Youth perspectives on mobile health adherence interventions: A qualitative study guided by the supportive accountability model.

OBJECTIVE: We applied a Supportive Accountability Model lens to understand how youth view remote human coaching versus automated reminders targeting medication adherence. METHODS: We used thematic analysis to interpret (N = 22) youths' responses to semi-structured interviews after 12 weeks of mobile health intervention. RESULTS: Participants reported that both coaching and automated reminders prompted them to take medication, improving their adherence. Participants found coaching helpful because they developed routines and strategies, were motivated to avoid disappointing their coach, and felt their coach cared for them. Automated support could be motivational for some but demanded less engagement. Participants described phone calls as disruptive to their daily lives, but conducive to developing a personal connection with their coach, whereas texts were easier and more flexible. Youth emphasized that individual preferences often differ. CONCLUSION: Human coaching was viewed as a more potent, engaging adherence intervention than automated reminders, although individual needs and preferences differed. Phone calls may enhance the experience of supportive accountability for adherence, but also pose greater acceptability and usability barriers than texting. PRACTICE IMPLICATIONS: Intervention developers should provide opportunities for youth to make personal connections with human adherence supporters and attend to youth preferences for communication modality.

Acute HIV Diagnosis After Initiation of Pre-exposure Prophylaxis in a Young Adult Patient: A Case Report.

Oral pre-exposure prophylaxis (PrEP) in the prevention of human immunodeficiency virus (HIV) infection is highly effective, yet the majority of sexually active adolescents and young adults (AYAs) at highest risk for HIV infection, particularly AYA males who have sex with males, have not been prescribed this medication. Provider hesitancy in prescribing PrEP to at-risk AYA patients is often associated with concerns about patient nonadherence and its effect on inducing HIV medication resistance. This case report has two aims. First, to outline the clinical course for an AYA patient prescribed PrEP for 3 months and then found to have HIV with an M184V resistance mutation and subsequently started on HIV treatment. And second, to illustrate how the benefits of PrEP initiation outweigh its risks by presenting clinical data on resistance patterns to PrEP medications. The patient eventually achieved viral suppression within 5 months of starting HIV treatment which has been sustained up to 2 years. This case illustrates that M184V resistance mutations, although rarely associated with PrEP, are unlikely to impact options for HIV treatment. Providers should recommend and prescribe oral PrEP to AYA patients at risk for HIV infection without concern for nonadherence leading to HIV medication resistance.

Pediatric subspecialty healthcare providers' views of recruitment during a randomized controlled trial of a mobile health intervention.

Background: Randomized clinical trials (RCTs) enrolling pediatric populations often struggle with recruitment. Engaging healthcare providers in the recruitment process may increase patients' and caregivers' willingness to participate in research. The purpose of this study was to understand the perspectives of pediatric subspecialty healthcare providers considering recruiting patients to participate in an mobile health (mHealth) RCT. Methods: We conducted 9 semi-structured interviews and 1 focus group with a total of N = 11 providers from various disciplines before the initiation of an mHealth RCT addressing medication nonadherence. Then, we conducted 5 follow-up interviews and 1 follow-up focus group with a total of 8 of these providers several months later. We used thematic analysis to generate themes describing providers' views of the RCT and patient recruitment. Results: Providers indicated that they were willing to recruit for this study because they believed that the intervention sought to address a significant problem. They also thought it made sense to intervene using technology for this age group. However, many providers thought that certain patients (e.g., those with mild, shorter-lasting adherence difficulties) were the most appropriate to recruit. They described how keeping the trial front of mind facilitated recruitment, and they advised researchers to use strategies to promote their ongoing awareness of the study if conducting similar research in the future. Conclusion: Pediatric healthcare providers are important stakeholders in mHealth intervention research. Engaging them in participant recruitment is a complex endeavor that might promote patient enrollment, but their views of research and demanding clinical roles are important to understand when designing study procedures.

Examining Recruitment Strategies in the Enrollment Cascade of Youth Living With HIV: Descriptive Findings From a Nationwide Web-Based Adherence Protocol.

