Perspectives on a Couples-Based, e-Health HIV Prevention Toolkit Intervention: A Qualitative Dyadic Study with Black, Heterosexual Couples in New York State.

Web-based technology provides an unparalleled opportunity to increase access and uptake of couples-based HIV prevention interventions. e-Health HIV prevention interventions for US Black heterosexual couples have largely been understudied. To address this gap, we applied the Assessment Phase of the ADAPT-ITT Framework to investigate Black heterosexual couples' perspectives on an existing e-Health, couples-based HIV prevention intervention. Applying a qualitative descriptive approach, joint dyadic interviews were conducted with 28 Black heterosexual couples from three jurisdictions in New York State. Content dyadic analysis revealed three descriptive categories: perspectives of the toolkit intervention (sub-codes: perceived relevance, reactions to core components), recommendations to enhance intervention relevancy (sub-codes: tailoring to relationship type, adding new content), and lasting intervention considerations (sub-codes: toolkit usability and language use). Overall, couples found the toolkit intervention content and usability acceptable and reflected on its potential to build sexual and relationship health. Couples recommended to enhance toolkit adaptability for varied couple's motivation and types re-consider terms like sexual agreements, and include content to facilitate communication regarding sensitive topics (e.g., childhood sexual trauma, co-parenting, family planning) and other issues that may have more relevance to the experience of US Black persons (i.e., wealth building).

Topics for Inclusive Parent-Child Sex Communication by Gay, Bisexual, Queer Youth.

The purposes of this study were to identify the sexuality-related topics parents and gay, bisexual, or queer (GBQ) adolescent males discussed at home and to describe the topics GBQ adolescent males recommend for parents to discuss with future cohorts of GBQ youth. Minimal research on parent-child sex communication with sexual minority adolescents prevents the development of interventions that would benefit adolescent males with same-sex attractions, behaviors and identities. As part of a multimethod qualitative study, we interviewed 30 GBQ adolescent males ages 15-20 and asked them to perform card sorts. From a list of 48 topics, we explored sexuality-related issues GBQ males were familiar with, the topics they discussed with a parent, and topics they suggested parents address with GBQ males at home. Most participants reported that parents assumed them heterosexual during sex talks prior to GBQ adolescent males' coming out. Participants challenged the heteronormative scripts used by parents when discussing sex and health. Participants identified sexuality topics that parents did not routinely cover during sex talks, but that GBQ youth felt would have been useful for them growing up with emergent identities. A non-heteronormative approach to parent-child sex communication is recommended to provide appropriate guidance about sex and HIV/STI prevention to this youth population. Our findings highlight a need to reconfigure parental sexuality scripts to be more inclusive when assisting GBQ males navigate adolescence.

Parents ASSIST (Advancing Supportive and Sexuality-Inclusive Sex Talks): Iterative Development of a Sex Communication Video Series for Parents of Gay, Bisexual, and Queer Male Adolescents.

Effective parent-child sex communication enhances heterosexual youths' efficacy to engage in health promotive behaviors, yet there is scarce research on parent-child sex communication with gay, bisexual, and queer (GBQ) sons during adolescence. Our aim is to describe the development of Parents ASSIST, a web-based series of animated videos for parents of GBQ adolescent males focused on (a) parental education about sexual health topics pertinent to this population's same-sex concerns, (b) modeling of communication skills for parents to broach and sustain inclusive discussions at home, and (c) norming the role of providers as reliable sources of support when parents seek GBQ-related health information. Community-based advisory boards, comprised of parents and health care providers, respectively, informed the intervention development. Based on study notes and the research team's reflections, we present lessons learned that focus on content-based and logistical challenges that arose during the intervention development process. This study extends practice and patient education by providing an innovative, primary intervention that partners with parents of an underserved youth population.

Knowing is not enough: a qualitative report on HIV testing among heterosexual African-American men.

