National-Level Disparities in Internet Access Among Low-Income and Black and Hispanic Youth: Current Population Survey.

BACKGROUND: Internet access is increasingly critical for adolescents with regard to obtaining health information and resources, participating in web-based health promotion, and communicating with health practitioners. However, past work demonstrates that access is not uniform among youth in the United States, with lower access found among groups with higher health-related needs. Population-level data yield important insights about access and internet use in the United States. OBJECTIVE: The aim of this study is to examine internet access and mode of access by social class and race and ethnicity among youth (aged 14-17 years) in the United States. METHODS: Using the Current Population Survey, we examined internet access, cell phone or smartphone access, and modes of connecting to the internet for adolescents in 2015 (unweighted N=6950; expanded weights N=17,103,547) and 2017 (unweighted N=6761; expanded weights N=17,379,728). RESULTS: Internet access increased from 2015 to 2017, but socioeconomic status (SES) and racial and ethnic disparities remained. In 2017, the greatest disparities were found for youth in low-income households (no home access=23%) and for Black youth (no home access=18%) and Hispanic youth (no home access=14%). Low-income Black and Hispanic youth were the most likely to lack home internet access (no home access, low SES Black youth=29%; low SES Hispanic youth=21%). The mode of access (eg, from home and smartphone) and smartphone-only analyses also revealed disparities. CONCLUSIONS: Without internet access, web-based dissemination of information, health promotion, and health care will not reach a significant segment of youth. Currently, SES and racial and ethnic disparities in access prolong health inequalities. Moreover, the economic impact of COVID-19 on Black, Hispanic, and low-income communities may lead to losses in internet access for youth that will further exacerbate disparities.

Oral HIV Self-Implemented Testing: Performance Fidelity Among African American MSM.

Oral-Self Implemented HIV Testing (Oral-SIT) offers a low-cost way to extend the reach of HIV testing systems. It is unclear, however, if high risk populations are able to perform the test with high fidelity. Using a simulation-based research design, we administered desensitized Oral-SIT kits to African American MSM (AAMSM; 17-24 years, N = 178). Participants were HIV negative or never tested, and had never self-administered an Oral-SIT kit. We assessed performance fidelity, and hypothesized antecedents. High levels of social stigma were associated with lower levels of training knowledge (Range = No Errors: 51.9%, 4 Errors: 0.6%) and performance fidelity (Range = No Errors: 39.9%, 3 Errors: 1.7%). Training knowledge and prior testing history were positively associated with performance fidelity. The present work extends research on HIV-related social stigma and suggests that social stigma inhibits knowledge acquisition and task performance. The Oral-SIT training materials were understood by individuals with a wide-range of educational backgrounds. Interventions are needed, however, to further improve Oral-SIT performance fidelity.

Impact of Human Resources on Implementing an Evidence-Based HIV Prevention Intervention.

Evidence-based interventions (EBIs) often require competent staff, or human resources (HR), for implementation. The empirical evidence characterizing the influence of HR fluctuations on EBI delivery is limited and conflicting. Using the Interactive Systems Framework, we explored staff fluctuation and the subsequent influence on RESPECT, an HIV prevention EBI. We conducted interviews with staff in two waves (n = 53, Wave I; n = 37, Wave II) in a national sample of organizations delivering RESPECT (N = 29). We analyzed interviews qualitatively to describe changes among RESPECT staff and explore the subsequent influences on RESPECT implementation. Organizations reported downsizing, turnover, and expansion of staff positions. Staff changes had multiple influences on RESPECT implementation including clients reached, fidelity to specific RESPECT protocols, and overall sustainability of RESPECT over time. HR fluctuations are common, and our analyses provide an initial characterization of the relationship between HR fluctuation and EBI implementation. Given the prominent influence of HR on EBI implementation, the Interactive Systems Framework is a useful guiding tool for future examinations.

Self-implemented HIV testing: perspectives on improving dissemination among urban African American youths.

