The Value of Assessing Self-Reported and Biological Indicators of Outcomes in Evaluating HIV Programs.

PURPOSE OF REVIEW: In this manuscript, we present recent findings concerning concordance and discrepancy between biological measures and self-reports of these three outcomes of HIV programs: HIV status, adherence to antiretroviral medications (ARVs) and use of and adherence to pre-exposure prophylaxis medication (PrEP), and condom use/unprotected sex. RECENT FINDINGS: Recent studies suggest that three successive rapid HIV tests (for those whose first test in positive) might be reasonably inexpensive and valid biological data to collect to combine with self-reports of HIV status, dried blood spots sufficiently affordable to combine with self-reports of adherence to ARVs and use of or adherence to PrEP, and that the discrepancy between self-reports of condom use and biomarkers of unprotected sex may be relatively small in high-income countries. Additional work on assessment of incorrect condom usage and breakage, standardized self-report measures of condom use, and more private data collection methodologies in low-income settings might reduce the recent observed discrepancies even further. Concordance between self-reports of HIV and biomarkers indicating HIV positive status has varied considerably, with much lower rates in low-income countries, where the stigma of HIV is still very high. Recommendation is for combining self-report data with the results of three successive rapid tests for those testing positive. For adherence, again agreement between self-reports and a variety of more objective and/or biological measures is only moderate. Dried blood spots (DBS) may be sufficiently inexpensive in low-resource settings that this may be the best biological method to combine with self-reports. In publications over the last 8 years, the discrepancy between self-reports of condom use and biomarkers for unprotected sex may be even lower than 20% after controlling for other features of the study, particularly in high-income countries. Our results suggest that more careful assessment of incorrect condom use and breakage as reasons other than intentional misreporting should be investigated more carefully and that more private data collection methods such as audio, computer-assisted self-interviewing (ACASI) might be employed more often in low-resource settings to reduce this discrepancy in those settings further. In addition, further analysis of the discrepancy between self-reports of condom use and biomarkers should be conducted of published studies using the correct calculation methods to be more certain of these findings.

U.S. transgender women's preferences for microeconomic interventions to address structural determinants of HIV vulnerability: a qualitative assessment.

BACKGROUND: Transgender women in the United States (U.S.) experience a disproportionate burden of HIV infection and challenges to engagement in HIV prevention and care. This excess burden is driven by structural and economic inequities. Microeconomic interventions may be effective strategies for reducing HIV inequities for this population. However, few studies have explored transgender women's preferences for microeconomic interventions to address structural determinants of HIV vulnerability. METHODS: We conducted individual interviews with 19 adult transgender women in 2 U.S. cities (Richmond, VA and St. Louis, MO) who reported one or more sexual risk behaviors and recent economic hardship related to employment/income, housing, or food security. Interviews were recorded, transcribed, and analyzed using thematic content analysis. RESULTS: The majority (74%) of transgender women were racial/ethnic minorities with mean age of 26.3 years. 89% were currently economically vulnerable; and 23% were employed full-time. 37% reported living with HIV. Participants expressed strong support for unrestricted vouchers, with many expressing the need for funds to support gender-affirming interventions. Assistance with how to budget and save and support for job acquisition, career planning, and employment sustainment were also preferred, including access to non-stigmatizing employment. Visible transgender leadership, group empowerment, and small (rather than large) numbers of participants were considered important aspects of intervention design for transgender women, including outreach through existing transgender networks to facilitate inclusion. Incorporating HIV counseling and testing to reduce vulnerability to HIV was acceptable. However, transgender women enrolled in the study preferred that HIV not be the focus of an intervention. CONCLUSIONS: Flexible microeconomic interventions that support gender affirming interventions, improve financial literacy, and provide living-wage non-stigmatizing employment are desired by economically vulnerable transgender women. While not focused on HIV, such interventions have the potential to reduce the structural drivers of HIV vulnerability among transgender women.

Combined effects of gender affirmation and economic hardship on vulnerability to HIV: a qualitative analysis among U.S. adult transgender women.

