Mediating effects of inequitable gender norms on intimate partner violence and contraceptive use in a cluster randomized control trial in Niger.

Previous research has demonstrated that the Reaching Married Adolescents intervention (RMA) was associated with changes in inequitable gender norms, intimate partner violence (IPV), and modern contraceptive use. This study seeks to understand if changes in inequitable gender norms mediate the RMA intervention's effects on contraceptive use and intimate partner violence (IPV). A four-arm cluster randomized control trial was conducted to evaluate effects of the RMA intervention (household visits, small groups, combination, control) on married adolescent girls and their husbands in Dosso, Niger (baseline: 1042 dyads; 24m follow-up: 737 dyads; 2016-2019). Mediation was assessed using inverse odds ratio weighting. In the small group intervention, of the total effect on IPV prevalence (8% reduction), indirect effects via inequitable gender norms is associated with a 2% decrease (95% CI: -0.07, 0.12) and direct effects with a 6% decrease (95% CI: -0.20, -0.02). For household visits, of the total effect on contraceptive use (20% increase), the indirect effect accounts for an 11% decrease (95% CI: -0.18, -0.01) and direct effect, a 32% increase (95% CI: 0.13, 0.44); similar to findings for the combination arm. This experimental evidence informs the value of changing underlying social norms to reduce IPV and increase contraception use.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Perceptions matter: Narratives of contraceptive implant robbery in Cape Town, South Africa.

Uptake of contraceptive implants has declined in South Africa since their introduction in 2014, with side effects and inadequate health provider training cited as primary contributors underlying a poor community perception of implants. In this paper we explore a theme that emerged unexpectedly during analysis of our research in Cape Town that may be an additional factor in this decline: narratives of women being assaulted by robbers who physically remove the implants for smoking as drugs. Narratives were described consistently across interviews and focus groups with youth (aged 18-24 years) and in interviews with health providers, with six participants (two young people, four health providers) sharing personal experiences of robbery. While there was a range of perspectives on whether narratives are based on real experiences or are myths, there was strong consensus that narratives of implant robbery may be influencing women's decisions around implant use in Cape Town. This is a potent example of how perceptions of new products can affect uptake and offers important lessons for implementers to reflect on in planning for rollout of other health technologies.

Family and School Connectedness Associated with Lower Depression among Latinx Early Adolescents in an Agricultural County.

Depression constitutes one of the greatest sources of morbidity and mortality for U.S. adolescents. Latinx are the fastest growing U.S. adolescent population, particularly in rural communities, and suffer from depression at higher rates than other racial/ethnic groups. Informed by community perspectives on adolescent health, we examined factors associated with depression among Latinx early adolescents in an agricultural community. We surveyed 599 predominantly Latinx 8th graders (12 to 15 years old) recruited from middle schools in Salinas, California. Depression was measured cross-sectionally with the Patient Health Questionnaire-8. Exposures included environmental, cultural, and family factors, assessed using validated measures. We used hierarchical logistic regression guided by Garcia Coll's Model for the Study of Developmental Competencies in Minority Children to examine associations between protective factors within each domain and depression. Eighty-six of the 599 youth (14%) scored above the clinical threshold for depression, with higher prevalence among females (19%) than males (10%), p = .001. Environmental (school connectedness and neighborhood social cohesion) and family factors were associated with a lower odds of depression (all p ≤ .01). Social cohesion in neighborhoods and family communication offered similarly strong protective associations with depression. Increased language assimilation was associated with an increased odds of depression (p = .007).

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

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

The PrEPARE Pretoria Project: protocol for a cluster-randomized factorial-design trial to prevent HIV with PrEP among adolescent girls and young women in Tshwane, South Africa.

