Family-Related Factors and HIV-Related Outcomes Among Black Young Men Who Have Sex with Men in Mississippi.

Given their disproportionate HIV incidence, there is a critical need to identify factors related to HIV risk among Black young men who have sex with men (YMSM) in the southeastern United States. This study investigated the association of family factors and HIV-related outcomes among Black YMSM in Mississippi ages 14-20 (n = 72). Multivariable regression models evaluated associations of family factors and outcomes. Greater parent/child communication about sex was associated with fewer lifetime male sex partners and lower odds of lifetime anal sex. Greater parental monitoring was associated with greater likelihood of future condom use. Sexual orientation disclosure was associated with more lifetime male sex partners. Parental monitoring and parent/child communication about sex were protective, suggesting that family-based interventions are promising for HIV prevention among Black YMSM in Mississippi. Results also indicated that YMSM who are "out" to family are important to reach, and families could be useful in encouraging healthy behaviors.

The Impact of a Mobile Gaming Intervention to Increase Adherence to Pre-exposure Prophylaxis.

Pre-exposure prophylaxis is effective in preventing HIV, but data show that its effectiveness is compromised by suboptimal adherence. This randomized controlled trial (n = 69) tested the impact of an iPhone game, Viral Combat, on PrEP adherence over 24 weeks. Tenofovir-diphosphate in red blood cells was collected as a biological outcome of adherence. At 24-weeks, intervention participants were 3.75 (95% CI: 1.20-11.77; p = 0.02) times as likely to engage in optimal PrEP dosing compared to controls. Viral Combat showed preliminary efficacy in improving PrEP adherence for diverse young men who have sex with men.

Predictors of viral suppression among youth living with HIV in the southern United States.

Youth living with HIV (YLH) in the United States (U.S.) face significant problems with achieving viral suppression, especially in the South. To examine this issue, YLH with a detectable viral load (N = 61) were recruited from the southern U.S and assessed over 16 weeks for health and treatment factors. Participants were part of a smartphone-based intervention trial. Analyses focused on predictors of viral suppression controlling for intervention effects. Fifty-three percent achieved suppression. In univariate models, YLH who engaged in condomless sex four to 16 weeks into the study (odds ratio [OR] = 4.00; compared to those who did not) and self-reported ≥ 90% antiretroviral adherence in the first four weeks of the study (OR = 25.00; compared to youth with <90%) had a higher likelihood of suppression. Shifts in adherence-related social support (OR = 4.98) and appointments kept (OR = 2.72) were also associated with suppression. YLH endorsing illicit drug use had a lower likelihood of suppression (OR = 0.16; compared to those without use). Effects (except drug use) remained significant or approached significance in a multivariate model. Adherence promotion efforts should consider this population's adherence-related social support, drug use, and risk for sexually transmitted infections.

Measuring Antiretroviral Adherence Among Young People Living with HIV: Observations from a Real-Time Monitoring Device Versus Self-report.

This report compares self-report (SR) antiretroviral (ARV) adherence data to adherence data collected via Wisepill, a real-time electronic monitoring (EM) device, among young people living with HIV (YPLH) in the southern United States. Participants (n = 66; ages 16 to 26) were followed for 14 weeks. Descriptive analyses were used to compare SR to EM data. Correlations and a linear regression were conducted to explore factors possibly associated with SR-EM discrepancies. We also examined associations between various levels of SR and EM adherence and viral suppression/non-suppression at 14 weeks. Rates of SR adherence were maintained between 87% and 92% while rates of EM adherence declined from 64% to 34%. YPLH who were ARV-experienced, had lower treatment motivation, and reported more frequent recent marijuana use, had a greater discrepancy between their SR and EM adherence levels compared to other YPLH. Higher rates of SR and EM adherence were independently associated with a decline in viral load. A sensitivity analysis also revealed that SR adherence was a better predictor of viral non-suppression, whereas EM adherence was a better predictor of viral suppression. These measurement approaches are discussed in the context of providing clinical care to YPLH.

Enhancing health among youth living with HIV using an iPhone game.