BACKGROUND: Transgender women ("trans women"), particularly African-American and Latina trans women, have disproportionately high prevalence of HIV in the United States (U.S.). In order to decrease gender dysphoria and overcome discrimination, trans women affirm their gender through social and medical transition, often in contexts of economic hardship and sexual risk. This study qualitatively examined how gender-affirming behaviors enhance or diminish vulnerability to HIV in light of structural and economic barriers to gender transition. METHODS: We conducted individual interviews with 19 adult trans women in two U.S. cities (Richmond, VA and St. Louis, MO) who reported one or more sexual risk behaviors and recent economic hardship related to employment/income, housing, or food security. Interviews were recorded, transcribed, and analyzed using thematic content analysis. RESULTS: The majority (74%) of trans women were racial/ethnic minorities with mean age of 26.3 years. Gender-affirming behaviors varied with 58% of trans women having legally changed their name and gender marker; 79% having initiated hormone therapy; and 11% having not initiated any medical or legal changes. None had undertaken surgical changes. Findings suggested that the process of gender transitioning resulted in both increasing and decreasing HIV risk. The high need for gender affirmation by male sex partners contributed to trans women's exposure to sexual objectification, sexual risk behaviors, and conflicting interests in HIV prevention messaging. Loss of housing and employment due to transition along with the high costs of transition products and medical visits increased reliance on sex work and created new obstacles in accessing HIV services. Trans women experienced lower HIV risk as they acquired legal and medical transition services, reshaped interactions with sex partners, and received gender-affirming support by others, including health providers, employers, peers, and housing professionals. Sexual abstinence was viewed as a negative consequence of incomplete transition, although characterized as a period of low HIV risk. CONCLUSIONS: Structural and policy initiatives that promote safe gender transition and economic stability in trans women may play a critical role in reducing HIV in this population. Addressing the harmful pressures for U.S. trans women to conform to perceived feminine stereotypes may also serve an important role.

Zika and Flint Water Public Health Emergencies: Disaster Training Tool Kits Relevant to Pregnant Women and Children.

Pregnant women and children and individuals suffering from chronic illness are disproportionally impacted by public health emergencies. To meet the healthcare needs of these populations, the nursing workforce must be capable of responding in a timely and appropriate manner. The goal of this project was to create interactive and engaging evidence-based educational tool kits to advance healthcare provider readiness in the management of population health in response to the Zika and Flint Water crises. A multipronged, mixed-methods approach was used to identify essential education needs and required core competencies. Data were synthesized from discussion with key informants, review of relevant documents, and surveys of schools of nursing, public health, and medicine. The ADDIE model was used to integrate results into the development of the online learning tool kits using the ThingLink software program. An innovative online educational program to prepare healthcare providers to rapidly identify, mitigate, and manage the impact of the Zika and Flint Water crises upon pregnant women and children was implemented by the Society for the Advancement of Disaster Nursing. Innovative online learning tool kits can advance healthcare provider readiness by increasing knowledge and understanding of key components of specific public health emergencies.

News of Biomedical Advances in HIV: Relationship to Treatment Optimism and Expected Risk Behavior in US MSM.

HIV treatment optimism and the ways in which news of HIV biomedical advances in HIV is presented to the most at-risk communities interact in ways that affect risk behavior and the incidence of HIV. The goal of the current study was to understand the relationships among HIV treatment optimism, knowledge of HIV biomedical advances, and current and expected increased risk behavior as a result of reading hypothetical news stories of further advances. Most of an online-recruited sample of MSM were quite knowledgeable about current biomedical advances. After reading three hypothetical news stories, 15-24% of those not living with HIV and 26-52% of those living with HIV reported their condom use would decrease if the story they read were true. Results suggest the importance of more cautious reporting on HIV biomedical advances, and for targeting individuals with greater treatment optimism and those living with HIV via organizations where they are most likely to receive their information about HIV.

Use of the Internet to Meet Sexual Partners, Sexual Risk Behavior, and Mental Health in Transgender Adults.