Despite having higher rates of HIV testing than all other racial groups, African-Americans continue to be disproportionately affected by the HIV epidemic in the United States. Knowing one's status is the key step to maintaining behavioral changes that could stop the spread of the virus, yet little is known about the individual- and socio-structural-level barriers associated with HIV testing and communication among heterosexual African-American men. To address this and inform the development of an HIV prevention behavioral intervention for heterosexual African-American men, we conducted computerized, structured interviews with 61 men, focus group interviews with 25 men in 5 different groups, and in-depth qualitative interviews with 30 men living in high HIV prevalence neighborhoods in New York City. Results revealed that HIV testing was frequent among the participants. Even with high rates of testing, the men in the study had low levels of HIV knowledge; perceived little risk of HIV; and misused HIV testing as a prevention method. Factors affecting HIV testing, included stigma, relationship dynamics and communication, and societal influences, suggesting that fear, low perception of risk, and HIV stigma may be the biggest barriers to HIV testing. These results also suggest that interventions directed toward African-American heterosexual men must address the use of "testing as prevention" as well as correct misunderstandings of the window period and the meaning of HIV test results, and interventions should focus on communicating about HIV.

Sexual Health and Well-Being: A Framework to Guide Care.

Although the acceptance of sex positivity centering pleasure and justice has grown, clinical and public health strategies for sexually transmitted infection management have remained focused on risk and adverse outcomes. To promote sex-positive health care practice in clinical settings and beyond, health care practitioners should use an integrated, patient-centered approach to sexual health. These strategies include initiating discussions, continued sexual health education, providing informative material for patients, and knowledge of different communication strategies. Patient-provider interactions might be enhanced by using such methods.

"Straight Talk" for African-American heterosexual men: results of a single-arm behavioral intervention trial.

In the United States, heterosexual transmission is the second leading cause of HIV/AIDS, and two-thirds of all heterosexually acquired cases diagnosed between 2005 and 2008 occurred among African-Americans. Few HIV prevention interventions have been designed specifically for African-American heterosexual men not seeking clinical treatment. Here we report results of a single-arm intervention trial of a theory-based HIV prevention intervention designed to increase condom use, reduce concurrent partnering and increase HIV testing among heterosexually active African-American men living in high HIV prevalence areas of New York City. We tested our hypothesis using McNemar discordant pairs exact test for binary variables and paired t-tests for continuous variables. We observed statistically significant declines in mean number of total and new female partners, unprotected sex partners, and partner concurrency in both primary and nonprimary sex partnerships between baseline and 3 months postintervention.

Condom use and concurrent partnering among heterosexually active, African American men: a qualitative report.

African Americans are overrepresented among heterosexual cases of HIV/AIDS in the USA. Inconsistent condom use and concurrent partnering are two sexual behaviors driving the heterosexual HIV epidemic in the African American community. To inform the development of an HIV prevention behavioral intervention to decrease concurrent partnering and increase condom use among African American heterosexual men, we conducted formative research, including 61 structured interviews, 5 focus groups with 25 men, and 30 in-depth qualitative interviews between July and December 2009. We used a grounded theoretical approach and categorizing strategies to code and analyze the qualitative data. Results around condom use confirmed earlier findings among heterosexual men in general: condoms diminish pleasure, interfere with erection, and symbolize infidelity. Although valued by some as a form of disease prevention and pregnancy prevention, condoms are often used only with specific types of female partners, such as new or casual partners, or due to visual risk assessment. Sex partner concurrency was described as normative and ascribed to men's "natural" desire to engage in a variety of sexual activities or their high sex drive, with little recognition of the role it plays in the heterosexual HIV epidemic. Fatherhood emerged among many men as a crucial life event and compelling motivation for reducing sexual risk behavior. Based on these results, we conclude that existing HIV prevention efforts to improve attitudes towards and motivate use of condoms either have not reached or have not been successful with African American heterosexual men. In designing behavioral interventions to decrease concurrent partnering and increase condom use, addressing negative attitudes towards condoms and partner risk assessment is critical, as is integrating novel motivational approaches related to identity as fathers and men in the African American community.

"Whenever you're ready to talk about it": Prompts and barriers to inclusive family sex communication with gay, bisexual, and queer sons.