BACKGROUND: Digital strategies and broadened eligibility criteria may optimize the enrollment of youth living with HIV in mobile health adaptive interventions. Prior research suggests that digital recruitment strategies are more efficient than traditional methods for overcoming enrollment challenges of youth living with HIV in the United States. OBJECTIVE: This study highlights the challenges and strategies that explain screening and enrollment milestones in a national web-based adherence protocol for youth living with HIV. METHODS: Baseline data from a national web-based HIV adherence protocol for youth living with HIV, collected from July 2018 to February 2021, were analyzed. A centralized recruitment procedure was developed, which used web-based recruitment via Online Master Screener; paid targeted advertisements on social media platforms (eg, Facebook and Reddit) and geosocial networking dating apps (eg, Grindr and Jack'd); and site and provider referrals from Subject Recruitment Venues and other AIDS service organizations, website referrals, and text-in recruitment. RESULTS: A total of 3 distinct cohorts of youth living with HIV were identified, marked by changes in recruitment strategies. Overall, 3270 individuals consented to screening, 2721 completed screening, 581 were eligible, and 83 completed enrollment. We examined sociodemographic and behavioral differences in completing milestones from eligibility to full enrollment (ie, submitting antiretroviral therapy and viral load data and completing the baseline web-based survey). Those with the most recent viral load tests >6 months ago were half as likely to enroll (odds ratio 0.45, 95% CI 0.21-0.94). Moreover, eligible participants with self-reported antiretroviral therapy adherence (SRA) between 50% and 80% were statistically significant (P<.001 to P=.03) and more likely to enroll than those with SRA >80%. CONCLUSIONS: The findings add to our knowledge on the use of digital technologies for youth living with HIV before and during the COVID-19 pandemic and provide insight into the impact of expanding eligibility criteria on enrollment. As the COVID-19 pandemic continues and the use of and engagement with social media and dating apps among youth living with HIV changes, these platforms should continue to be investigated as potential recruitment tools. Using a wide variety of recruitment strategies such as using social media and dating apps as well as provider referral mechanisms, increasing compensation amounts, and including SRA in enrollment criteria should continue to be studied with respect to their ability to successfully recruit and enroll eligible participants. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/11183.

Designing an mHealth Roadmap for the Journey to Self-Management: A Qualitative Study with Adolescents and Young Adults Living with Chronic Illness.

OBJECTIVES: Adolescents and young adults (AYA) with chronic illnesses often struggle with illness self-management. The objective of this study is to understand how AYA with various chronic illnesses develop self-management skills and which mobile health (mHealth) strategies they believe could be helpful. METHODS: Semi-structured interviews were conducted with patients, between 16 to 20 years old, living with at least one chronic illness (N = 19), between 2018 and 2019 in Los Angeles, CA. Three coders completed thematic coding to understand how AYA develop and maintain self-management skills, to inform the development of mHealth interventions appropriate across a variety of chronic conditions. RESULTS: Results suggest that AYA develop self-management skills through several strategies, including (1) getting organized, (2) making it work for me and (3) keeping the right mentality. AYA described developing these strategies through: (1) receiving social support, (2) accessing helpful tools and technologies, and (3) going through a maturation process. They provided recommendations for mHealth intervention developers. DISCUSSION: The results suggest that an appealing mHealth intervention could support AYA patients in proactively acquiring self-management skills and prevent having to rely on trial and error or uneven access to guidance and support. Interventions should be responsive to individual technology preferences and practices.

High Prevalence of Anal High-Grade Squamous Intraepithelial Lesions, and Prevention Through Human Papillomavirus Vaccination, in Young Men Who Have Sex With Men Living With Human Immunodeficiency Virus.