The purpose of this study was to examine the use of the internet to meet sexual partners among transgender individuals and examine correlates of this use, including sexual risk behavior, discrimination experiences, and mental health. A sample of 166 transgender adults (112 male-to-female transgender women and 54 female-to-male transgender men) were recruited in community venues and anonymously completed measures assessing these variables. Most participants (64.5 %) were HIV-negative, 25.2 % were HIV-positive, and 10.3 % did not know their HIV status. Overall, 33.7 % of participants reported having met a sexual partner over the internet, which did not differ significantly between transgender women and men. Among these individuals, transgender women reported significantly more lifetime internet sexual partners (median = 3) than transgender men (median = 1). Use of the internet to meet sexual partners was associated with lower self-esteem but not with depression, anxiety, somatic distress or discrimination experiences. Among transgender women, use of the internet to meet sexual partners was associated with each of the 11 sexual risk behaviors examined, including having multiple partners, sex under the influence of drugs, number of unprotected anal or vaginal sex acts, and history of commercial sex work. The use of the internet to meet partners was not associated with sexual risk behavior among transgender men (0/11 variables assessed). Although the internet is a common mode of meeting sexual partners among some transgender adults, it may also be a potential venue for prevention interventions targeting transgender individuals at particularly high risk for HIV acquisition.

Exemplification of HAART and HIV/AIDS: A News Experiment.

Recent data show that the number of deaths from HIV has declined but the disease continues to spread. An emerging line of research suggests that the apparent increase may be due to complacency, whereby faith in medicine encourages risk-taking behavior. This study examines the hypothesis that certain approaches in the news media could disproportionately influence perceptions of treatment success even when paired with statistics. College students and gay men, recruited in the community, were exposed to a fictional news story in which the ratio of four cases of people taking antiretroviral (ARV) medications was varied in two conditions. The story was either consistent with or inconsistent with the success-rate data presented by an alleged medical expert in the story. Participants' perceptions of ARV success were estimated following exposure to the story. As expected, the personal news stories influenced estimation of ARV success more than the presence of statistical success rate data. Consistent with previous exemplification research, the size of the effect suggests that the stories influenced judgments of the true success rate by roughly 10 to 20%. The effect was moderated by sexual orientation, but not by gender. Exemplification as a journalistic tendency may be one factor that contributes to unrealistic faith in medical advancements. These data suggest that future research should explore in detail the extent and context of HIV/AIDS reporting using exemplification theory with considerations for how reporting might be modified to have less of an effect on increased sexual risk-taking.

Development and implementation of mass media campaigns to delay sexual initiation among African American and White youth.

Reducing new HIV/STD infections among at-risk adolescents requires developing and evaluating evidence-based health communication approaches. Research overwhelmingly supports the conclusion that early sexual initiation is associated with STDs and other negative outcomes in later years (e.g., unintended pregnancy). The authors' research group secured funding from the National Institute of Mental Health to develop, implement, and rigorously evaluate televised mass media campaigns to delay initiation of sexual intercourse among African American and White adolescents in two cities in the Southeastern United States. The focus of the present study is on the development and implementation of the campaigns, including (a) rationale and theoretical underpinnings; (b) collection, screening, and assessment of existing public service announcements; (c) development of new public service announcements; (d) study design and campaign airing plan; and (e) message exposure achieved in the campaigns. Health communication campaigns hold much promise in reaching at-risk adolescent populations with targeted, timely, and relevant risk-reduction messages.

The effects of framing and fear on ratings and impact of antimarijuana PSAs.