Despite growing evidence that parent-child sex communication (PCSC) is a positive strategy for adolescent sexual health outcomes, there is little research about what prompts and impedes these conversations among parents of gay, bisexual, and queer (GBQ) adolescent sons. Using interview data from a multi-method qualitative study, we analyzed parental perspectives (N=15) on non-heteronormative sex communication with GBQ adolescent sons. Our results revealed that parents are most likely to engage in sex communication if they established open communication with their child, accepted their child's sexual orientation, encouraged safe sex practices, and were knowledgeable about LGBTQ issues. Conversely, parents who experience communication discomfort were unable to engage in inclusive and comprehensive sex conversations, thus creating a barrier to effective sex-positive communication. These findings have implications for future research and interventions that promote parents' ability to successfully facilitate conversations about sexual health with their sexuality diverse children.

Factors associated with differential uptake of seasonal influenza immunizations among underserved communities during the 2009-2010 influenza season.

Influenza vaccination coverage remains low and disparities persist. In New York City, a community-based participatory research project (Project VIVA) worked to address this issue in Harlem and the South Bronx by supplementing existing vaccination programs with non-traditional venues (i.e., community-based organizations). We conducted a 10 min survey to assess access to influenza vaccine as well as attitudes and beliefs towards influenza vaccination that could inform intervention development for subsequent seasons. Among 991 participants recruited using street intercept techniques, 63% received seasonal vaccine only, 11% seasonal and H1N1, and 26% neither; 89% reported seeing a health care provider (HCP) during the influenza season. Correlates of immunization among those with provider visits during the influenza season included being US-born, interest in getting the vaccine, concern about self or family getting influenza, an HCP's recommendation and comfort with government. Among those without an HCP visit, factors associated with immunization included being US born, married, interest in getting the vaccine, understanding influenza information, and concern about getting influenza. Factors associated with lack of interest in influenza vaccine included being born outside the US, Black and uncomfortable with government. In medically underserved areas, having access to routine medical care and understanding the medical implications of influenza play an important role in enhancing uptake of seasonal influenza vaccination. Strategies to improve vaccination rates among Blacks and foreign-born residents need to be addressed. The use of non-traditional venues to provide influenza vaccinations in underserved communities has the potential to reduce health disparities.

Using an Intersectional Framework to Understand the Challenges of Adopting Pre-exposure Prophylaxis (PrEP) Among Young Adult Black Women.

Introduction: There is limited functional knowledge and utilization of pre-exposure prophylaxis (PrEP) among young adult Black cisgender women (YBW). Methods: We conducted four focus groups with YBW using an intersectional framework to explore multiple levels of factors that impede YBW awareness, interest, and utilization of PrEP in conjunction with their sexual and reproductive healthcare needs. Results: Influences at the cultural-environmental level included a lack of information and resources to access to PrEP and medical mistrust in the healthcare system. At the social normative level, influences included attitudes towards the long-term effects on sexual and reproductive health and self-efficacy to follow the PrEP regimen. At the proximal intrapersonal level, influences included anticipated HIV stigma from family and peers along with the fear of rejection from their main partners. Conclusions: Translation of these results indicated that interventions to increase PrEP utilization and adherence among YBW will require multi-level strategies to address barriers to integrating HIV prevention into sexual and reproductive healthcare.

Dimensions of Sexual Health Conversations among U.S. Black Heterosexual Couples.

Sexual health communication is an important feature of healthy intimate relationships; however, some couples may avoid discussing difficult matters (e.g., HIV/STI testing, sexual satisfaction) to minimize interpersonal conflict. From October 2018 to May 2019 in New York State, we conducted a multi-method descriptive pilot study to characterize Black heterosexual couples' (N = 28) sexual health conversations. Partners individually completed an online sexual health/relationship survey before engaging in-person for a joint dyadic qualitative in-depth interview. Quantitative descriptive statistics demonstrated that most absolute score differences among couple's preferences for sexual health outcomes, communal coping and sexual relationship power were mainly small, but greatest regarding extra-dyadic sexual behaviors. A qualitative descriptive approach discerned, motivation and norms for sexual health conversations, and communication patterns. Thematic and content analysis revealed two central themes: initiating and sustaining sexual health conversations, and leveraging features of the couples to promote sexual health. Integrated findings indicate that couples possess varied communication patterns that operate with motivations for sexual health conversations toward subsequent sexual health promotion. Equitable and skewed communication patterns emerged as relationship assets that can be leveraged to optimize sexual health. There is also opportunity for future work to address communication regarding extra-dyadic behavior and preferences. Asset-based considerations are discussed.