BACKGROUND: Despite increased prevention efforts, HIV remains the leading cause of death among adolescent girls and young women in South Africa. Although research indicates important determinants of HIV acquisition at the individual and interpersonal levels, structural-level stigma and discrimination continue to be critical barriers to reaching and retaining this key population for HIV prevention and sexual and reproductive health services. Innovative and multilevel interventions are needed that can address the intersectional structural and gender issues that young women face, including stigma, alcohol and drug use, gender-based violence, and other risk factors when seeking health services. Oral pre-exposure prophylaxis (PrEP) taken daily has been found to be an effective biomedical HIV prevention tool. Testing a comprehensive gender-focused biobehavioral HIV prevention intervention that is inclusive of social ecological determinants, such as stigma and discrimination reduction in clinics, is critical for reducing HIV among adolescent girls and young women. METHODS: This project involves both a Community Collaborative Board and a Youth Advisory Board in helping to adapt the Young Women's Health CoOp intervention and the Health Policy Project (HPP) Stigma and Discrimination (S&D) reduction training curriculum to the setting and population. This study uses a two-by-two factorial design with stratified randomization of 12 clinics, each with distinct catchment areas. The Young Women's Health CoOp addresses substance use, sexual risk, violence prevention and sexual negotiation, condom demonstration, and problem solving with the following additions: knowledge of PrEP, the importance of PrEP adherence, and sexual and reproductive health. Adolescent girls and young women will be assessed with behavioral and biological measures at baseline, 3-, 6- and 9-month follow-up. The S&D reduction training is provided for all staff in the clinics randomized to this condition. Clinic staff will be surveyed at baseline, 4- and 8-month follow-up. We will recruit 900 AGYW from communities in the 12 clinic catchment areas. DISCUSSION: The study findings, if efficacious across the outcomes, will be incorporated into the gender-focused HIV prevention intervention toolkit and disseminated to inform multilevel prevention approaches. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT04048551 (Recruiting). Registered: August 7, 2019 (Retrospectively registered).

Cyber Sexual Harassment: Prevalence and association with substance use, poor mental health, and STI history among sexually active adolescent girls.

INTRODUCTION: The current study aims to assess the prevalence, perpetrators, and consequences of cyber sexual harassment (CSH) among adolescent females. METHODS: Sexually active adolescent females (N = 159) ages 15-19 were recruited from a health clinic in a low-income, urban area of southeast San Diego County, California to complete a tablet-administered survey that included items on sexual violence and harassment, including CSH. Using logistic regression models, we assessed CSH in relation to substance use, poor mental health outcomes and STI history. RESULTS: Participants were, on average, 17 years of age and half were currently in a relationship. The majority of girls (68%) reported at least one form of CSH, which included receiving unwanted sexual messages/photos (53%), receiving unwanted messages asking them to do something sexual (49%), being pressured to send sexual photos (36%), and having sexual photos shared without permission (6%). Perpetrators included known and unknown males; almost a third (27%) reported perpetration by a relationship partner. In logistic regression models adjusting for race, CSH was associated with: past 30-day alcohol use, drug use (ever), feeling depressed (past 30 days), and feeling anxious (past 30 days) (Odds Ratios ranged: 2.9-7.5). CSH was also associated with past-year suicidal thoughts and STI diagnosis (ever) (p < 0.05, ORs not presented due to small numbers). CONCLUSIONS: Our findings suggest that in some subgroups, CSH appears to be affecting the majority of girls, which is especially concerning given its association with multiple poor health outcomes.

Young Women's Ratings of Three Placebo Multipurpose Prevention Technologies for HIV and Pregnancy Prevention in a Randomized, Cross-Over Study in Kenya and South Africa.

End-user input is critical to inform development of multipurpose prevention technology (MPT) products that prevent HIV and pregnancy. The TRIO Study, conducted in Kenya and South Africa, enrolled 277 HIV-negative women aged 18-30 in a randomized cross-over study to use each placebo MPT (daily oral tablets, monthly injections, and monthly vaginal ring) for one month. At the end of each month, participants rated how much they liked using the product on a 5-point Likert scale (5 = liked very much). We compared mean ratings using paired t-tests and examined sociodemographic-, attribute-, and behavior-related characteristics associated with ratings using multivariable linear regression and data from in-depth interviews. After use, mean ratings were significantly higher for injections [4.3 (SD = 1.0)] compared with tablets [3.0 (SD = 1.3)] and rings [3.3 (SD = 1.4)] (p < 0.001); mean ratings for rings were significantly higher than for tablets (p = 0.013). Mean ratings of a hypothetical active MPT increased for all products after the one-month period of use, with the greatest increase for rings, the least familiar product. In multivariable analysis, acceptability of key product attributes (e.g., product look) were associated with a significant increase of ≥ 1 point in the mean rating across all three products (p ≤ 0.001). Perceived ability to use the product without partner knowledge was associated with a higher mean rating for rings (b = 0.50; p = 0.006). The acceptability of product attributes contributed significantly to the rating of all products, highlighting the value of choice in pregnancy and HIV prevention to accommodate diverse users.

Testosterone and sexual risk among transmen: a mixed methods exploratory study.

