urge public health practitioners and healthcare providers to consider and incorporate the outlined approaches to improve HIV outcomes along the continuum of care and ultimately reduce disparities in HIV affecting the quality of life of Black MSM living in the South.

Improving Linkage, Retention, and Reengagement in HIV Care in 12 Metropolitan Areas.

The Centers for Disease Control and Prevention developed the Enhanced Comprehensive HIV Prevention Planning (ECHPP) project to support 12 health departments' improvement of their HIV prevention and care portfolios in response to new national guidelines. We systematically analyzed 3 years of progress reports to learn how grantees put into practice local intervention strategies intended to link people to, and keep them in, HIV care. All grantees initiated seven activities to support these strategies: (1) improve surveillance data systems, (2) revise staffing duties and infrastructures, (3) update policies and procedures, (4) establish or strengthen partnerships, (5) identify persons not in care, (6) train personnel, and (7) create ways to overcome obstacles to receiving care. Factors supporting ECHPP grantee successes were thorough planning, attention to detail, and strong collaboration among health department units, and between the health department and external stakeholders. Other jurisdictions may consider adopting similar strategies when planning and enhancing HIV linkage, retention, and reengagement efforts in their areas. ECHPP experiences, lessons learned, and best practices may be relevant when applying new public health policies that affect community and health care practices jurisdiction-wide.

Internalised homophobia is differentially associated with sexual risk behaviour by race/ethnicity and HIV serostatus among substance-using men who have sex with men in the United States.

OBJECTIVES: There is a continuing need to identify factors associated with risk for HIV transmission among men who have sex with men (MSM), including a need for further research in the ongoing scientific debate about the association of internalised homophobia and sexual risk due partly to the lack of specificity in analysis. We assess the association of internalised homophobia by race/ethnicity within HIV serostatus for a large sample of substance-using MSM at high risk of HIV acquisition or transmission. METHODS: Convenience sample of substance-using (non-injection) MSM reporting unprotected anal sex in the prior 6 months residing in Chicago, Los Angeles, New York and San Francisco. The analytic sample included HIV-negative and HIV-positive black (n=391), Latino (n=220), and white (n=458) MSM. Internalised homophobia was assessed using a published four-item scale focusing on negative self-perceptions and feelings of their own sexual behaviour with men, or for being gay or bisexual. Analyses tested associations of internalised homophobia with recent risk behaviour, stratified by laboratory-confirmed HIV serostatus within race/ethnicity, and controlling for other demographic variables. RESULTS: In multivariate analysis, internalised homophobia was inversely associated (p<0.05) with recent unprotected anal sex among black MSM, and not significantly associated with sexual risk behaviour among white and Latino MSM. CONCLUSIONS: More research is needed to further identify nuanced differences in subpopulations of MSM, but these results suggest differentially targeted intervention messages for MSM by race/ethnicity.

Correlates of Seroadaptation Strategies Among Black Men Who have Sex with Men (MSM) in 4 US Cities.

We assessed associations of demographic, psychosocial, and substance use factors with seroadaptation strategies among 835 BMSM in four US cities. Seroadaptation strategies were practiced by 59.8 % of men, with 10.5 % practicing 100 % condom use, 26.5 % serosorting, 7.2 % condom serosorting, and 15.6 % seropositioning. In multivariable analyses, compared to men who used no seroadaptation strategies, serosorters were older, were less likely to be HIV infected, had fewer male sex partners, and had higher levels of social support and sexual self-efficacy. Condom serosorters had less psychological distress, were more likely to use methamphetamine, and had higher levels of sexual self-efficacy. Seropositioners were older, were less likely to be HIV infected, to have a main partner, and report alcohol/drug use with sex, while having higher levels of sexual self-efficacy. Seroadaptation practices among BMSM need to be considered to address perceived safer sex strategies and strengthen access to a broader reach of culturally-relevant prevention efforts.

Using High-Impact HIV Prevention to Achieve the National HIV/AIDS Strategic Goals in Miami-Dade County, Florida: A Case Study.