BACKGROUND: Despite promising outcomes of antiretroviral therapy (ART), challenges to improving adherence among youth living with HIV (YLWH) exist. Mobile games are popular among youth and may improve skills related to resilience, coping, and ART adherence. This study examines the preliminary effects of an iPhone game/app on ART adherence, viral load, and relevant knowledge and attitudes among YLWH in Jackson, MS. METHODS: A RCT with 61 YLWH tested the impact of BattleViro, an ART-related iPhone game, over 16 weeks. Participants, ages 14-26, were recruited from HIV clinics and randomly assigned to receive BattleViro or a non-HIV-related game. All participants received a medication monitoring device. Chi-square and t-test analyses examined baseline differences between conditions. Continuous outcomes were examined using analyses of covariance (ANCOVAs) controlling for baseline scores. Cohen's d effect size differences (ESD) between groups were calculated. RESULTS: The sample was 79% male, 97% Black, and 74% non-heterosexual, with a mean age of 22 years. A third had started ART in the past 3 months. There were no demographic differences between conditions. Examination of ESDs revealed that BattleViro demonstrated promising, but nonsignificant, improvements in HIV knowledge (ESD = 0.50), ART knowledge (ESD = 0.42) and social support (ESD = 0.62). Exploratory moderation analyses revealed interactions between BattleViro and newly starting ART. Those newly starting ART in the BattleViro condition, compared to those in the control, experienced a 0.96 log greater decrease in viral load (ESD=-2.21, F = 4.33, p = 0.04), better adherence (71% vs. 48%; ESD = 1.15, F = 3.90, p = 0.05), more HIV knowledge (ESD = 0.90), and more ART knowledge (ESD = 0.72). CONCLUSION: BattleViro showed promising improvements in HIV knowledge, ART knowledge and social support. Also, there was improved adherence and viral load outcomes specifically among those newly starting ART. ART initiation may be an opportunity to empower and motivate YLWH to build healthy skills.

The role of family functioning in parenting practices of court-involved youth.

Court-involved youth engage in risky sex behaviors at higher rates than non-offending peers and are at particular risk for adverse sexual health outcomes. Parenting practices, such as parent-child sexual communication and parental monitoring, may protect court-involved youth from engaging in risky sexual behavior. Parent psychological distress and family dysfunction may, however, compromise parenting practices for court-involved youth. This study examined associations among parent mental health symptoms, family functioning, and parenting practices within 157 parent-youth dyads who were court-referred for mental health treatment. Results revealed that greater parent mental health symptoms were directly related to greater family dysfunction and indirectly associated with poorer parental monitoring through worse family functioning. Findings suggest that directly addressing parent mental health needs in family-based adolescent sexual health programming for court-involved youth may be effective in improving parent-child relationships and family processes that support long term sexual health outcomes for adolescents.

Examining physical and virtual sexual and drug risk venue co-attendance among PrEP-eligible Latinx sexual minority men.

Disparities in Latinx sexual minority men (LSMM) pre-exposure prophylaxis (PrEP) initiation and adherence demonstrate the need for innovative strategies to improve outcomes along the PrEP Care Continuum. The purpose of this study was to examine physical and virtual risk venue co-attendance among LSMM of varying stages of PrEP use living in South Florida, an Ending the HIV Epidemic (EHE) priority jurisdiction. Venue co-attendance may be leveraged to support equitable dissemination and implementation (D&I) of HIV and drug use preventive interventions to LSMM. Ninety-four LSMM completed surveys on PrEP use and identified physical and virtual sexual and drug risk venues (where men seek sex partners and/or have sex or access or use drugs). Bivariate analyses examined differences in demographics and venue endorsement by PrEP status. Exponential random graph models examined endorsement of venues by PrEP status. One-mode projection visualizations portray the structure of venue co-attendance networks by PrEP status. Participants identified 49 physical and virtual sexual and drug risk venues. A homophily effect of PrEP status on venue endorsement was identified for both sexual and drug risk venues. Network size and density differed by PrEP status and whether the venue was identified as a sexual or drug risk location. Online dating apps, bars, and saunas had the highest centrality in each network type suggesting their potential role in implementing preventive programming. This study identified specific sexual and drug risk venues that may be leveraged to both disseminate targeted PrEP and harm reduction information and to implement interventions to improve PrEP uptake and adherence among LSMM living in EHE priority jurisdictions.

Peer Influence on Motivation to Use Pre-Exposure Prophylaxis Among Latino Sexual Minority Men in Miami, Florida: A Network Autocorrelation Model.