A laboratory experiment, funded by the U.S. National Institutes of Health, involved 243 U.S. undergraduate students and employed a 2 (gain-framed vs. loss-framed) × 2 (high vs. low threat) plus control group pretest-posttest experimental design to assess the combined effects of frame (gain vs. loss) and level of threat of public service announcements (PSAs) about marijuana on attitudes, beliefs, and intentions related to marijuana, as well as the relationship of message condition to ratings of PSAs. Results suggest that loss-framed messages may lead to greater perceived threat, as well as reactance, and gain-framed messages may lead to a greater reduction in positive attitudes toward marijuana than loss-framed messages. Finally, frame and threat may interact in a complex way. Further research is suggested to replicate these findings. A substantial body of carefully crafted and systematic research studies examining both content and features of messages increasingly informs mass media prevention efforts, including the development of public service announcements (PSAs). Although the significance of messages on commercial broadcast stations may be diminishing with the increasing role and impact of new media, many of the basic questions addressed by this research are likely to apply across media channels. Nonetheless, important questions about what makes a message effective in changing an individual's attitudes or behavior remain to be answered. In this paper, the authors focus on two theoretically derived strategies that offer possibilities for developing persuasive messages: framing and threat.

Mechanisms through which reciprocal filial values protect wellbeing of Chinese adult-child caregivers in the US.

In this study, we explored the role of reciprocal filial values in protecting the wellbeing of Chinese adult-child caregivers in the US. Using survey data obtained from 137 Chinese adult-child caregivers living in seven US cities, we tested a latent variable model using structural equation modeling. In this model, informed by role theory, social exchange theory and stress-coping theory, reciprocal filial values affect caregiver wellbeing in the face of caregiver role strain, both directly and indirectly through protective effects of role rewards and coping. In the final model, reciprocal filial values had both direct and indirect protective effects on caregivers' wellbeing, offering evidence to address culturally sensitive issues in family caregivers with similar filial values.

Determinants of an HIV Preventive Vaccine among a Highly Vulnerable Population: African American Men Who Have Sex with Men.

African American men who have sex with men (MSM) are disproportionately impacted by HIV and may benefit from the development of an HIV vaccine. African American MSM are adversely affected by discrimination as a function of both their race and sexual behaviors. This may further increase the challenges associated with persuading them to adopt an HIV vaccine. Developing a knowledge base characterizing African American MSM HIV vaccine perceptions, attitudes, and concerns may help strengthen how healthcare providers and other health stakeholders describe and discuss the advent of an HIV vaccine. This study assessed the knowledge, attitudes, beliefs, and intentions related to HIV vaccination among African American MSM. This study comprised 432 African American MSM, 18-64 years, residing in the United States. Vaccine intention was defined as how likely it is that an individual would adopt an HIV vaccine if a vaccine was available and it was 90% effective against HIV, easy to obtain, free, and had few side effects. Relative to African American MSM who intend to delay receiving an HIV vaccination, controlling for age, education, and income, early vaccine adopters who had received ≥ 2 COVID-19 vaccinations and who had high WHO HIV Vaccine Positive Attitude Scale scores were, respectively, 3.2 times and 2.4 times more likely to report the intention to vaccinate within one year. Early vaccine adopters were also 2.4 times more likely to feel that HIV prevention support discriminates against African American MSM. Those reporting three or more sexual partners and medical mistrust were, respectively, 60% and 59% more likely to report the intention to delay HIV vaccination. The lack of a knowledge base on HIV vaccine perceptions and acceptability is a missed opportunity to provide guidance on how stakeholders, such as health providers and policymakers, should address HIV vaccine hesitancy once this crucial vaccine is licensed. The key factors affecting vaccine adoption are valuable in developing and implementing campaigns to enhance the HIV vaccine coverage in this vulnerable population.

In-depth investigation of interpersonal discussions in response to a safer sex mass media campaign.

We know from theory and limited research that people talk about campaign messages-and that these conversations may play an important role in campaign reach and possibly even efficacy. We know very little, however, about what individuals talk about and with whom they talk. The current study seeks to fill this gap by reporting qualitative and descriptive quantitative data from interviews conducted with 139 young adults about conversations that took place in the context of a large, televised safer sex mass media campaign. Results indicated that public service announcements (PSAs) were often viewed in the company of friends and significant others, and that it was not uncommon for conversations about the PSAs to take place. Three broad categories of conversations that took place involved discussions about PSA realism, the seriousness of the message, and humor. While in some cases conversations seemed to advance the goal of the campaign (e.g., participants discussed sexually transmitted disease [STD] risk and condom use), in other cases they did not (e.g., participants discussed the lack of realism in a particular PSA). Implications for campaign theory, design, and implementation are discussed.