BACKGROUND: Men who have sex with men (MSM) are at high risk for human papillomavirus (HPV)-related anal cancer. Little is known about the prevalence of low-grade squamous intraepithelial lesions (LSILs) and the anal cancer precursor, high-grade squamous intraepithelial lesions (HSILs), among young MSM with HIV (MSMLWH). HPV vaccination is recommended in this group, but its safety, immunogenicity, and protection against vaccine-type HPV infection and associated LSILs/HSILs have not been studied. METHODS: Two hundred and sixty MSMLWH aged 18-26 years were screened at 17 US sites for a clinical trial of the quadrivalent (HPV6,11,16,18) HPV (qHPV) vaccine. Those without HSILs were vaccinated at 0, 2, and 6 months. Cytology, high-resolution anoscopy with biopsies of lesions, serology, and HPV testing of the mouth/penis/scrotum/anus/perianus were performed at screening/month 0 and months 7, 12, and 24. RESULTS: Among 260 MSMLWH screened, the most common reason for exclusion was detection of HSILs in 88/260 (34%). 144 MSMLWH were enrolled. 47% of enrollees were previously exposed to HPV16. No incident qHPV type-associated anal LSILs/HSILs were detected among men naive to that type, compared with 11.1, 2.2, 4.5, and 2.8 cases/100 person-years for HPV6,11,16,18-associated LSILs/HSILs, respectively, among those previously exposed to that type. qHPV was immunogenic and safe with no vaccine-associated serious adverse events. CONCLUSIONS: 18-26-year-old MSMLWH naive to qHPV vaccine types were protected against incident qHPV type-associated LSILs/HSILs. Given their high prevalence of HSILs, there is an urgent need to vaccinate young MSMLWH before exposure to vaccine HPV types, before initiating sexual activity, and to perform catch-up vaccination.

A Uniquely Targeted, Mobile App-Based HIV Prevention Intervention for Young Transgender Women: Adaptation and Usability Study.

BACKGROUND: Young transgender women (YTW) are a key population for HIV-related risk reduction, yet very few interventions have been developed to meet their needs. Mobile health interventions with the potential for both efficacy and wide reach are a promising strategy to reduce HIV risk among YTW. OBJECTIVE: This study aims to adapt an efficacious group-based intervention to a mobile app, Project LifeSkills, to reduce HIV risk among YTW, and to test its acceptability and usability. METHODS: The group-based intervention was adapted to a mobile app, LifeSkills Mobile, with input from an expert advisory group and feedback from YTW collected during user-centered design sessions. A beta version of the app was then tested in a usability evaluation using a think-aloud protocol with debriefing interviews, recordings of screen activity, and assessments of usability via the Post-Study System Usability Questionnaire (PSSUQ) and the Health Information Technology Usability Evaluation Scale (Health-ITUES). RESULTS: YTW (n=8; age: mean 24 years, SD 3 years; racial or ethnic minority: 7/8, 88%) provided feedback on the app prototype in design sessions and then tested a beta version of the app in a usability trial (n=10; age: mean 24 years, SD 3 years; racial or ethnic minority: 8/10, 80%). Both usability ratings (Health-ITUES: mean 4.59, SD 0.86; scale range: 1-5) and ratings for satisfaction and accessibility (PSSUQ: mean 4.64, SD 0.90; scale range 1-5) were in the good to excellent range. No functional bugs were identified, and all mobile activities were deployed as expected. Participant feedback from the usability interviews indicated very good salience of the intervention content among the focal population. Participants' suggestions to further increase app engagement included adding animation, adding audio, and reducing the amount text. CONCLUSIONS: We conclude that the LifeSkills Mobile app is a highly usable and engaging mobile app for HIV prevention among YTW.

The Healthy Young Men's Cohort: Health, Stress, and Risk Profile of Black and Latino Young Men Who Have Sex with Men (YMSM).

Young men who have sex with men (YMSM), especially YMSM of color, are at increased risk for a wide range of threats to their health and well-being. In this study, we recruited and surveyed an urban sample of 448 young African American/Black (Black), Hispanic/Latino (Latino), and multi-racial/ethnic YMSM, ages 16-24 years (mean = 22.3 years), about stressful life events, their health and mental health, their access to and utilization of care, and their involvement in risk-related behaviors. We found that the majority reported experiences of racism (87%) and homophobia (76%). A high percentage reported food insecurity/hunger (36%), residential instability (15%), financial hardship (63%), and conflict with family/friends (62%). The prevalence of risk behaviors was also high, including recent use of tobacco (46%), alcohol (88%), and marijuana (72%), and 41% tested positive for 1+ drugs. Furthermore, 26% tested positive for 1+ sexually transmitted infections (STIs). Over half (56%) reported being worried about their health, 33% reported having a chronic health condition and 31% a mental health condition, and 45% had wanted/needed mental health services during the past year. Further, 17% reported suicidal ideation/had planned a suicide attempt and 26% had ever engaged in self-injurious behaviors. Significant differences by race/ethnicity and HIV status included residential status/food insecurity, type of racism/homophobia, drug use, and STIs. These findings demonstrate how vulnerable this population is with respect to a wide range of structural and social determinants of health that may be important drivers of behavioral, health, mental health outcomes, and potentially long-term health disparities.