Despite the availability of pre-exposure prophylaxis (PrEP), Latino sexual minority men (LSMM) continue to experience disparities in PrEP uptake and subsequently, HIV vulnerability. Social network norms are an underutilized solution to increase PrEP uptake. We used a peer influence model (network autocorrelation model) to examine the role of social network descriptive norms (i.e., actual behaviors) surrounding PrEP use. A total of 11 sociocentric networks of 13 friends (n = 143 LSMM) were recruited into our study from 2018 to 2019 in South Florida. Most participants were in PrEP pre-contemplation (n = 44), and almost one-third of our sample were using PrEP (n = 38). Three network autocorrelation models were estimated using an empirically informed Bayesian analysis. We found a positive association between participants' Motivational PrEP Cascade (MPC) position and their network members' (friends') cascade position based on three different measures of connection even when accounting for PrEP knowledge: friendship (ρ = 0.22; 95% CIa = 0.01-0.42), emotional closeness (ρ = 0.24; 95% CI = 0.03-0.44), and frequency of interaction (ρ = 0.22; CI = 0.03-0.42). Our findings highlight that an individual's progress in the MPC may be influenced by their network members' progress in the MPC, suggesting that LSMM using PrEP may serve as role models to their peers for PrEP use due to descriptive norms. Our findings further suggest that PrEP interventions for LSMM along the MPC can be implemented at the social network level.

"Test-To-PrEP": Assessing Reach and Adoption of a New Approach to Increase HIV Testing and PrEP Knowledge Using HIV Self-Test Kit Distribution Through PrEP Clients' Social Networks.

BACKGROUND: HIV self-testing (HIVST) can increase the reach of HIV testing. Preexposure prophylaxis (PrEP) clients may be ideal distributors of HIVST kits and PrEP information within their social networks. This study uses the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to evaluate the distribution of HIVST bundled with PrEP information ("Test-to-PrEP" kits) among egocentric friendship networks of PrEP users. METHODS: The study was conducted in Miami from November 2021 to March 2022. Enrolled PrEP clients (egos; n = 100) were offered Test-to-PrEP kits for distribution. Egos and Test-to-PrEP kit users completed brief online surveys. Descriptive statistics are reported for participants, their reported network members, and users of the Test-to-PrEP kits. Logistic and Poisson regression assessed the relationship between characteristics of egos, alters, and the distribution of Test-to-PrEP kits. RESULTS: The 100 enrolled egos reported a total of 414 alters. Participants received 293 Test-to-PrEP kits for distribution with 47 of the 100 participants distributing at least 1 kit. Of those who scanned the quick-response code and responded to the survey, 16.2% reported no previous HIV test and 38.5% reported no prior knowledge of PrEP; 32.5% reported interest in distributing Test-to-PrEP kits, 3 successfully distributed kits, and 2 initiated PrEP. CONCLUSIONS: An approach using PrEP clients' social networks can disseminate HIVST bundled with PrEP information to critical populations including individuals lacking knowledge of PrEP or who have never been tested for HIV. Future studies will assess whether this use of network effects can increase reach and efficiency of HIV testing and PrEP information distribution.

A community-based participatory research approach to the development, refinement, and distribution of Test-to-PrEP: A peer-to-peer distributed at-home HIV self-test and prevention information kit in Miami-Dade, Florida.

In the US, there is a need for interventions that address gaps in awareness, interest, and uptake of HIV testing and biomedical HIV prevention strategies, such as pre-exposure prophylaxis and non-occupational post-exposure prophylaxis. The Test-to-PrEP intervention; an HIV self-test bundled with prevention information that was distributed via a social network strategy, was found to be effective at bridging said gaps. This manuscript presents the development and design of Test-to-PrEP, in which a community-based participatory research approach was used. The intervention combines peer-to-peer distribution of HIV self-testing kits with tailored HIV prevention education. Key features include culturally sensitive educational materials, a strategic emphasis on the connection between intervention distributors and recipients, and rigorous training protocols. Our process led to the creation of materials that were neutral to sexual identity, highlighting the importance of inclusivity and cultural relevance. It also led to a mechanism that allows enhanced network member selection. Stakeholder guidance ensured the initiative was well-aligned with community needs, enhancing its potential acceptability and effectiveness. By centering community needs and cultural nuances, interventions like Test-to-PrEP can potentially increase their reach and efficacy. Our development process underscores the importance of community engagement, cultural relevance, and well-defined reporting.

