Health Care Provider Decisions to Initiate Oral HIV Preexposure Prophylaxis in New York City Public Sexual Health Clinics.

BACKGROUND: Oral HIV preexposure prophylaxis (PrEP) is safe and effective but underutilized. Health care providers' beliefs about PrEP and attitudes toward people who could benefit may affect PrEP access. METHODS: This mixed-methods study (2016-2018) was conducted in 8 New York City public sexual health clinics that implemented a PrEP program. Data included 32 in-depth qualitative interviews with clinicians, quantitatively coded to reflect their PrEP beliefs; a provider questionnaire; and 6 months of medical record visit data for these providers. Among patients with a PrEP indication, we examined the odds of a patient being initiated on PrEP associated with providers' PrEP beliefs and demographic characteristics, and patient characteristics. RESULTS: Providers reported strong support for offering PrEP to eligible patients. The majority denied concerns about possible development of drug-resistant viral strains, giving PrEP to people who might not benefit, and PrEP toxicity. Nevertheless, about one-third agreed with each of these concerns, and 55% thought PrEP use might limit condom use. Of 2176 patients with a PrEP indication, 20% were initiated. Providers with more restrictive PrEP beliefs did not have lower odds of initiating patients on PrEP. Women as well as Black and Latinx patients were less likely to be initiated on PrEP. CONCLUSIONS: Contrary to our hypotheses, providers' negative PrEP beliefs did not seem to reduce initiation of PrEP for eligible patients. This may be attributable to clear clinical protocols, strong staff support, and training on implementing PrEP in this setting. Racial and gender disparities in PrEP uptake urgently require attention.

Reducing HIV/STI Risk Among Adolescents Aged 12 to 14 Years: a Randomized Controlled Trial of Project Prepared.

Despite calls for evidence-based HIV/STI prevention programs for youth aged 12 to 14 transitioning to adolescence, few effective programs exist. In a two-group intent-to-treat randomized trial in the Bronx, NY, 397 participants were randomly assigned to Project Prepared or an attention control, TEEN. Participants completed surveys at baseline, 6 months, and 12 months. Prepared had two components, an 11-session program and a 3-week internship. Content covered sexual risk behavior, social cognitions, gender norms, relationships, and resilience. TEEN built communication skills and had the same intensity and structure as Prepared but no sexual content. In both, boys and girls were trained together in mixed groups of ~ 11 teens. Primary outcomes were HIV knowledge, self-efficacy, condom outcome expectancy, and behavioral intentions. Secondary outcomes were relationship expectations and endorsement of risky gender norms. Generalized estimating equation analyses showed youth randomized to Prepared had significant improvements compared to TEEN at T2 in HIV knowledge, sexual self-efficacy, and outcome expectancy for condom use. At T3, there were significant differences favoring Prepared in outcome expectancy for condom use, sexual self-efficacy, and intention for partner communication about HIV/AIDS or STIs. Analyses by gender showed program effects in both boys (intention to talk to a partner about condom use, abstinence self-efficacy, sexual self-efficacy, and condom outcome expectancy) and girls (gender norms, and abstinence outcome expectancy). Prepared effectively reduced risk in young adolescents. ClinicalTrials.gov ID: NCT01880450, Protocol ID: 2008-551.

Evaluation of Pediatric Human Papillomavirus Vaccination Provider Counseling Written Materials: A Health Literacy Perspective.

BACKGROUND AND OBJECTIVES: Despite recommendations supporting human papillomavirus (HPV) vaccination, pediatric vaccination rates remain suboptimal in the United States; lack of tools to support provider counseling is one barrier. We sought to evaluate HPV-related counseling materials for readability, suitability, and content, and assess parent perceptions of materials, using a health literacy perspective. METHODS: A systematic search was conducted for written materials developed for HPV vaccination counseling by examining state Department of Health Web sites and associated links to local and national organizations. Materials were assessed for the following: 1) readability (Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Fry), 2) suitability (understandability and actionability) (Suitability Assessment of Materials; Patient Education Materials Assessment Tool for Printable Materials), and 3) coverage of 8 key content areas (recommended by Centers for Disease Control and Prevention). Semistructured interviews were conducted with English-speaking parents or caregivers of children 9 to 17 years of age from 3 pediatric clinics (New York, Ohio, Illinois) serving predominantly low-income families to assess perceptions and usefulness of 4 handouts selected for review. RESULTS: Thirty-eight documents were assessed. Mean ± standard deviation (SD) reading grade level was 9.4 ± 2; 10.5% (n = 4) had a reading level of 6th grade or below; 68.4% (n = 26) were considered not suitable. Mean understandability was 41.7% and mean actionability was 20.7%. Only 5.3% (n = 2) addressed all 8 content areas mean ± SD (number of areas = 6.7 ± 1.2). Brochure comprehensiveness and inclusion of a personal story were cited as factors that would be helpful in influencing parents to vaccinate against HPV. CONCLUSIONS: Few written materials for HPV vaccination counseling were optimal from a health literacy best practices perspective. Content comprehensiveness was important for informed decision making.