: In response to the release of the National HIV/AIDS Strategy, the Centers for Disease Control and Prevention developed the "Enhanced Comprehensive HIV Prevention Planning" project, which provided support to health departments in 12 Metropolitan Statistical Areas with the highest AIDS prevalence to strengthen local HIV programs. We describe a case study of how 1 Metropolitan Statistical Area, Miami-Dade County, developed and implemented a locally tailored plan. Examples include actions to reinforce local partnerships and identify neighborhoods with highest unmet needs, an improved condom distribution system to assist local HIV care providers, collaboration with local stakeholders to establish a new walk-in center for transgender client needs, and overcoming incompatibilities in health department and Ryan White Program computer record systems to facilitate faster and more efficient patient services. These examples show how jurisdictions both within Florida and elsewhere can create low-cost and sustainable activities tailored to improve local HIV prevention needs.

HIV testing among sexually active Hispanic/Latino MSM in Miami-Dade County and New York City: opportunities for increasing acceptance and frequency of testing.

HIV testing behavior is important in understanding the high rates of undiagnosed infection among Hispanic/Latino men who have sex with men (MSM). Correlates of repeat/recent testing (within the past year and ≥5 tests during lifetime) and test avoidance (never or >5 years earlier) were examined among 608 sexually active Hispanic/Latino MSM (Miami-Dade County and New York City). Those who reported repeat/recent testing were more likely to have incomes over $30,000, speak English predominately, and have visited and disclosed same-sex behavior to a health care provider (HCP) in the past year. Those who were classified as test avoiders were less likely to have incomes over $10,000 and to have seen an HCP in the past year. The main reason for not testing (in both groups) was fear of HIV positivity; however, twice as many test avoiders considered this their main reason, and more test avoiders had confidentiality concerns. Results suggest that messages to encourage testing among Hispanic/Latino MSM may be most effective if past testing patterns and reasons for not testing are considered. HCPs can play an important role by consistently offering HIV tests to MSM and tailoring messages based on prior testing histories.

Strengthening COVID-19 vaccine confidence & demand during the US COVID-19 emergency response.

In October 2020, the CDC's Vaccinate with Confidence strategy specific to COVID-19 vaccines rollout was published. Adapted from an existing vaccine confidence framework for childhood immunization, the Vaccinate with Confidence strategy for COVID-19 aimed to improve vaccine confidence, demand, and uptake of COVID-19 vaccines in the US. The objectives for COVID-19 were to 1. build trust, 2. empower healthcare personnel, and 3. engage communities and individuals. This strategy was implemented through a dedicated unit, the Vaccine Confidence and Demand (VCD) team, which collected behavioral insights; developed and disseminated toolkits and best practices in collaboration with partners; and collaborated with health departments and community-based organizations to engage communities and individuals in behavioral interventions to strengthen vaccine demand and increase COVID-19 vaccine uptake. The VCD team collected and used social and behavioral data through establishing the Insights Unit, implementing rapid community assessments, and conducting national surveys. To strengthen capacity at state and local levels, the VCD utilized "Bootcamps," a rapid training of trainers on vaccine confidence and demand, "Confidence Consults", where local leaders could request tailored advice to address local vaccine confidence challenges from subject matter experts, and utilized surge staffing to embed "Vaccine Demand Strategists" in state and local public health agencies. In addition, collaborations with Prevention Research Centers, the Institute of Museum and Library Services, and the American Psychological Association furthered work in behavioral science, community engagement, and health equity. The VCD team operationalized CDC's COVID-19 Vaccine with Confidence strategy through behavioral insights, capacity building opportunities, and collaborations to improve COVID-19 vaccine confidence, demand, and uptake in the US. The inclusion of applied behavioral science approaches were a critical component of the COVID-19 vaccination program and provides lessons learned for how behavioral science can be integrated in future emergency responses.