Race-Based Sexual Stereotypes, Gendered Racism, and Sexual Decision Making Among Young Black Cisgender Women.

Background. Due to their intersecting racial identity and gender identity, Black women are characterized by stigmatizing race-based sexual stereotypes (RBSS) that may contribute to persistent, disproportionately high rates of adverse sexual and reproductive health outcomes. RBSS are sociocognitive structures that shape Black women's social behavior including their sexual scripts. Objective. The purpose of this study was to explore the influence of RBSS on the sexual decision making of young Black women (YBW). Methods. We conducted four focus groups with 26 YBW between the ages of 18 and 25, living in a New York City neighborhood with a high HIV prevalence. Qualitative analysis was used to identify emergent themes within the domains of sexual decision making as it relates to safer sex practices and partner selection. Results. Thematic analyses revealed that RBSS may cause women to adopt more traditional gender stereotypes and less likely to feel empowered in the sexual decision making. Participants reported that RBSS may lead Black women to being resistant to learning new information about safer sex practices, feeling less empowered within intimate relationships, and jeopardizing their sexual well-being to affirm themselves in other social areas encouraging unprotected sex and relationships with men who have multiple sex partners. Discussion and Conclusion. Future research should focus on understanding the social and cultural factors that influence Black women's power in maintaining and improving their sexual health, including the aforementioned stereotypes that have influenced how others may view them as well as how they view themselves.

Applying a Nursing Perspective to Address the Challenges Experienced by Cisgender Women in the HIV Status Neutral Care Continuum: A Review of the Literature.

ABSTRACT: The field of HIV research has grown over the past 40 years, but there remains an urgent need to address challenges that cisgender women living in the United States experience in the HIV neutral status care continuum, particularly among women such as Black women, who continue to be disproportionately burdened by HIV due to multiple levels of systemic oppression. We used a social ecological framework to provide a detailed review of the risk factors that drive the women's HIV epidemic. By presenting examples of effective approaches, best clinical practices, and identifying existing research gaps in three major categories (behavioral, biomedical, and structural), we provide an overview of the current state of research on HIV prevention among women. To illustrate a nursing viewpoint and take into account the diverse life experiences of women, we provide guidance to strengthen current HIV prevention programs. Future research should examine combined approaches for HIV prevention, and policies should be tailored to ensure that women receive effective services that are evidence-based and which they perceive as important to their lives.

Participatory Design of a Web-Based HIV Oral Self-Testing Infographic Experiment (HOTIE) for Emerging Adult Sexual Minority Men of Color: A Mixed Methods Randomized Control Trial.

Health communication is a key health promotion approach for translating research findings into actionable information. The purpose of this study was to use participatory design to create and then test the usability and comprehension of an HIV self-testing infographic in a sample of 322 emerging adult, sexual minority men of color. Our study objectives addressed three challenges to HIV self-testing: (1) correct usage of the test stick, (2) understanding the number of minutes to wait before reading the result, and (3) how to correctly interpret a negative or a positive HIV result. This study was a two-phase, sequential, mixed methods, pilot, online, randomized controlled trial. Results suggested a significant mean difference between the control and intervention groups on HIV self-testing knowledge, with the control group outperforming the intervention group. However, two-thirds or better of the participants in the intervention group were able to comprehend the three critical steps to HIV self-testing. This was a promising finding that has resulted in the authors' development of additional recommendations for using participatory design for visual aid development in HIV prevention research. Participatory design of an HIV self-testing infographic is a rigorous approach, as a health communication strategy, to address public health priorities.