Comparing Different Measures of Retention in Care Among a Cohort of Adolescents and Young Adults Living with Behaviorally-Acquired HIV.

Young people living with HIV (YLWH) have some of the lowest rates of retention in HIV care, putting them at risk for negative health outcomes. To better understand retention in care in this age group, we conducted a retrospective cohort analysis of YLWH initiating care at a multidisciplinary, adolescent-focused HIV clinic (N = 344). Retention was calculated using a variety of definitions, and relationships between different definitions were assessed. During the 1-year study period, on average YLWH missed two scheduled appointments, and attended 80% of appointments, usually at least once every 3 months. About one-quarter experienced a 6-month gap in care and about two-thirds met the Health Resources and Services Administration's retention criteria. Although most retention definitions were significantly correlated, not all were. Researchers, clinicians, and policymakers should consider the impact of varying definitions of retention, in order to optimally measure this outcome in YLWH, a key vulnerable population.

A Focus on the HIV Care Continuum Through the Healthy Young Men's Cohort Study: Protocol for a Mixed-Methods Study.

BACKGROUND: No group is at greater risk for acquiring HIV than young men who have sex with men (YMSM), particularly black or African American (AA) and Hispanic or Latino (L) YMSM living in inner cities, who account for the largest number of new HIV infections each year. Although pre-exposure prophylaxis (PrEP), postexposure prophylaxis (PEP), and treatment as prevention hold enormous promise for changing the course of the epidemic, AA/L-YMSM are the least likely population to be receiving primary health care and HIV prevention/care and are the least likely to be using PrEP and PEP. OBJECTIVE: The overarching aim of the Healthy Young Men's (HYM) cohort study is to conduct longitudinal research with a cohort of AA/L-YMSM to prevent new HIV infections, reduce transmission, and reduce HIV/AIDS-related disparities by focusing on successful engagement in care. Findings from this research will be used to inform the development of new interventions designed to engage AA/L-YMSM in the HIV prevention and care continua. METHODS: Longitudinal research (baseline and follow-up assessments every 6 months for a total of 8 waves of data collection) is ongoing with a new cohort of 450 high-risk AA/L-YMSM in Los Angeles. Participants were recruited using a venue-based and social media sampling design. In addition to self-report surveys, the study protocol includes the collection of urine to assess recent use of illicit drugs and the collection of blood and rectal/throat swabs to test for current sexually transmitted infection (STI)/HIV infection. An additional sample of blood/plasma (10 mL for 4 aliquots and 1 pellet) is also collected and stored in the HYM cohort study biorepository for future research. By design, we recruited 400 HIV-negative participants and 50 HIV-positive (HIV+) participants. This mixed-methods study design includes collection and triangulated analysis of quantitative, qualitative, and biological measures (ie, drug use, STI/HIV testing, and adherence to antiretroviral therapy among HIV+ participants) at baseline and every 6 months. The HYM cohort study will provide a platform from which new and emerging biomedical prevention strategies (eg, PrEP, rectal microbicides, and PEP) and other HIV prevention and care engagement interventions can be developed and evaluated with AA/L-YMSM. RESULTS: To date, all participants in the HYM cohort study have been recruited and baseline assessment has been conducted. CONCLUSIONS: The findings from this research will be used to inform the development of new and/or adaptation of existing evidence-based HIV prevention interventions and interventions designed to engage this population in the HIV prevention and care continua. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/10738.

Pre-vaccination prevalence of anogenital and oral human papillomavirus in young HIV-infected men who have sex with men.