Common roots: a contextual review of HIV epidemics in black men who have sex with men across the African diaspora.

Pooled estimates from across the African diaspora show that black men who have sex with men (MSM) are 15 times more likely to be HIV positive compared with general populations and 8·5 times more likely compared with black populations. Disparities in the prevalence of HIV infection are greater in African and Caribbean countries that criminalise homosexual activity than in those that do not criminalise such behaviour. With the exception of US and African epidemiological studies, most studies of black MSM mainly focus on outcomes associated with HIV behavioural risk rather than on prevalence, incidence, or undiagnosed infection. Nevertheless, black MSM across the African diaspora share common experiences such as discrimination, cultural norms valuing masculinity, concerns about confidentiality during HIV testing or treatment, low access to HIV drugs, threats of violence or incarceration, and few targeted HIV prevention resources.

Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis.

BACKGROUND: We did a meta-analysis to assess factors associated with disparities in HIV infection in black men who have sex with men (MSM) in Canada, the UK, and the USA. METHODS: We searched Embase, Medline, Google Scholar, and online conference proceedings from Jan 1, 1981, to Dec 31, 2011, for racial comparative studies with quantitative outcomes associated with HIV risk or HIV infection. Key words and Medical Subject Headings (US National Library of Medicine) relevant to race were cross-referenced with citations pertinent to homosexuality in Canada, the UK, and the USA. Data were aggregated across studies for every outcome of interest to estimate overall effect sizes, which were converted into summary ORs for 106,148 black MSM relative to 581,577 other MSM. FINDINGS: We analysed seven studies from Canada, 13 from the UK, and 174 from the USA. In every country, black MSM were as likely to engage similarly in serodiscordant unprotected sex as other MSM. Black MSM in Canada and the USA were less likely than other MSM to have a history of substance use (odds ratio, OR, 0·53, 95% CI 0·38-0·75, for Canada and 0·67, 0·50-0·92, for the USA). Black MSM in the UK (1·86, 1·58-2·18) and the USA (3·00, 2·06-4·40) were more likely to be HIV positive than were other MSM, but HIV-positive black MSM in each country were less likely (22% in the UK and 60% in the USA) to initiate combination antiretroviral therapy (cART) than other HIV-positive MSM. US HIV-positive black MSM were also less likely to have health insurance, have a high CD4 count, adhere to cART, or be virally suppressed than were other US HIV-positive MSM. Notably, despite a two-fold greater odds of having any structural barrier that increases HIV risk (eg, unemployment, low income, previous incarceration, or less education) compared with other US MSM, US black MSM were more likely to report any preventive behaviour against HIV infection (1·39, 1·23-1·57). For outcomes associated with HIV infection, disparities were greatest for US black MSM versus other MSM for structural barriers, sex partner demographics (eg, age, race), and HIV care outcomes, whereas disparities were least for sexual risk outcomes. INTERPRETATION: Similar racial disparities in HIV and sexually transmitted infections and cART initiation are seen in MSM in the UK and the USA. Elimination of disparities in HIV infection in black MSM cannot be accomplished without addressing structural barriers or differences in HIV clinical care access and outcomes. FUNDING: None.

Correlates of unprotected vaginal or anal intercourse with women among substance-using men who have sex with men.

The role men who have sex with men and women (MSMW) play in heterosexual HIV transmission is not well understood. We analyzed baseline data from Project MIX, a behavioral intervention study of substance-using men who have sex with men (MSM), and identified correlates of unprotected vaginal intercourse, anal intercourse, or both with women (UVAI). Approximately 10 % (n = 194) of the men reported vaginal sex, anal sex, or both with a woman; of these substance-using MSMW, 66 % (129) reported UVAI. Among substance-using MSMW, multivariate analyses found unemployment relative to full/part-time employment (OR = 2.28; 95 % CI 1.01, 5.17), having a primary female partner relative to no primary female partner (OR = 3.44; CI 1.4, 8.46), and higher levels of treatment optimism (OR = 1.73; 95 % CI 1.18, 2.54) increased odds of UVAI. Strong feelings of connection to a same-race gay community (OR = 0.71; 95 % CI 0.56, 0.91) and Viagra use (OR = 0.31; 95 % CI 0.10, 0.95) decreased odds of UVAI. This work suggests that although the proportion of substance-using MSM who also have sex with women is low, these men engage in unprotected sex with women, particularly with primary female partners. This work highlights the need for further research with the substance using MSMW population to inform HIV prevention interventions specifically for MSMW.