Just4Us: Development of a Counselor-Navigator and Text Message Intervention to Promote PrEP Uptake Among Cisgender Women at Elevated Risk for HIV.

ABSTRACT: In the United States, pre-exposure prophylaxis (PrEP) uptake among eligible cisgender women has been slow, despite the availability of oral PrEP since 2012. Although women make up nearly 20% of those living with HIV, there are currently few PrEP uptake interventions for cisgender women at elevated risk for acquiring HIV. Here we describe the process used to design and pre-pilot test Just4Us, a theory-based behavioral intervention to promote PrEP initiation and adherence among PrEP-eligible cisgender women. This work was part of a multiphase study conducted in New York City and Philadelphia, two locations with HIV rates higher than the national average. The counselor-navigator component of the intervention was designed to be delivered in a 60- to 90-min in-person session in the community, followed by several phone calls to support linkage to care. An automated text messaging program was also designed for adherence support. Just4Us addressed personal and structural barriers to PrEP uptake using an empowerment framework by building on women's insights and resources to overcome barriers along the PrEP cascade. Usability pre-pilot testing results were favorable and provided valuable feedback used to refine the intervention.

Sexual Orientation Identity Disparities in Mammography Among White, Black, and Latina U.S. Women.

Purpose: Our goal was to examine sexual orientation identity disparities in mammography in relationship to race/ethnicity among U.S. women. Methods: Using nationally representative 2013-2017 National Health Interview Survey data, we used multivariable logistic regression to estimate the odds of receiving a mammogram in the past year in relationship to sexual orientation identity among White, Black, and Latina U.S. women 40-75 years of age (N = 45,031) separately, adjusting for demographic factors. We also assessed whether socioeconomic and health care factors attenuated sexual orientation identity disparities in mammography across racial/ethnic groups. Results: Among White women, bisexual women had significantly lower adjusted odds of mammography compared to heterosexual women (odds ratio = 0.70, 95% confidence interval: 0.50-0.99). Among Black women, the adjusted odds of mammography were significantly higher among bisexual women relative to heterosexual women (2.53, 1.08-5.92). Black lesbian women appeared to have lower adjusted odds of mammography compared to their heterosexual counterparts; however, this difference was not statistically significant (0.80, 0.46-1.38). Similarly, among Latina women, lesbian women also seemed to have lower adjusted odds of mammography relative to heterosexual women, but this disparity was also not statistically significant (0.64, 0.37-1.13). Adding socioeconomic factors completely attenuated the disparity between White bisexual and heterosexual women (0.76, 0.52-1.10). Conclusions: Sexual orientation identity disparities in receiving a mammogram in the past year differed in relationship to race/ethnicity among White, Black, and Latina U.S. women. Additional research with larger samples of Black and Latina lesbian and bisexual women is needed to more accurately estimate and explain observed differences.

Utilization of an Animated Electronic Health Video to Increase Knowledge of Post- and Pre-Exposure Prophylaxis for HIV Among African American Women: Nationwide Cross-Sectional Survey.