A network-individual-resource model for HIV prevention.

HIV is transmitted through dyadic exchanges of individuals linked in transitory or permanent networks of varying sizes. A theoretical perspective that bridges key individual level elements with important network elements can be a complementary foundation for developing and implementing HIV interventions with outcomes that are more sustainable over time and have greater dissemination potential. Toward that end, we introduce a Network-Individual-Resource (NIR) model for HIV prevention that recognizes how exchanges of resources between individuals and their networks underlies and sustains HIV-risk behaviors. Individual behavior change for HIV prevention, then, may be dependent on increasing the supportiveness of that individual's relevant networks for such change. Among other implications, an NIR model predicts that the success of prevention efforts depends on whether the prevention efforts (1) prompt behavior changes that can be sustained by the resources the individual or their networks possess; (2) meet individual and network needs and are consistent with the individual's current situation/developmental stage; (3) are trusted and valued; and (4) target high HIV-prevalence networks.

Ready to Respond: A Survey of Interdisciplinary Health-Care Students and Administrators on Disaster Management Competencies.

BACKGROUND: A sense of competency and confidence in disaster management is linked to response willingness and efficacy. This study assessed current health-care student disaster competency curricula and resultant confidence. METHODS: A survey was sent to students and administrators in nurse practitioner (NP), master of public health (MPH), and medical/osteopathic schools (MD/DO), assessing curriculum coverage of 15 disaster management competencies (1-4, total 15-60), and confidence in performing 15 related behaviors (1-7, total 15-105). One-way analysis of variance with Tukey's post-hoc and Mann-Whitney U-tests were used to examine group differences. RESULTS: A total of 729 students and 72 administrators completed the survey. Low coverage of all topics was reported by both students and administrators (mean 24.4; SD 9.6). Among students, NP students (21.66 ± 8.56) scored significantly lower than MD/DO (23.32 ± 8.19; P < 0.001) and MPH students (26.58 ± 9.06; P < 0.001) on curriculum coverage. Both administrators and students expressed low confidence in competence, with students significantly lower (P < 0.001). NP students scored higher (63.12 ± 20.69; P < 0.001) than both MPH (54.85 ± 17.82) and MD/DO (51.17 ± 19.71; P < 0.001) students. CONCLUSIONS: Health-care students report low coverage of topics considered to be necessary disaster response competencies, as well as their confidence to execute functions. This may negatively impact willingness and ability of these professionals to respond effectively in a disaster.

Effects of a school-based, theory-driven HIV and pregnancy prevention curriculum.

CONTEXT: Although a number of interventions are effective at reducing risky adolescent sexual behavior, it may be possible to make them even more effective by addressing adolescents' approaches to risk-taking. METHODS: Schools were assigned to teach one of three curricula in a quasi-experimental intervention study: the school's standard pregnancy and HIV prevention curriculum; the Reducing the Risk curriculum; or a modified Reducing the Risk curriculum, adapted for high sensation seekers and impulsive decision makers. A sample of 1,944 students from 17 schools was surveyed at three time points between 1995 and 1997. Mixed models regression and logistic regression were used to examine the difference in impact among curricula. RESULTS: Differences in the impact of the original and modified Reducing the Risk interventions were not significant for the total sample or for high sensation seekers and impulsive decision makers separately. Students from both intervention groups demonstrated short-term improvements in knowledge; students who received their schools' standard curriculum were significantly more likely than those assigned to either intervention to have initiated sexual intercourse by the third time point (odds ratio, 2.4). CONCLUSION: More work is necessary to understand the best ways to design classroom messages that will be effective in reducing the risk behaviors of high sensation seekers and impulsive decision makers.

Effects of a televised two-city safer sex mass media campaign targeting high-sensation-seeking and impulsive-decision-making young adults.