Expanding PrEP Services for Men Who Have Sex With Men and Transgender Persons Through Health Department Programs: Key Processes and Outcomes From Project PrIDE, 2015-2019.

OBJECTIVE: Pre-exposure prophylaxis (PrEP) Implementation, Data to Care, and Evaluation (PrIDE) was a demonstration project implemented by 12 state and local health departments during 2015-2019 to expand PrEP services for men who have sex with men (MSM) and transgender persons at risk for HIV infection. We describe findings from the cross-jurisdictional evaluation of the project. METHODS: We analyzed work plans, annual progress reports, and aggregate quantitative program data submitted by funded health departments (n = 12) to identify key activities implemented and summarize key project outcomes. RESULTS: PrIDE jurisdictions implemented multiple health equity-focused activities to expand PrEP services to priority populations, including building program capacity, conducting knowledge and awareness campaigns, providing PrEP support services, and addressing barriers to PrEP use. Overall, PrIDE jurisdictions identified 44 813 persons with PrEP indications. Of these, 74.8% (n = 33 500) were referred and 33.1% (n = 14 821) were linked to PrEP providers, and 25.3% (n = 11 356) were prescribed PrEP. Most persons prescribed PrEP were MSM or transgender persons (87.9%) and persons from racial and ethnic minority groups (65.6%). However, among persons with PrEP indications, non-Hispanic Black/African American persons (14.9% of 18 782) were less likely than non-Hispanic White persons (31.0% of 11 633) to be prescribed PrEP (z = -33.57; P < .001). CONCLUSIONS: PrIDE jurisdictions successfully expanded PrEP services for MSM, transgender persons, and racial and ethnic minority groups by implementing health equity-focused activities that addressed barriers to PrEP services. However, PrEP prescription was generally low, with significant disparities by demographic characteristics. Additional targeted interventions are needed to expand PrEP services, achieve equity in PrEP use, and contribute to ending the HIV epidemic in the United States.

Expanding Data to Care Programs to Improve HIV Care Continuum Among Men Who Have Sex With Men and Transgender Persons: Key Processes and Outcomes From Project PrIDE, 2015-2019.

OBJECTIVES: During 2015-2019, five local and state health department jurisdictions implemented Data to Care (D2C) programs supported by Project PrIDE (Pre-exposure prophylaxis, Implementation, Data to Care, and Evaluation) to improve linkage or reengagement in HIV medical care among persons with HIV (PWH) who had gaps in care, particularly among men who have sex with men (MSM) and transgender persons. We describe findings from the cross-jurisdiction evaluation of the project. METHODS: We conducted a qualitative analysis of the final progress reports submitted by PrIDE jurisdictions to the Centers for Disease Control and Prevention to identify key D2C activities implemented and challenges encountered. We also conducted descriptive analysis on aggregate quantitative data to summarize key D2C program outcomes. RESULTS: PrIDE jurisdictions implemented multiple activities to build their D2C capacity, identify PWH who were not in care or virally suppressed, provide linkage/reengagement services, and monitor outcomes. Overall, 11 463 PWH were selected for follow-up, 45% of whom were MSM or transgender persons. Investigations were completed for 8935 (77.9%) PWH. Only 2323 (26.0%) PWH were confirmed not in care or virally suppressed; 1194 (51.4%) were subsequently linked/reengaged in care; among those, 679 (56.9%) were virally suppressed at last test. PrIDE jurisdictions identified data-related (eg, incomplete or delayed laboratory results), program capacity (eg, insufficient staff), and social and structural (eg, unstable housing) challenges that affected their D2C implementation. CONCLUSIONS: PrIDE jurisdictions successfully enhanced their D2C capacity, reached priority populations who were not in care or virally suppressed, and improved their engagement in care and health outcomes. Data-related and non-data-related challenges limited the efficiency of D2C programs. Findings can help inform other D2C programs and contribute to national HIV prevention goals.