BACKGROUND: Despite renewed focus on biomedical prevention strategies since the publication of several clinical trials highlighting the efficacy of pre-exposure prophylaxis (PrEP), knowledge of postexposure prophylaxis (PEP) and PrEP continues to remain scarce among women, especially among African American women who are disproportionally affected by HIV. In an effort to address this barrier and encourage uptake of PEP and PrEP, an electronic health (eHealth) video was created using an entertainment-education format. OBJECTIVE: The study aimed to explore the feasibility, acceptability, and preference of an avatar-led, eHealth video, PEP and PrEP for Women, to increase awareness and knowledge of PEP and PrEP for HIV in a sample of African American women. METHODS: A cross-sectional, Web-based study was conducted with 116 African American women aged 18 to 61 years to measure participants' perceived acceptability of the video on a 5-point scale: poor, fair, good, very good, and excellent. Backward stepwise regression was used to the find the outcome variable of a higher rating of the PEP and PrEP for Women video. Thematic analysis was conducted to explore the reasons for recommending the video to others after watching the eHealth video. RESULTS: Overall, 89% of the participants rated the video as good or higher. A higher rating of the educational video was significantly predicted by: no current use of drugs/alcohol (beta=-.814; P=.004), not having unprotected sex in the last 3 months (beta=-.488; P=.03), higher income (beta=.149; P=.03), lower level of education (beta=-.267; P=.005), and lower exposure to sexual assault since the age of 18 years (beta=-.313; P=.004). After watching the eHealth video, reasons for recommending the video included the video being educational, entertaining, and suitable for women. CONCLUSIONS: Utilization of an avatar-led eHealth video fostered education about PEP and PrEP among African American women who have experienced insufficient outreach for biomedical HIV strategies. This approach can be leveraged to increase awareness and usage among African American women.

Getting youth PrEPared: adolescent consent laws and implications for the availability of PrEP among youth in countries outside of the United States.

INTRODUCTION: Youth under the age of 25 are at high risk for HIV infection. While pre-exposure prophylaxis (PrEP) has the potential to curb new infections within this population, it is unclear how country-specific laws and policies that govern youth access to sexual and reproductive health (SRH) services impact access to PrEP. The purpose of this review was to analyse laws and policies concerning PrEP implementation and SRH services available to youth in countries with a high HIV incidence. To the best of our knowledge this is the first systematic assessment of country-level policies that impact the availability of PrEP to adolescent populations. METHODS: We conducted a review of national policies published on or before 12 June 2018 that could impact adolescents' access to PrEP, SRH services and ability to consent to medical intervention. Countries were included if: (1) there was a high incidence of HIV; (2) they had active PrEP trials or PrEP was available for distribution; (3) information regarding PrEP guidelines were publicly available. We also included a selected number of countries with lower adolescent HIV incidence. Internet and legal database searches were used to identify policies relevant to adolescent PrEP (e.g. age of consent to HIV testing). RESULTS AND DISCUSSION: Fifteen countries were selected for inclusion in this review. Countries varied considerably in their respective laws and policies governing adolescents' access to PrEP, HIV testing and SRH services. Six countries had specific polices around the provision of PrEP to youth under the age of 18. Five countries required people to be 18 years or older to access HIV testing, and six countries had specific laws addressing adolescent consent for- and access to- contraceptives. CONCLUSIONS: Adolescents' access to PrEP without parental consent remains limited or uncertain in many countries where this biomedical intervention is needed. Observational and qualitative studies are needed to determine if and how adolescent consent laws are followed in relation to adolescent PrEP provisions. Intensified efforts to amend laws that limit adolescent access to PrEP and restrict the establishment of national guidelines supporting adolescent PrEP are also needed to address the epidemic in this group.

Transactional Sex, Substance Use, and Sexual Risk: Comparing Pay Direction for an Internet-Based U.S. Sample of Men Who Have Sex with Men.

Demographic, behavioral, and structural factors among four mutually exclusive transactional sex categories were assessed in an online sample of 7217 sexually active US men who have sex with men (MSM): (1) No Trade Sex group (87%); (2) Sellers, accepting money or drugs for sex (5%); (3) Buyers, giving money or drugs for sex (6%); and (4) Sellers and Buyers, accepting and giving money or drugs for sex (2%). Separate multivariable logistic regressions compared men who did not report past 60-day transactional sex with men in the three transactional sex groups. Sellers were more likely to report being black or Asian (versus white), low income, a recent STI diagnosis, six or more recent male anal sex partners, and polydrug use. Buyers were more likely to report being older, higher income, urban residence, incarceration history, a recent STI diagnosis, and having non-main sex partners. Sellers and Buyers were more likely to report a higher income, incarceration history, six or more recent male anal sex partners, and polydrug use. Findings suggest that public health policy and HIV prevention harm reduction strategies should address the distinct sexual and behavioral risk patterns among MSM who engage in transactional sex based on payment direction.