We examined the potential for increasing the reach of HIV testing to African American youths through the dissemination of oral-HIV testing. From 2012 through 2013 we examined the perceptions of alternatives to pharmacy dissemination of SITs in African American youths (5 focus groups) and service providers (4 focus groups), and conducted an ethnographic study of pharmacies (n = 10). Participants perceived significant advantages to delivering SITs through community health and services for adolescents (e.g., increased confidentiality, reduced stigma) over pharmacy dissemination. Given proper attention to fit, SIT dissemination could be facilitated through distribution by health and social service sites, and by improving elements of pharmacy dissemination.

ADAPTATIONS TO AN HIV COUNSELING AND TESTING INTERVENTION FROM A COUNSELOR PERSPECTIVE.

Understanding the balance between fidelity and adaptation for evidence-based interventions has the potential to improve their translation from research to practice. The Translation into Practice study explores variation in program implementation within organizations utilizing the RESPECT program, an HIV counseling and testing intervention. Counselors (N = 70) were interviewed using a semistructured interview guide to examine both the influential factors on, and the subsequent adaptations to, RESPECT. Almost all counselors reported making adaptations (N = 69). Adaptations were made both to key characteristics (mean [M] = 2.24, standard deviation [SD] = 1.3) and to core components (M = 0.5, SD = 0.8). Counselors identified the environmental context and factors within the counseling context as common influences leading to adaptation. These findings suggest adaptations were a routine part of program usage. To improve implementation of the RESPECT program, further research is needed to assess the degree to which adaptations can be made to better meet the needs of agencies and clients without compromising fidelity.

Examining Sexual Health Organizational Networks in Urban African American Communities Using Social Network Theory.

PURPOSE: Collaboration among organizations offering sexual health and youth development services has the potential to provide youth with effective sexual health support. However, formally structured efforts (eg, coalition formation) may be impractical or unsuitable for low-income communities where resources are often already limited. Social network theories provide an alternative approach for building collaborative organizational networks. APPROACH: Research aims to evaluate the barriers and facilitators to collaboration in sexual health organizational networks. SETTING: Organizations in low income, urban, communities in Chicago and San Francisco that serve African American adolescents. PARTICIPANTS: Providers (n = 22) from organizations that offer sexual health services and youth development services. METHODS: Focus groups (n = 4) were conducted and analyzed utilizing a combination of coding strategies. RESULTS: Barriers to collaboration included resource limitations and competition, differences in organizational roles and deliverables, and prejudice and stigma. Identifying common ground among organizations was found to be a facilitator to collaboration. Social network concepts in conjunction with study findings lead to the development of a practice model that hypothesizes a pathway for organizations to improve collaboration without formally structured efforts. CONCLUSION: Our findings offer ways to encourage collaboration among organizations that support youth sexual health in low-income, urban, African American communities without relying on formal structures. Such collaborations may be critical for improving the provision of comprehensive sexual health support.

Norms governing urban African American adolescents' sexual and substance-using behavior.

Using a probability-based neighborhood sample of urban African American youth and a sample of their close friends (N = 202), we conducted a one-year longitudinal study to examine key questions regarding sexual and drug using norms. The results provide validation of social norms governing sexual behavior, condom use, and substance use among friendship groups. These norms had strong to moderate homogeneity; and both normative strength and homogeneity were relatively stable over a one-year period independent of changes in group membership. The data further suggest that sex and substance using norms may operate as a normative set. Similar to studies of adults, we identified three distinct "norm-based" social strata in our sample. Together, our findings suggest that the norms investigated are valid targets for health promotion efforts, and such efforts may benefit from tailoring programs to the normative sets that make up the different social strata in a given adolescent community.

Vaccine perceptions among Oregon health care providers.