This study evaluates the ability of a safer sex televised public service announcement (PSA) campaign to increase safer sexual behavior among at-risk young adults. Independent, monthly random samples of 100 individuals were surveyed in each city for 21 months as part of an interrupted-time-series design with a control community. The 3-month high-audience-saturation campaign took place in Lexington, KY, with Knoxville, TN, as a comparison city. Messages were especially designed and selected for the target audience (those above the median on a composite sensation-seeking/impulsive-decision-making scale). Data indicate high campaign exposure among the target audience, with 85%-96% reporting viewing one or more PSAs. Analyses indicate significant 5-month increases in condom use, condom-use self-efficacy, and behavioral intentions among the target group in the campaign city with no changes in the comparison city. The results suggest that a carefully targeted, intensive mass media campaign using televised PSAs can change safer sexual behaviors.

Longitudinal test of a multiple domain model of adolescent condom use.

A comprehensive multiple domain model (MDM) to understand condom use in adolescents was proposed and tested using structural equation modeling of data at three time points. The proposed model integrates social psychological theory, demographic and personality factors, social environment, and situational/contextual variables. Adolescents who were sexually active at time 2 (6 months after baseline) and time 3 (1 year after time 2) and completed surveys at all three time points were included in the analyses (N = 511). An iterative process of model testing resulted in a structural equation model that provided a good fit to the data (CFI = .92, RMSEA = .04). Models comparing gender and race as moderators also were calculated and supported the generalizability of the model. Results provide support for an MDM that goes beyond traditional social psychological models for a broader understanding of condom use in adolescents. Implications for further theory testing and safer sexual interventions are discussed.

Efficacy of an American alcohol and HIV prevention curriculum adapted for use in South Africa: results of a pilot study in five township schools.

The high prevalence of HIV among young people in African countries underscores a pressing need for effective prevention interventions. Adapting school-based prevention programs developed in the United States for use in African schools may present an alternative to the time-consuming process of developing home-grown programs. The researchers report the results of a pretest-posttest field trial of an alcohol/HIV prevention curriculum adapted from an American model and delivered to ninth-grade students in five South African township schools. The revised intervention was based primarily on the Project Northland alcohol prevention and Reducing the Risk safer sex programs. The researchers found significant differences in change from baseline to follow-up between students in intervention and comparison groups on intentions to use a condom; drinking before or during sex; and, among females, sex refusal self-efficacy. The results of the field trial suggest that behavioral interventions developed in Western countries may be rapidly adapted to work in other cultural contexts.

Personality traits as predictors of intentions to seek online information about STDs and HIV/AIDS among junior and senior college students in Taiwan.

The purpose of this cross-sectional study is to examine how personality traits such as sensation- seeking and impulsive decision-making affect Taiwanese college students' intentions to seek online information about sexually transmitted diseases (STDs) and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). Five hundred thirty-five (n = 535) junior and senior college students in Taiwan were recruited and completed self-report questionnaires. This study found high sensation-seekers were more likely to seek information about STDs and HIV/AIDS on the Internet than low sensation-seekers. Impulsive decision-makers were less likely than rational decision-makers to seek information about STDs and HIV/AIDS on the Internet. These findings suggest that personality needs to be considered as an exploratory factor which potentially influences intentions to seek STD and HIV/AIDS information on the Internet among Taiwanese college students.

Using community ties to facilitate school-based prevention research.

One of the greatest obstacles to conducting school-based HIV/STD/pregnancy prevention research with adolescents is the reluctance of administrators or site-based decision-making councils to commit their teachers and students to participation in a project designed and managed by an outside group of researchers. A major concern is that researchers may not understand or agree with community sensitivities about such personal topics. By first establishing a collaborative relationship with health district educators currently working in Appalachian schools and residing in those communities, one finds a distinct advantage in terms of gaining admittance to area schools. The presence of local health educators at formative meetings also alloys many concerns of community members, as they view these local participants as monitors of outsider research efforts, thereby protecting the community culture from undue outside influence. During the course of the current study, health educators found they also learned more about their communities and about HIV prevention.