The aims of this study were to: 1) determine prevalence of anogenital and oral HPV, 2) determine concordance between HPV at anal, perianal, scrotal/penile, and oral sites; and 3) describe factors associated with anogenital HPV types targeted by the 9-valent vaccine. Data were collected from 2012 to 2015 among men who have sex with men 18-26 years of age enrolled in a vaccine trial (N = 145). Penile/scrotal, perianal, anal, and oral samples were tested for 61 HPV types. Logistic regression was used to identify factors associated with types in the 9-valent vaccine. Participants' mean age was 23.0 years, 55.2% were African-American, and 26.2% were Hispanic; 93% had anal, 40% penile, and 6% oral HPV. Among those with anogenital infection, 18% had HPV16. Concordance was low between anogenital and oral sites. Factors independently associated with a 9-valent vaccine-type HPV were: race (African-American vs. White, OR=2.67, 95% CI=1.11-6.42), current smoking (yes vs. no, OR=2.37, 95% CI=1.03-5.48), and number of recent receptive anal sex partners (2+ vs. 0, OR=3.47, 95% CI=1.16-10.4). Most MSM were not infected with HPV16 or HPV18, suggesting that they may still benefit from HPV vaccination, but anogenital HPV was very common, highlighting the importance of vaccinating men before sexual initiation. CLINICAL TRIAL NUMBER: NCT01209325.

Adaptive Antiretroviral Therapy Adherence Interventions for Youth Living With HIV Through Text Message and Cell Phone Support With and Without Incentives: Protocol for a Sequential Multiple Assignment Randomized Trial (SMART).

BACKGROUND: Youth living with HIV (YLH) aged 13 to 24 years made up over a fifth (21%) of new HIV diagnoses in 2016, yet only 27% of YLH are virally suppressed. YLH have been shown to be poorly adherent to antiretroviral therapy (ART); however, there has been limited research investigating how to increase adherence in YLH. Mobile health (mHealth) interventions may be one promising way to do this. OBJECTIVE: This study (ATN [Adolescent Trials Network] 144 SMART) aimed to compare adaptive interventions that could increase ART adherence in YLH aged 15 to 24 years. This includes mHealth initiatives, the tapering of interventions, and the use of incentives. Cost-effectiveness of sequencing the interventions without incentives before providing incentives and the savings on societal costs due to suppressed viral loads will be determined. This protocol is part of the ATN Scale It Up program described in this issue by Naar et al. METHODS: This study uses a Sequential Multiple Assignment Randomized Trial design. Approximately 190 participants are being recruited, enrolled, and randomized to either cell phone support or text message support. Both intervention groups receive 3 months of intervention, followed by a second randomization based on response to the intervention. Responders test tapering their intervention, and nonresponders test receiving incentives. RESULTS: Data collection for this study is projected to begin in August 2018 and last until June 2020. CONCLUSIONS: This is an innovative study, particularly in terms of population, intervention types, focus on cost-effectiveness, and recruitment. This study could be particularly effective in improving adherence in YLH while reducing long-term individual and societal costs. TRIAL REGISTRATION: ClinicalTrials.gov NCT03535337; https://clinicaltrials.gov/ct2/show/NCT03535337 (Archived by WebCite at http://www.webcitation.org/74alXb92z). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/11183.

Cell phone support to improve medication adherence among solid organ transplant recipients.

For many adolescent and young adult solid organ transplant recipients, medication non-adherence is a mortal issue. This study investigated the feasibility, acceptability, and potential efficacy of a 12-week cell phone support intervention to improve immunosuppressant medication adherence. A small sample (N = 8) of non-adherent adolescent and young adult transplant recipients, aged 15-20.5 years, was enrolled. Cell phone support consisted of short calls each weekday including medication reminders, discussion of needs, problem-solving support, and promotion of clinic and community resources. Changes in adherence were measured by self-report and laboratory values, and intervention acceptability, adherence barriers, social support, depression, and substance use were assessed by self-report. Pre-post effect sizes showed medium-to-large improvements in adherence, lasting through a 12-week follow-up assessment. There were also small-to-medium changes in adherence barriers, social support, and depression. However, acceptability and feasibility were limited, due to a low rate of enrollment by eligible male participants. Cell phone support interventions may promote medication adherence among adolescents and young adults. Cell phone support warrants further investigation, including a randomized controlled trial to evaluate efficacy.

The Impact of Cell Phone Support on Psychosocial Outcomes for Youth Living with HIV Nonadherent to Antiretroviral Therapy.

Mobile health interventions to promote adherence to antiretroviral therapy among adolescents and young adults living with HIV represent a promising strategy. This pilot study (N = 37) evaluated the psychosocial impacts of an efficacious adherence intervention, cell phone support (CPS). Participants receiving CPS reported significant decreases in perceived stress, depression, and illicit substance use, and increases in self-efficacy during at least one study assessment period, in comparison to participants receiving usual care. Future research using a larger sample should test for mediators of treatment efficacy to further characterize how cell phone interventions impact adherence.

Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts.

Importance: Transmasculine youth, who are assigned female at birth but have a gender identity along the masculine spectrum, often report considerable distress after breast development (chest dysphoria). Professional guidelines lack clarity regarding referring minors (defined as people younger than 18 years) for chest surgery because there are no data documenting the effect of chest surgery on minors. Objective: To examine the amount of chest dysphoria in transmasculine youth who had had chest reconstruction surgery compared with those who had not undergone this surgery. Design, Setting, and Participants: Using a novel measure of chest dysphoria, this cohort study at a large, urban, hospital-affiliated ambulatory clinic specializing in transgender youth care collected survey data about testosterone use and chest distress among transmasculine youth and young adults. Additional information about regret and adverse effects was collected from those who had undergone surgery. Eligible youth were 13 to 25 years old, had been assigned female at birth, and had an identified gender as something other than female. Recruitment occurred during clinical visits and via telephone between June 2016 and December 2016. Surveys were collected from participants who had undergone chest surgery at the time of survey collection and an equal number of youth who had not undergone surgery. Main Outcomes and Measures: Outcomes were chest dysphoria composite score (range 0-51, with higher scores indicating greater distress) in all participants; desire for chest surgery in patients who had not had surgery; and regret about surgery and complications of surgery in patients who were postsurgical. Results: Of 136 completed surveys, 68 (50.0%) were from postsurgical participants, and 68 (50.0%) were from nonsurgical participants. At the time of the survey, the mean (SD) age was 19 (2.5) years for postsurgical participants and 17 (2.5) years for nonsurgical participants. Chest dysphoria composite score mean (SD) was 29.6 (10.0) for participants who had not undergone chest reconstruction, which was significantly higher than mean (SD) scores in those who had undergone this procedure (3.3 [3.8]; P < .001). Among the nonsurgical cohort, 64 (94%) perceived chest surgery as very important, and chest dysphoria increased by 0.33 points each month that passed between a youth initiating testosterone therapy and undergoing surgery. Among the postsurgical cohort, the most common complication of surgery was loss of nipple sensation, whether temporary (59%) or permanent (41%). Serious complications were rare and included postoperative hematoma (10%) and complications of anesthesia (7%). Self-reported regret was near 0. Conclusions and Relevance: Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age.

Preferences for Injectable PrEP Among Young U.S. Cisgender Men and Transgender Women and Men Who Have Sex with Men.

Young men who have sex with men account for approximately 20% of incident HIV infections in the U.S. Antiretroviral pre-exposure prophylaxis (PrEP) administered as a daily pill has been shown to decrease HIV acquisition in at-risk individuals. New modalities for PrEP are being developed and tested, including injectable PrEP; however, acceptability of these emerging modalities has not yet been examined in youth. We conducted six focus groups with 36 young men and transgender men and women who have sex with men in Boston, Chicago, and Los Angeles in 2016 to assess interest in and preference for different PrEP modalities. Youth were purposively recruited based on diversity of age, race/ethnicity, and prior PrEP experience. Data were coded using content coding based on key domains of the interview guide, in particular around the central themes of interest in and barriers and facilitators to injectable PrEP use. Participants were knowledgeable about oral PrEP but suggested barriers to broader uptake, including stigma, marginalization, and access to information. While participants were split on preference for injectable versus oral PrEP, they agreed quarterly injections may be more manageable and better for those who have adherence difficulties and for those who engage in sex more frequently. Concerns specific to injectable PrEP included: severity/duration of side effects, pain, level of protection prior to next injection, distrust of medical system and injections, and cost. Understanding barriers to and preferences for diverse prevention modalities will allow for more HIV prevention options, improved products, and better interventions, thus allowing individuals to make informed HIV prevention choices.

HIV-Infected Young Men Demonstrate Appropriate Risk Perceptions and Beliefs about Safer Sexual Behaviors after Human Papillomavirus Vaccination.