Little research has explored the link between the behavioural effects of testosterone use among transmen and HIV risk. We conducted a mixed methods study to explore testosterone use among transmen and the behavioural effects on HIV risk. A sample of 122 transmen from San Francisco participated in a cross-sectional quantitative survey and 14 transmen participated in 2 focus group discussions. Most participants (81.9%) were currently taking hormones. Participants attributed testosterone use to new sexual behaviours among 69% of transmen, changes in sexual attraction (49%), and increased frequency of sexual activity (72%). Among current testosterone users, 3.3% had cisgender men as partners before starting testosterone, whereas after starting testosterone, 25.4% did. Similarly, 4.1% had a transgender woman as a sexual partner before starting testosterone and 13.9% after starting testosterone. Findings suggest that testosterone's side effects were associated with transmen's desires for sex with cisgender men who have sex with men. The reported increase in attraction to and sex with partners from populations with a high HIV prevalence may have important implications for HIV risk among transmen, especially as the availability of transgender health services may draw transmen to a context in which HIV prevalence is high.

Women's Health and Mindfulness (WHAM): A Randomized Intervention Among Older Lesbian/Bisexual Women.

INTRODUCTION: Lesbian and bisexual (LB) women have higher body weight than heterosexual women. Interventions focused on health and well-being versus weight loss may be more likely to succeed among LB women. This article describes effects of Women's Health and Mindfulness, a 12-week pilot intervention addressing mindfulness, healthy eating, and physical activity, on outcomes associated with chronic disease risk among overweight and obese LB women older than 40 years. METHOD: Eighty women were randomized, using a stepped-wedge design, to either an immediate- or a delayed-start intervention group; the delayed-start group served as the control. Eligible participants were aged 40 years or older, identified as LB, and had a body mass index of 27 or greater. We compared differences in biological markers of chronic disease, mindfulness, nutrition, and physical activity between immediate- and delayed-start intervention groups. RESULTS: We observed clinically significant improvements in low-density lipoprotein cholesterol but no change in hemoglobin A1c. We found evidence of intervention effects on improved mindfulness and mindful eating scores and on nutrition (improved vegetable intake). CONCLUSIONS: The Women's Health and Mindfulness pilot intervention appears to have initiated positive behavioral and physical health changes in this population. Refinements to the intervention model, such as extended intervention duration, and longer term follow-up are warranted to determine sustained effects.

Seek, Test and Disclose: knowledge of HIV testing and serostatus among high-risk couples in a South African township.

OBJECTIVES: HIV testing and disclosure of results to partners is an important strategy in HIV prevention but is under-researched within heterosexual partnerships. To address this gap, we describe patterns of HIV testing, discrepancies between beliefs and biologically confirmed HIV status of each partner, and characteristics of mutually correct knowledge of HIV status among heterosexual couples in a high-prevalence community. METHODS: The study recruited 290 high-risk heterosexual couples in stable relationships from a township in Cape Town, South Africa. Male patrons of shebeens (drinking establishments) were approached to participate with their main partner in an intervention designed to reduce substance use, violence and unsafe sex. All participants were tested for HIV at baseline and asked about their partner's past HIV testing and current status. Using the couple as the unit of analysis, we conducted logistic regression to identify partnership and individual characteristics associated with having mutually correct knowledge of partner's HIV status. RESULTS: Half (52%) of women and 41% of men correctly knew whether their partner had ever been tested for HIV. 38% of women, 28% of men and in 17% of couples, both members reported mutually correct knowledge of their partner's HIV status. Correlates of correct knowledge included married/cohabitating (aOR 2.69, 95% CI 1.35 to 5.40), both partners HIV-negative (aOR 3.32 (1.38 to 8.00)), women's acceptance of traditional gender roles (aOR 1.17 (1.01 to 1.40)) and men's relationship satisfaction (aOR 2.22 (1.01 to 4.44)). CONCLUSIONS: Findings highlight the need to improve HIV testing uptake among men and to improve HIV disclosure among women in heterosexual partnerships. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov registration NCT01121692.

Pre-exposure Prophylaxis Adherence Measured by Plasma Drug Level in MTN-001: Comparison Between Vaginal Gel and Oral Tablets in Two Geographic Regions.

Despite strong evidence that daily oral pre-exposure prophylaxis (PrEP) reduces HIV risk, effectiveness across studies has varied. Inconsistent adherence constitutes one explanation. Efforts to examine adherence are limited when they rely on self-reported measures. We examined recent adherence as measured by plasma tenofovir (TFV) concentration in participants of MTN-001, a phase 2 cross-over trial comparing oral tablet and vaginal gel formulations of TFV among 144 HIV-uninfected women at sites in the United States (U.S.) and sub-Saharan Africa (SSA). Adherence to daily product use was higher in the U.S. than in the SSA sites. Within region, however, adherence was similar between products. In the U.S., gel adherence was higher among married women, and lower among women using male condoms and injectable contraceptives. At the SSA sites, gel adherence was lower for younger women. Inconsistent adherence points to challenges in use of daily PrEP, even during a trial of short duration.