Barriers and facilitators to engagement of vulnerable populations in HIV primary care in New York City.

BACKGROUND: Engagement in HIV care helps to maximize viral suppression, which in turn, reduces morbidity and mortality and prevents further HIV transmission. With more HIV cases than any other US city, New York City reported in 2012 that only 41% of all persons estimated to be living with HIV (PLWH) had a suppressed viral load, whereas nearly three-quarters of those in clinical care achieved viral suppression. Thus, retaining PLWH in HIV care addresses this central goal of both the US National HIV/AIDS Strategy and Governor Cuomo's plan to end the AIDS epidemic in New York State. METHODS: We conducted 80 in-depth qualitative interviews with PLWH in 4 New York City populations that were identified as being inconsistently engaged in HIV medical care: African immigrants, previously incarcerated adults, transgender women, and young men who have sex with men. RESULTS: Barriers to and facilitators of HIV care engagement fell into 3 domains: (1) system factors (eg, patient-provider relationship, social service agencies, transitions between penal system and community), (2) social factors (eg, family and other social support; stigma related to HIV, substance use, sexual orientation, gender identity, and incarceration), and (3) individual factors (eg, mental illness, substance use, resilience). Similarities and differences in these themes across the 4 populations as well as research and public health implications were identified. CONCLUSIONS: Engagement in care is maximized when the social challenges confronted by vulnerable groups are addressed, patient-provider communication is strong, and coordinated services are available, including housing, mental health and substance use treatment, and peer navigation.

The Adult Roles Models Program: Feasibility, Acceptability, and Initial Outcomes.

We present the feasibility and acceptability of a parent sexuality education program led by peer educators in community settings. We also report the results of an outcome evaluation with 71 parents who were randomized to the intervention or a control group, and surveyed one month prior to and six months after the 4-week intervention. The program was highly feasible and acceptable to participants, and the curriculum was implemented with a high level of fidelity and facilitator quality. Pilot data show promising outcomes for increasing parental knowledge, communication, and monitoring of their adolescent children.

Barriers and facilitators of linkage to HIV primary care in New York City.

One in 5 people living with HIV are unaware of their status; they account for an estimated 51% of new infections. HIV transmission can be reduced through a "Test and Treat" strategy, which can decrease both viral load and risk behaviors. However, linkage of newly diagnosed HIV-positive persons to care has proved challenging. We report quantitative and qualitative data on linkage to care from HIV testing sites that partnered with the New York City Department of Health and Mental Hygiene to implement "The Bronx Knows" (TBK), an initiative that tested 607,570 residents over 3 years. During TBK, partner agencies reported the aggregate number of HIV tests conducted, the number of confirmed positives (overall and new), and the number of confirmed positives linked to medical care. We conducted qualitative interviews with directors of 24 of 30 TBK HIV testing agencies to identify linkage barriers and selected 9 for case studies. Barriers to linkage fell into 3 domains: (1) health care system factors (long wait for provider appointments, requirement of a positive confirmatory test before scheduling an appointment, system navigation, and disrespect to patients); (2) social factors (HIV stigma); and (3) characteristics of risk populations (eg, mental illness, homelessness, substance use, and immigrant). Best practices for linkage included networking among community organizations, individualized care plans, team approach, comprehensive and coordinated care services, and patient peer navigation. Research and public health implications are discussed.

The Turn the Tables Technique (T(3)): A Program Activity to Provide Group Facilitators Insight into Teen Sexual Behaviors and Beliefs.

The Turn the Tables Technique (T(3)) is an activity designed to provide group facilitators who lead HIV/STI prevention and sexual health promotion programs with detailed and current information on teenagers' sexual behaviors and beliefs. This information can be used throughout a program to tailor content. Included is a detailed lesson plan of T(3), a description of the purpose of T(3), how it was implemented, the context in which it was used, how T(3) addressed common challenges in HIV prevention with teenagers, and future implications for its use.

Recruitment of African American and Latino Adolescent Couples in Romantic Relationships: Lessons Learned.

BACKGROUND: There is considerable literature on effective engagement strategies for recruiting adolescents individually for health research studies, but literature on recruiting adolescent couples is new and minimal. PURPOSE: This paper describes the recruitment strategies used for Teen Connections, a longitudinal study that recruited 139 mainly African American and Latino adolescent couples in romantic relationships living in New York City. METHOD: We collected data in Microsoft Access and documented the date each recruitment strategy was implemented, date each partner was enrolled, and amount of effort required to enroll participants. We identified individual and relationship characteristics from each partner's baseline survey. RESULTS: We found that relationship type and characteristics, language used in printed materials, parental consent, implementing a screener questionnaire, and gender of partner had implications for enrollment in TC. DISCUSSION: Couples studies are highly demanding but achievable with dedicated staff and access to a large number of youth. TRANSLATION TO HEALTH EDUCATION PRACTICE: Research on sexual health and risk often relies on individual reports of dyadic events. Adolescent couples' studies may not be pursued because of recruitment limitations, but they can provide invaluable insight into relationship dynamics, characteristics etc. that may help design better health education interventions, and should be pursued nonetheless.