The aim of this study was to identify risk perceptions after human papillomavirus (HPV) vaccination among HIV-infected young men who have sex with men. On average, participants appropriately perceived themselves to be at lower than neutral risk for HPV (mean subscale score 4.2/10), at higher than neutral risk for other sexually transmitted infections (7.0/10), and that safer sexual behaviors were still important (8.5/10). Higher perceived risk of HPV was associated with African-American race (p = .03); higher perceived risk of other sexually transmitted infections with White race (p = .01) and higher knowledge about HPV (p = .001); and higher perceived need for safer sexual behaviors with consistent condom use (p = .02). The study provides reassuring data that HIV-infected young men who have sex with men generally have appropriate risk perceptions and believe that safer sexual behaviors after vaccination are still important. These findings mirror the results of studies in HIV-infected young women and HIV-uninfected adolescents.

Physiologic Response to Gender-Affirming Hormones Among Transgender Youth.

PURPOSE: The purpose of this study was to examine the physiologic impact of hormones on youth with gender dysphoria. These data represent follow-up data in youth ages 12-23 years over a two-year time period of hormone administration. METHODS: This prospective, longitudinal study initially enrolled 101 youth with gender dysphoria at baseline from those presenting consecutively for care between February 2011 and June 2013. Physiologic data at baseline and follow-up were abstracted from medical charts. Data were analyzed by descriptive statistics. RESULTS: Of the initial 101 participants, 59 youth had follow-up physiologic data collected between 21 and 31 months after initiation of hormones available for analysis. Metabolic parameters changes were not clinically significant, with the exception of sex steroid levels, intended to be the target of intervention. CONCLUSIONS: Although the impact of hormones on some historically concerning physiologic parameters, including lipids, potassium, hemoglobin, and prolactin, were statistically significant, clinical significance was not observed. Hormone levels physiologically concordant with gender of identity were achieved with feminizing and masculinizing medication regimens. Extensive and frequent laboratory examination in transgender adolescents may be unnecessary. The use of hormones in transgender youth appears to be safe over a treatment course of approximately two years.

Behavioral and Health Outcomes for HIV+ Young Transgender Women (YTW) Linked To and Engaged in Medical Care.

We describe health and psychosocial outcomes of HIV+ young transgender women (YTW) engaged in care across the United States. When compared to other behaviorally infected youth (BIY), YTW reported higher rates of unemployment (25% vs. 19%), limited educational achievement (42% vs 13%), and suboptimal ART adherence (51% vs. 30%). There was no difference in likelihood of having a detectable viral load (38% vs. 39%) between groups. However, particular isolating psychosocial factors (unstable housing, depression, and lack of social support for attending appointments) increased predicted probability of viral detection to a greater extent among YTW that may have important health implications for this marginalized youth population.

Supranormal thymic output up to 2 decades after HIV-1 infection.

OBJECTIVES: AIDS is caused by CD4 T-cell depletion. Although combination antiretroviral therapy can restore blood T-cell numbers, the clonal diversity of the reconstituting cells, critical for immunocompetence, is not well defined. METHODS: We performed an extensive analysis of parameters of thymic function in perinatally HIV-1-infected (n = 39) and control (n = 28) participants ranging from 13 to 23 years of age. CD4 T cells including naive (CD27 CD45RA) and recent thymic emigrant (RTE) (CD31/CD45RA) cells, were quantified by flow cytometry. Deep sequencing was used to examine T-cell receptor (TCR) sequence diversity in sorted RTE CD4 T cells. RESULTS: Infected participants had reduced CD4 T-cell levels with predominant depletion of the memory subset and preservation of naive cells. RTE CD4 T-cell levels were normal in most infected individuals, and enhanced thymopoiesis was indicated by higher proportions of CD4 T cells containing TCR recombination excision circles. Memory CD4 T-cell depletion was highly associated with CD8 T-cell activation in HIV-1-infected persons and plasma interlekin-7 levels were correlated with naive CD4 T cells, suggesting activation-driven loss and compensatory enhancement of thymopoiesis. Deep sequencing of CD4 T-cell receptor sequences in well compensated infected persons demonstrated supranormal diversity, providing additional evidence of enhanced thymic output. CONCLUSION: Despite up to two decades of infection, many individuals have remarkable thymic reserve to compensate for ongoing CD4 T-cell loss, although there is ongoing viral replication and immune activation despite combination antiretroviral therapy. The longer term sustainability of this physiology remains to be determined.