Barriers and facilitators to HIV pre-exposure prophylaxis uptake among transgender women in Colombia: A qualitative analysis using the COM-B model.

Transgender women [TGW] in Colombia are disproportionately affected by HIV due to their low sociodemographic conditions, varied risk behaviours, difficulty accessing health services, and discrimination. Offering pre-exposure prophylaxis [PrEP] as part of a combination of prevention strategies is an appropriate option for this population to reduce their risk of HIV infection. However, little is known about how to implement a PrEP program for TGW in Colombia. Between June and October 2020, we conducted individual interviews with 16 TGW from four different cities in Colombia. The interviews assessed contextual influences, knowledge, skills, perceptions, and beliefs. We used qualitative thematic analysis to identify themes and the Capability, Opportunity, Motivation, and Behavior framework to further delineate barriers and possible interventions. After delineating the main themes across the three subdomains of the model, nine barriers were identified: one related to capability, knowledge, and perception of PrEP; six related to opportunity, which includes, family relations, sexual work environment, stable partner relations, interactions with healthcare workers, health service provision, and community interactions and opportunities; and two related to motivation, mental health, and concerns about medication side effects. Mapping barriers with interventions generated the following intervention functions: education, training, enablement, and environmental structure; and the following policy functions: communication/marketing, legislation, and changes in service provision. Examples of possible interventions are presented and discussed.

AC-2020-12-1420.R1 - HIV care providers' familiarity, concerns, and attitudes about HIV PrEP in Colombia: insights from the PrEP-Col-Study.

In 2019, Colombia approved the combination of tenofovir disoproxil fumarate/emtricitabine for HIV Pre-Exposure Prophylaxis (PrEP). Therefore, we conducted a situational analysis in HIV-care providers to identify barriers and facilitators for PrEP implementation. A survey was applied to a non-probabilistic sample of health care workers of HIV-specialized clinics. We examined PrEP awareness and familiarity, comfort with PrEP-related activities, perceived barriers for PrEP implementation, concerns, and attitudes. Poisson regressions assessed the relationship between these factors and the variable "having a plan to offer PrEP". The participation rate was 41% and included physicians (42.6%) and other health professionals (57.4%). Fifty-one percent of the participants reported more than five years of experience caring for people living with HIV. Forty-two percent of non-physician health care workers were nurses. Most reported high familiarity/comfort with PrEP-relevant activities. Concerns about PrEP were prevalent (> 50%) and included causing more harm than good, reducing condom use, medication non-adherence, drug resistance, and healthcare system barriers. Physicians had a plan to offer PrEP (72.2%) more often than other health professionals (52.6). Having a plan to offer PrEP was related to PrEP knowledge and comfort assessing sexual behavior and providing HIV counseling. Overall, about half of HIV-care providers seemed ready to offer PrEP and constitute an asset for PrEP implementation efforts in Colombia. PrEP awareness among non-physicians, PrEP concerns, and negative attitudes need to be addressed to enhance implementation.

Scales to Assess Knowledge, Motivation, and Self-Efficacy for HIV PrEP in Colombian MSM: PrEP-COL Study.

OBJECTIVE: We evaluated the construct validity Spanish version of knowledge, stigma, norms, and self-efficacy scales regarding PrEP in MSM. METHODS: Sample of 287 MSM. Exploratory confirmatory factor analysis and item response theory were used to validate the constructs. Correlations and confidence interval-based estimation of relevance analyses were conducted to correlate the scales with willingness and intention to use PrEP. RESULTS: Attitude, stigma, and descriptive and subjective norms scales showed good construct validity and were related to intention and willingness to use PrEP. However, the knowledge scale and self-efficacy scales require further refinement. CONCLUSIONS: The study provides useful information for assessing information, motivation, and self-efficacy related to PrEP use. Our results could be used to test the scales and the theoretical model in other contexts to confirm their usefulness.

Examining a syndemic framework for HIV and sexually transmitted infections risk in Cali, Colombia / Examinando un marco sindémico para el VIH y el riesgo de infecciones de transmisión sexual en Cali, Colombia / Examinando um marco sindémico para o vih e o risco de infeções de transmissão sexual em Cali, Colômbia

Abstract Objective: We examined the role played by four psychosocial conditions: forced sex, early sexual initiation, and misuse of alcohol and illicit drugs on the risk of HIV and sexually transmitted infections in Cali-Colombia between 2013 and 2015. Methods: Using data from an HIV counseling and testing campaign in Cali, Colombia, we tested the effect of the accumulation and interactions of the four psychosocial conditions on both outcomes. Results: A total of 604 participants were representative subjects from key affected communities: men who have sex with men, transgender women and female sex workers. A total of 733 participants were heterosexual women and men. Only drug abuse was associated with HIV positivity (Prevalence ratio=2.3, CI 95%: 1.3-4.1), while all psychosocial conditions were associated with sexually transmitted infection history. The accumulation of the syndemic conditions was related to a higher likelihood of sexually transmitted infection history. None of the interactions tested was significant. Conclusions: Our findings highlight the importance of comprehensive mental health interventions in addressing HIV epidemics in Colombia.