Health care providers exert a significant influence on parental pediatric vaccination decisions. We conducted hour-long interviews with traditional and alternative health care providers in which we explored a range of associations between vaccination perceptions and practice. A key finding was that the Health Belief Model constructs of perceived susceptibility to and severity of either an illness or an adverse vaccine event partially explained health care provider (HCP) beliefs about the risks or benefits of vaccination, especially among alternative care providers. Low or high perceived susceptibility to a vaccine-preventable disease (VPD) or of the severity of a given VPD affects whether an HCP will promote or oppose pediatric vaccination recommendations. Beyond these perceptions, health and vaccination beliefs are affected by the contextual factors of personal experience, group norms, immunology beliefs, and beliefs about industry and government. Building powerful affective heuristics might be critical to balancing the forces that defeat good public health practices.

A pilot study of HIV/STI risk among men having sex with men using erectile dysfunction medications: challenges and opportunities for sexual medicine physicians.

INTRODUCTION: A growing literature suggests relationships between erectile dysfunction medications (EDM) and riskier sexual behavior among men who have sex with men (MSM). Questions remain concerning EDM use and related HIV/sexually transmitted infections (STI) risk among older MSM, particularly those 40 years and over, for whom EDM may be medically warranted. AIM: This exploratory pilot study explores the relationship between EDM and risky sexual behavior in a convenience sample of MSM using EDM and attending historic sex-on-premises venues. METHODS: We examined anonymous surveys from 139 MSM. Bivariate relationships were examined. We then fit a multiple logistic regression model to determine predictors of engaging in unprotected anal intercourse (UAI) at last EDM, using variables identified as being significantly related to UAI in the bivariate analyses. Potential predictors entered the model in a stepwise fashion. MAIN OUTCOME MEASURES: The primary outcome measure was engaging in UAI at last EDM use. RESULTS: MSM participating in the study ranged from 27 to 77 years and averaged 52.0 years (standard deviation = 10.73 years). These participants were primarily older MSM; fewer were younger MSM (12.12%), under age 40. Participants reporting UAI at last EDM use (N = 41) were significantly younger (P < 0.01). Men visiting bars within the last 6 months reported less UAI (P < 0.01). Both variables were independent predictors of UAI in the logistic regression model (P < 0.01). CONCLUSIONS: Similar to reports from younger MSM, our findings suggest older MSM using EDM and reporting UAI are also recreational drug users. We include recommendations for urologists and other sexual medicine physicians treating MSM who may be at elevated risk for HIV/STI infection because of joint EDM and club drug use.

Implementation problems and adaptations among organizations delivering school-based dental sealant programs.

OBJECTIVES: Although research supports the effectiveness of school-based dental sealant programs (SBDSPs) in increasing access to dental care and reducing dental caries, there is limited information on the implementation processes that impact success at the population level. This study assessed SBDSP program implementation in terms of problems (and adaptations) encountered during school and client (students) recruitment, client attendance, and workforce capacity. These four factors are necessary for reaching eligible youth. METHODS: We interviewed program personnel (n = 18) at five organizations delivering SBDSPs in Oregon in 2018. Qualitative analysis employed a directed content approach. RESULTS: Specific implementation problems included the following: school recruitment: workforce limitations, school refusals, community objections; client recruitment: ineffective recruitment materials, poor parent/guardian engagement, consent form shortcomings, poor consent forms dissemination and return, low school cooperation; client attendance: poor school cooperation, physical barriers, scheduling conflicts; workforce capacity: insufficient size, high turnover. Participants reported that their respective organizations successfully adapted to resolve these implementation problems with some exceptions (e.g., insufficiencies in workforce capacity). CONCLUSION: Implementation problems related to school and client recruitment, client attendance, and workforce capacity may impact SBDSP reach. Adaptations to address these problems provide a basis for specific program recommendations. Larger systemic and translational problems were also observed, and recommendations were made regarding organizational communication and the need for additional pre-implementation planning and pilot testing.

Shifting Coronavirus Disease 2019 Testing Policy and Research to Include the Full Translation Pipeline.

The current severe acute respiratory syndrome coronavirus 2 testing policy and practice limits testing as a prevention tool. Radical shifts are required to increase the scale of rapid testing strategies and improve dissemination and implementation of venue-based and self-testing approaches. Attention to the full translation pipeline is required to reach high-risk segments of the population.