Project PrIDE in Context: Evolution of Evaluation in the Centers for Disease Control and Prevention's Multi-Jurisdictional HIV Prevention Demonstration Projects.

Over the past decade, CDC has been implementing a high-impact prevention (HIP) approach to HIV, directing funds towards activities with the greatest likelihood of reducing new infections and disparities. Corresponding to this shift, the Division of HIV/AIDS Prevention (DHAP) began funding a series of multi-site demonstration projects to provide extra support and evaluative capacity to select health departments to initiate new HIP programming, with the intention of ascertaining and sharing lessons with other health departments. In this paper, we provide context for the PrEP, Implementation, Data2Care, Evaluation (PrIDE) evaluation by describing the evolution of evaluation goals and activities across three prior demonstration projects, highlighting four areas of change: 1) integrated evaluation and program implementation; 2) local program evaluation in addition to cross-site performance monitoring; 3) prescriptive allocation of resources to support local program evaluation; and 4) expansion beyond single site program evaluation to identify effective cross-site programmatic strategies. Together, these changes reflect our own learning about achieving the greatest contribution from multi-site projects and set the stage for unique aspects of program evaluation within PrIDE. We describe these features, concluding with lessons learned from this most recent approach to structuring and supporting evaluation within CDC DHAP's health department demonstration projects.

Depression is associated with sexual risk among men who have sex with men, but is mediated by cognitive escape and self-efficacy.

Men who have sex with men (MSM) show high rates of HIV infection, and higher rates of depression than non-MSM. We examined the association between depression and sexual risk among "high risk" MSM. Evidence has been mixed regarding the link between depression and risky sex, although researchers have rarely considered the role of psychosocial vulnerabilities such as self-efficacy for sexual safety or "escape" coping styles. In a national sample (N = 1,540) of HIV-positive and HIV-negative MSM who reported unprotected sex and drug use with sex partners, we found evidence that depression is related to HIV transmission risk. Self-efficacy for sexual safety and cognitive escape mediated the link between depression and risk behavior, suggesting that psychosocial vulnerability plays an important role in the association of depression with sexual risk. These findings may help us construct more accurate theories regarding depression and sexual behavior, and may inform the design of sexual safety interventions.

Project PrIDE in context: Evolution of evaluation in the centers for disease control and prevention's multi-jurisdictional HIV prevention demonstration projects.

Over the past decade, CDC has been implementing a high-impact prevention (HIP) approach to HIV, directing funds towards activities with the greatest likelihood of reducing new infections and disparities. Corresponding to this shift, the Division of HIV/AIDS Prevention (DHAP) began funding a series of multi-site demonstration projects to provide extra support and evaluative capacity to select health departments to initiate new HIP programming, with the intention of ascertaining and sharing lessons with other health departments. In this paper, we provide context for the PrEP, Implementation, Data2Care, Evaluation (PrIDE) evaluation by describing the evolution of evaluation goals and activities across three prior demonstration projects, highlighting four areas of change: 1) integrated evaluation and program implementation; 2) local program evaluation in addition to cross-site performance monitoring; 3) prescriptive allocation of resources to support local program evaluation; and 4) expansion beyond single site program evaluation to identify effective cross-site programmatic strategies. Together, these changes reflect our own learning about achieving the greatest contribution from multi-site projects and set the stage for unique aspects of program evaluation within PrIDE. We describe these features, concluding with lessons learned from this most recent approach to structuring and supporting evaluation within CDC DHAP's health department demonstration projects.