Mapping Implementation Science with Expert Recommendations for Implementing Change (MIS-ERIC): Strategies to Improve PrEP Use among Black Cisgender Women Living in Mississippi.

BACKGROUND: Black women are disproportionately affected by the HIV epidemic. Strategies to increase Black women's use of pre-exposure prophylaxis (PrEP) are needed. METHODS: Interviews were conducted in Mississippi (MS) with Black, cisgender women at risk for HIV, and community healthcare clinic (CHC) staff who work directly with this population. Reflexive thematic analysis was used to identify barriers and select appropriate implementation strategies to increase PrEP care. RESULTS: Twenty Black women and twelve CHC staff were interviewed. PrEP use barriers resulted from low HIV risk awareness, lack of PrEP knowledge, and structural and stigma-related barriers. Methods for PrEP education and motivation included normalizing PrEP in public communications, providing education at places where women congregate, and tailoring PrEP content with Black women as educators. The Expert Recommendations for Implementing Change (ERIC) project provides a way for implementation scientists to select strategies that are consistent within research and practice across studies. Strategies from the ERIC project were selected to address implementation barriers. CONCLUSIONS: Tailoring PrEP implementation protocols to increase Black women's access, engagement, and adherence to PrEP is needed. This is one of the first implementation studies to incorporate these four implementation concepts into a single study: (1) implementation outcomes, (2) i-PARIHS, (3) ERIC's strategy list, and (4) operationalizing the strategies using the Proctor et al., guidelines. Results provide an in-depth comprehensive list of implementation strategies to increase PrEP uptake for Black women in MS.

Factors associated with PrEP adherence among MSM living in Jackson, Mississippi.

Understanding the determinants of pre-exposure prophylaxis (PrEP) adherence is integral to reducing HIV incidence in the United States, especially for those at highest risk. To this end, the present study explored demographic, psychosocial, and behavioral factors related to adherence among 43 Southern, predominately Black, men who have sex with men (MSM). During the study months, 46% of the sample reported being nonadherent to PrEP. Those with more sexual partners (p = .05), greater self-efficacy for taking PrEP (p = .03), and those who felt condoms were less important (p = .02), were more likely to be adherent to PrEP at six-month follow-up. Further interventions that consider perceived sexual risk, condom use, and adherence self-efficacy are needed to improve PrEP adherence among Southern MSM.

A Mobile Intervention to Improve Uptake of Pre-Exposure Prophylaxis for Southern Black Men Who Have Sex With Men: Protocol for Intervention Development and Pilot Randomized Controlled Trial.

BACKGROUND: The uptake of pre-exposure prophylaxis (PrEP) has been slow for young black men who have sex with men (BMSM) living in the southern United States. This is a significant issue because 8 of the 10 states with the highest rates of new HIV infections are in the South. Jackson, Mississippi (MS), the site of this project, has the second highest AIDS diagnosis rate in the nation and the highest rate of HIV infection for young, urban BMSM. This study will develop and test an engaging, interactive, and cost-effective mobile messaging intervention to improve engagement in PrEP care for BMSM aged 18 to 35 years living in Jackson, MS. OBJECTIVE: The goals of this mixed methods study are to (1) conduct qualitative interviews with young BMSM in Jackson, MS, to understand individual, community, and structural barriers affecting engagement in PrEP-related care, (2) assemble a PrEP mobile messaging intervention that includes text messages with publicly available internet content (websites and YouTube videos) that provide factual information, motivational materials, and behavioral skills related to PrEP and HIV prevention, and (3) evaluate the preliminary efficacy of the intervention in a randomized controlled study with PrEP-eligible BMSM receiving care in STI/HIV testing clinics in Jackson, MS. METHODS: This research protocol will be conducted in 2 phases. A development phase will involve in-depth interviews (n=30) with PrEP-eligible BMSM who receive care in STI/HIV testing clinics in MS. These interviews will allow researchers to select the texted material that will be sent out during the intervention. The second phase will consist of an unblinded, small, randomized controlled trial among 66 new participants to examine the preliminary efficacy of the intervention compared with enhanced standard of care (ESC) on attendance at a PrEP services appointment (the first step in initiating PrEP care) and receipt of a PrEP prescription, based on self-report and electronic medical records. The free, publicly available material will be sent to PrEP-eligible BMSM in 8 to 16 interactive text messages over 4 weeks. Study assessments will occur at enrollment and at 4- and 16-weeks postenrollment and can be completed online or in person. All participants will be recruited from a local clinic. RESULTS: Institutional review board approval was received on January 16, 2017, and research activities, subsequently, began in February 2018. Recruitment for the study concluded in November 2019. In total, 65 participants were randomized with 33 being assigned to the intervention and 32 to ESC. Collection of follow-up data is ongoing. CONCLUSIONS: This PrEP mobile messaging intervention aims to increase uptake of PrEP by BMSM in the southern United States. This intervention uses interactive, tailored text messaging and appealing free Web content (publicly accessible educational websites and YouTube videos) to promote linkage to PrEP care and increase HIV preventative behaviors. A cost-effective PrEP mobile messaging intervention has great potential to improve information about PrEP, improve motivation to use PrEP, and decrease stigma and structural barriers that often prevent engagement in PrEP-related medical care. TRIAL REGISTRATION: ClinicalTrials.gov NCT03308097; https://clinicaltrials.gov/ct2/show/NCT03308097. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15781.