Use of effective training and quality assurance strategies is associated with high-fidelity EBI implementation in practice settings: a case analysis.

High-quality implementation of evidence-based interventions is important for program effectiveness and is influenced by training and quality assurance (QA). However, gaps in the literature contribute to a lack of guidance on training and supervision in practice settings, particularly when significant adaptations in programs occur. We examine training and QA in relationship to program fidelity among organizations delivering a widely disseminated HIV counseling and testing EBI in which significant adaptations occurred due to new testing technology. Using a maximum variation case study approach, we examined training and QA in organizations delivering the program with high- and low-fidelity (agencies: 3 = high; 3 = low). We identified themes that distinguished high- and low-fidelity agencies. For example, high-fidelity agencies more often employed a team approach to training; demonstrated use of effective QA strategies; leveraged training and QA to identify and adjust for fit problems, including challenges related to adaptations; and understood the distinctions between RESPECT and other testing programs. The associations between QA and fidelity were strong and straightforward, whereas the relationship between training and fidelity was more complex. Public health needs high-quality training and QA approaches that can address program fit and program adaptations. The study findings reinforced the value of using effective QA strategies. Future work should address methods of increasing program fit through training and QA, identify a set of QA strategies that maximize program fidelity and is feasible to implement, and identify low-cost supplemental training options.

Overcoming cultural barriers to implementing oral HIV self-testing with high fidelity among Tanzanian youth.

Tanzanian youth have high levels of HIV risk and poor access to HIV-testing. Oral self-implemented testing (Oral-SIT) provides an alternative that reduces barriers to HIV-testing. We examined adaptations to Oral-SIT training components in a randomized experiment to evaluate a "train-the-trainer" strategy for improving comprehension of graphic training materials. Participants (N = 257, age = 14-19 years) were randomly assigned to one of two self-training conditions: graphic instruction book (GIB) or Video-GIB. Outcomes included behavioral performance fidelity, self-reported comprehension, and intentions to seek treatment. Video-GIB participants, relative to GIB-only participants, had higher performance fidelity scores, made fewer performance errors, had better instruction comprehension, and were more likely to intend to seek treatment. Oral-SIT timing errors were significantly more common among GIB-only participants. Graphic training materials in conjunction with a "train-the-trainer" video has significant potential for increasing Oral-SIT's reach by overcoming technological and literacy barriers.

Comparison of patient- and clinician-collected anal cytology samples to screen for human papillomavirus-associated anal intraepithelial neoplasia in men who have sex with men.

BACKGROUND: Human papillomavirus (HPV)-associated anal cancer is increasing in prevalence and is more common among men who have sex with men and HIV-positive individuals than cervical cancer is among women in the United States. Cytology screening can detect the anal cancer precursor, anal intraepithelial neoplasia (AIN). Little is known about self-collected samples for AIN screening, and few community-based AIN estimates exist. OBJECTIVE: To compare the sensitivity of self-collected versus clinician-collected anal cytology specimens to detect biopsy-confirmed AIN and the prevalence estimate of AIN in a community sample. DESIGN: Cross-sectional study. Participants were mailed anal cytology self-collection kits with instructions. Clinicians repeated anal cytology and performed high-resolution anoscopy with biopsies as the diagnostic reference standard. SETTING: San Francisco, California. PATIENTS: Community-based sample of men who have sex with men. MEASUREMENTS: Prevalence of anal HPV and AIN. Sensitivity and specificity of self-collected and clinician-collected anal cytology specimens to diagnose AIN were calculated. RESULTS: Biopsy-proven AIN was diagnosed in 57% of HIV-positive and 35% of HIV-negative participants (P = 0.04), and 80% provided adequate self-collected specimens for interpretation. The sensitivity of cytology to detect AIN in HIV-positive men was 75% (95% CI, 51% to 93%) when self-collected and 90% (CI, 68% to 99%) when clinician-collected; respective values in HIV-negative men were 48% (CI, 26% to 70%) and 62% (CI, 38% to 82%). The specificity of cytology to detect AIN in HIV-positive men was 50% (CI, 22% to 78%) when self-collected and 64% (CI, 36% to 86%) when clinician-collected; respective values in HIV-negative men were 86% (CI, 71% to 94%) and 85% (CI, 72% to 93%). LIMITATIONS: The study sample was from a narrowly defined geographical area. Participants self-reported HIV status. CONCLUSION: In a community-based sample, a high proportion of HIV-positive and HIV-negative men who have sex with men have AIN. The sensitivity of cytology to detect AIN is higher for clinician-collected versus self-collected specimens and for HIV-positive versus HIV-negative men. The specificity of cytology to detect AIN is higher in HIV-negative versus HIV-positive men. However, the probability of AIN in a patient with a negative cytology result may not be low enough (23% for HIV-negative men and 45% for HIV-positive men with a patient-collected specimen) for clinicians to be comfortable recommending no anoscopy for those with a negative cytology result if done as a one-time test. These data raise the question of whether the optimal population screening strategy is cytology screening with anoscopy only for those who test positive or whether anoscopy should be recommended for everyone in these risk groups. Given limited resources and the limited number of clinicians trained in anoscopy, cytology screening may be the best current approach to identifying disease in the at-risk population.