A Mobile Gaming Intervention for Persons on Pre-Exposure Prophylaxis: Protocol for Intervention Development and Randomized Controlled Trial.

BACKGROUND: In the United States, young minority men who have sex with men (MSM) are the most likely to become infected with HIV. Pre-exposure prophylaxis (PrEP) is an efficacious and promising prevention strategy. However, PrEP's safety and effectiveness can be greatly compromised by suboptimal adherence to treatment. To maximize the positive impact of PrEP, it is necessary to combine its prescription with cost-effective behavioral interventions that promote adherence and decrease HIV risk behaviors. In this project, we developed a theoretically informed app/gaming intervention to engage young MSM in learning information, practicing behaviors, and improving motivation for HIV preventative behaviors and PrEP adherence. OBJECTIVE: The goal of this project was to develop and test a cutting-edge, engaging, and entertaining app/gaming intervention for improving adherence to PrEP and building HIV prevention knowledge, skills, and behavior. METHODS: This study was conducted in two phases. In the developmental phase, we conducted qualitative interviews with young MSM (n=20) to guide the development of the gaming intervention. In the randomized controlled trial, we tested the preliminary efficacy of the gaming intervention compared to a comparison condition among young MSM. Subjects were recruited from the University of Mississippi Medical Center HIV/STI testing clinics (n=60). RESULTS: Institutional review board approval was received in February 2015. Research activities began in June 2015 and are still ongoing. CONCLUSIONS: This app/gaming intervention aimed to improve PrEP adherence and HIV preventative behaviors in young MSM. Engaging young MSM in learning information, practicing behaviors, and improving motivation for increased adherence to PrEP has the potential to decrease HIV seroconversion. It is important to develop interventions that are enjoyable, engaging, and easily incorporated into clinical settings. TRIAL REGISTRATION: ClinicalTrials.gov RCT02611362; https://tinyurl.com/y65gkuwr. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18640.

Creating a Theoretically Grounded Gaming App to Increase Adherence to Pre-Exposure Prophylaxis: Lessons From the Development of the Viral Combat Mobile Phone Game.

BACKGROUND: In the United States, young minority men who have sex with men (MSM) are most likely to become infected with HIV. The use of antiretroviral medications to reduce the risk of acquiring HIV infection (pre-exposure prophylaxis, PrEP) is an efficacious and promising prevention strategy. There have been significant advances regarding PrEP, including the definitive demonstration that PrEP reduces HIV acquisition and the development of clinical prescribing guidelines. Despite these promising events, the practical implementation of PrEP can be challenging. Data show that PrEP's safety and effectiveness could be greatly compromised by suboptimal adherence to treatment, and there is concern about the potential for an increase in HIV risk behavior among PrEP users. Due to these challenges, the prescribing of PrEP should be accompanied by behavioral interventions to promote adherence. OBJECTIVE: This study aimed to develop an immersive, action-oriented iPhone gaming intervention to improve motivation for adherence to PrEP. METHODS: Game development was guided by social learning theory, taking into consideration the perspectives of young adult MSM who are taking PrEP. A total of 20 young men who have sex with men (YMSM; aged 18-35 years) were recruited from a sexually transmitted infection (STI), HIV testing, and PrEP care clinic in Jackson, Mississippi, between October 2016 and June 2017. They participated in qualitative interviews guided by the information-motivation-behavioral skills (IMB) model of behavior change. The mean age of participants was 26 years, and all the participants identified as male. Acceptability of the game was assessed with the Client Service Questionnaire and session evaluation form. RESULTS: A number of themes emerged that informed game development. YMSM taking PrEP desired informational game content that included new and comprehensive details about the effectiveness of PrEP, details about PrEP as it relates to doctors' visits, and general information about STIs other than HIV. Motivational themes that emerged were the desire for enhancement of future orientation; reinforcement of positive influences from partners, parents, and friends; collaboration with health care providers; decreasing stigma; and a focus on personal relevance of PrEP-related medical care. Behavioral skills themes centered around self-efficacy and strategies for adherence to PrEP and self-care. CONCLUSIONS: We utilized youth feedback, IMB, and agile software development to create a multilevel, immersive, action-oriented iPhone gaming intervention to improve motivation for adherence to PrEP. There is a dearth of gaming interventions for persons on PrEP. This study is a significant step in working toward the development and testing of an iPhone gaming intervention to decrease HIV risk and promote adherence to PrEP for YMSM.

Mental Health Symptoms and Parenting Stress of Parents of Court-Involved Youth.

Youth involved in the juvenile justice system are at risk for emotional and behavioral problems. However, research with court-involved adolescents has neglected to examine the mental health of their parents, who may also have significant personal and parenting stress. This sample consisted of 144 parent-adolescent dyads. Adolescents (aged 11 to 17 years) identified by court officials were referred to the study to receive mental health treatment. Parents and adolescents completed surveys about their mental health diagnoses, treatment, and family relationships. Using the clinical cut-off for the global severity index of the Symptom Checklist-90-Revised, bivariate and multiple logistic regression analyses were performed to examine group differences between parents with and without significant mental health symptoms. Results indicated that 35% of parents endorsed clinically significant mental health symptoms. Parents with clinically significant symptoms, compared to those without, reported significantly greater parenting stress (p < .05), and were more likely to have received prior mental health treatment (54% vs. 25%; p < .05) and a psychiatric diagnosis (52% vs. 19%; p < .05). Our findings revealed that more than one in three parents of court-involved adolescents are currently experiencing significant mental health symptoms. Improved mental health screening and intervention that incorporates the unique needs of families is recommended, including the possible use of family-based approaches as well as individualized treatment for the parents of court-involved youth.

The Role of Affect Management for HIV Risk Reduction for Youth in Alternative Schools.

OBJECTIVE: Adolescents in alternative schools for behavioral and emotional problems have an earlier sexual onset and higher rates of sexual risk than their peers. They also often have difficulty managing strong emotions, which can impair sexual decision making. Human immunodeficiency virus (HIV) prevention programs for these adolescents may be most effective if skills for coping with strong emotions during sexual situations are included. METHOD: This article reports the 6-month outcomes of a three-arm randomized controlled trial comparing an HIV prevention intervention with affect management (AM) to a standard, skills-based HIV prevention intervention (SB), and a general health promotion intervention (HP). HP was similar to a general health class, and SB was based on previous effective HIV prevention programs used with community adolescents, whereas AM included affect management skills in addition to effective HIV prevention skills. Youth (N = 377) in two US cities were 13 to 19 years of age and attending alternative schools for behavioral and emotional problems. RESULTS: Multiple logistic regression analyses, adjusted for the baseline scores, age, and gender, found that adolescents in AM were significantly less likely to report being sexually active at follow-up (80% versus 91%, adjusted odds ratio = 0.28, 95% CI = 0.08-0.96) and more consistently using condoms than those in HP at follow-up (62%, versus 39%, adjusted odds ratio = 3.42, CI = 1.10-10.63). CONCLUSION: Affect management techniques tested in this project, focused on sexual situations, are similar to those that are used in dialectical behavioral therapy (DBT) and in clinical practice. These data suggest that these techniques might decrease risk behaviors and improve the health of adolescents with emotional/behavioral problems. Clinical trial registration information-Therapeutic Schools: Affect Management and HIV Prevention; http://clinicaltrials.gov/; NCT00500487.