"You've Gotta be Careful": Familial Messages Regarding Sexual Behavior and Sexual Relationships among African American Adolescents.

BACKGROUND: Research on the sexual behaviors of African American youth has primarily focused on associated risks, with a dearth of studies examining a fuller representation of African American adolescents' sexual lives. This study explored the range of messages African American adolescents receive from family members regarding sexual behavior and sexual relationships. METHODS: Participants were 52 sexually experienced African American youth (male = 32, female = 20) between the ages of 15 and 17 recruited from community-based organizations in the United States. Youth participated in individual in-depth qualitative interviews, and data were analyzed using a phenomenological framework. RESULTS: Participants received a variety of messages about sexual behavior and sexual relationships from a range of family members including parents, siblings, grandmothers, aunts/uncles, and cousins. Types of messages clustered into three domains: sexual decision-making, quantity and quality of sexual activity, and sexual health promotion; with themes and sub-themes emerging within each area. CONCLUSION: Gender differences in the types of messages received are explored, and applications of the findings to the development of family-involved community interventions that promote sexual and reproductive health are discussed.

Awareness of Kaposi's sarcoma-associated herpesvirus among men who have sex with men.

BACKGROUND: Despite burgeoning scientific knowledge about Kaposi's sarcoma-associated herpesvirus (KSHV), the etiologic agent of Kaposi's sarcoma (KS), little is known about awareness of this virus in the general community. This is particularly the case for men who have sex with men (MSM), the group at greatest risk for infection. METHODS: The California Health Interview Survey was a random digit- dial survey of over 50,000 households. Men aged 18 to 64 years who self-identified as gay or bisexual were subsequently recontacted for a follow-up study of HIV-related knowledge and behavior in which they were asked if they had heard of KS and to describe the cause of KS. RESULTS: Of 398 MSM interviewed, 73.0% (95% CI 65.0-79.7) had heard of KS. However, only 6.4% (95% CI 4.4-9.2) of participants correctly identified that KS is caused by KSHV or a virus other than HIV. Postgraduate education, urban residence, and concurrent HIV infection were all independently associated with greater awareness of the viral origin of KS. CONCLUSION: Awareness of KSHV is very low, overall, among MSM and only somewhat higher, but still unacceptably low, among HIV-infected MSM. Significant efforts are needed to increase awareness of KSHV as a sexually transmitted infection in this population.

Immunology beliefs as a factor in vaccine opposition among complementary and alternative medical providers.

OBJECTIVES: Parental pediatric vaccine decisions are influenced by parents' health provider networks. Complementary and alternative medical providers may be key influences in the networks of those parents who do not vaccinate their children. METHODS: From March to July 2013, we conducted semi-structured interviews of Oregon complementary and alternative medical providers (N = 36) in five disciplines likely to treat parents or children, or both, and whose practitioners are known to express opinions about vaccines and vaccination. We interviewed them concerning their immunology beliefs, vaccine positions, and what these providers recommend to their patients concerning vaccines. We conducted face-to-face interviews and analyzed the interview data using thematic analysis methodology. RESULTS: This article identifies the range and type of immunological beliefs of complementary and alternative medical providers concerning pediatric vaccine recommendations. From repeated readings of the data, we identified three areas of alternative immunological beliefs among complementary and alternative medical providers (i.e. "natural is best," "innate intelligence," and "the fragile immune system"). In addition, complementary and alternative medical providers who embraced mainstream medicine were likely to be vaccine accepters and to mention vaccines as a positive health measure to their patients-these themes were "vaccines prevent illness" and "herd immunity." CONCLUSION: Complementary and alternative medical providers influence their patients' vaccination decisions, particularly urging caution or complete vaccine avoidance, and may be a major influence in states like Oregon with high non-medical exemption rates. Complementary and alternative medical providers come to their anti-vaccine positions largely through post-graduation continuing education courses and seminars. In Oregon, such courses are unregulated and not vetted.

Changes in prevalence of HIV infection and sexual risk behavior in men who have sex with men in San Francisco: 1997 2002.

OBJECTIVES: We assessed differences in HIV prevalence and sexual risk behavior among men who have sex with men (MSM) between 1997 and 2002 in San Francisco. METHODS: We used 2 population-based random-digit-dial telephone surveys of MSM households in San Francisco in 1997 (n=915) and 2002 (n=879). RESULTS: Estimated HIV prevalence increased from 19.6% in 1997 to 26.8% in 2002. Measures of sexual risk also increased. Unprotected anal intercourse with a partner of different or unknown HIV serostatus increased from 9.3% to 14.6%. Mean number of male partners increased from 10.7 to 13.8. The largest reported increase was 18.9% to 26.8% for "serosorting," or choosing unprotected anal intercourse partners believed to have the same HIV serostatus as oneself. Men aged 30 to 50 reported the largest increase in unprotected anal intercourse, whereas men aged 18 to 29 reported the largest increase in serosorting. Changes in the age distribution did not explain the increase in risky behavior. CONCLUSIONS: Both HIV prevalence and sexual risk increased substantially among MSM in San Francisco between 1997 and 2002. Serosorting is being adopted more frequently than condom use by young MSM, but its effectiveness as a harm reduction strategy is not known.

Knowledge of sexual partner's HIV serostatus and serosorting practices in a California population-based sample of men who have sex with men.

OBJECTIVES: To describe knowledge of primary and secondary sexual partner's HIV serostatus and sexual practices, including serosorting, among men who have sex with men (MSM) living in California. METHODS: Men who self-identified as gay/bisexual in the 2001 California Health Interview Survey, a statewide biennial random-digit-dial survey interviewing more than 50,000 adults on a variety of health topics, were recontacted in 2002 and interviewed by telephone about injection drug use, their own and partner's HIV serostatus, and sexual risk behaviors. RESULTS: Among 220 men who reported a primary partner, 86% [95% confidence interval (CI): 77-92] knew their primary partner's serostatus; 62% (95% CI, 52-70) of the 250 men who reported a secondary partner knew their most recent secondary partner's HIV serostatus. Knowledge of one's most recent secondary partner's HIV serostatus was inversely related to history of injecting recreational drugs (odds ratio, 0.22; P < 0.01), and reporting a primary partner in the past year (odds ratio, 0.37; P < 0.05). Two-fifths (41%) of HIV-positive men and three-fifths (62%) of HIV-negative men engaged in serosorting (serocordant unprotected anal intercourse) with their primary partners, whereas 33% HIV-positive men and 20% HIV-negative men did so with their most recent secondary partners. CONCLUSIONS: This population-based survey documented the extent to which MSM know their partners' serostatus and practice serosorting behaviors. The findings emphasize the need for studies to report serocordant and serodiscordant unprotected anal intercourse separately, as the former presents significant lower risk of HIV transmission.