Resumen Objetivo: Examinar el papel desempeñado por cuatro afecciones psicosociales: sexo forzado, iniciación sexual temprana, uso inadecuado de alcohol y drogas ilícitas en el riesgo de VIH e infecciones de transmisión sexual, en Cali-Colombia entre 2013-2015. Métodos: Utilizando datos de una campaña de consejería y pruebas de VIH en Cali, Colombia, probamos el efecto de la acumulación e interacciones de las cuatro condiciones psicosociales en la positividad al VIH y la positividad a otras enfermedades de transmisión sexual. Resultados: 604 participantes de las principales comunidades afectadas: hombres que tienen sexo con hombres, mujeres transgénero y trabajadoras sexuales. 733 participantes mujeres y hombres heterosexuales. Solo, abuso de drogas se asoció con positividad VIH (Razón de prevalencia = 2.3, IC 95%: 1.3-4.1), mientras que, todas las condiciones psicosociales se asociaron con historia de infecciones de transmisión sexual. La acumulación de condiciones sindémicas se relacionó con mayor probabilidad de historia de infecciones de transmisión sexual. Ninguna interacción probada fue significativa. Conclusiones: Nuestros hallazgos resaltan la importancia de intervenciones integrales de salud mental para abordar la epidemia de VIH en Colombia.

Resumo Objetivo: Examinar o papel desempenhado por quatro afeções psicossociais: sexo forçado, iniciação sexual precoce, uso inadequado de álcool e drogas ilícitas no risco de VIH e infeções de transmissão sexual, em Cali-Colômbia entre 2013-2015. Métodos: Utilizando dados duma campanha de aconselhamento e testes de VIH em Cali, Colômbia, testamos o efeito da acumulação e interações das quatro condições psicossociais na positividade ao VIH e a positividade a outras doenças de transmissão sexual. Resultados: 604 participantes das principais comunidades afetadas: homens que tem sexo com homens, mulheres transgênero e trabalhadoras sexuais. 733 participantes mulheres e homens heterossexuais. Só, abuso de drogas se associou com positividade VIH (Razão de prevalência = 2.3, IC 95%: 1.3-4.1), enquanto que, todas as condições psicossociais se associaram com história de infeções de transmissão sexual. Acumulação de condições sindémicas (palavra que reúne o social e o biológico) se relacionou com maior probabilidade de história de infeções de transmissão sexual. Nenhuma interação provada foi significativa. Conclusões: Nossos descobrimentos ressaltam a importância de intervenções integrais de saúde mental para abordar a epidemia de VIH na Colômbia.

Examining a syndemic framework for HIV and Sexually Transmitted Infections Risk in Cali, Colombia / Examinando un marco sindémico para el VIH y el riesgo de infecciones de transmisión sexual en Cali, Colombia / Examinando um marco sindémico para o vih e o risco de infeções de transmissão sexual em Cali, Colômbia

Objective: We examined the role played by four psychosocial conditions: forced sex, early sexual initiation, and misuse of alcohol and illicit drugs on the risk of HIV and sexually transmitted infections in Cali-Colombia between 2013 and 2015. Methods: Using data from an HIV counseling and testing campaign in Cali, Colombia, we tested the effect of the accumulation and interactions of the four psychosocial conditions on both outcomes. Results: A total of 604 participants were representative subjects from key affected communities: men who have sex with men, transgender women and female sex workers. A total of 733 participants were heterosexual women and men. Only drug abuse was associated with HIV positivity (Prevalence ratio=2.3, CI 95%: 1.3­4.1), while all psychosocial conditions were associated with sexually transmitted infection history. The accumulation of the syndemic conditions was related to a higher likelihood of sexually transmitted infection history. None of the interactions tested was significant. Conclusions: Our findings highlight the importance of comprehensive mental health interventions in addressing HIV epidemics in Colombia.

Objetivo: Examinar el papel desempeñado por cuatro afecciones psicosociales: sexo forzado, iniciación sexual temprana, uso inadecuado de alcohol y drogas ilícitas en el riesgo de VIH e infecciones de transmisión sexual, en Cali-Colombia entre 2013-2015. Métodos: Utilizando datos de una campaña de consejería y pruebas de VIH en Cali, Colombia, probamos el efecto de la acumulación e interacciones de las cuatro condiciones psicosociales en la positividad al VIH y la positividad a otras enfermedades de transmisión sexual. Resultados: 604 participantes de las principales comunidades afectadas: hombres que tienen sexo con hombres, mujeres transgénero y trabajadoras sexuales. 733 participantes mujeres y hombres heterosexuales. Solo, abuso de drogas se asoció con positividad VIH (Razón de prevalencia = 2.3, IC 95%: 1.3­4.1), mientras que, todas las condiciones psicosociales se asociaron con historia de infecciones de transmisión sexual. La acumulación de condiciones sindémicas se relacionó con mayor probabilidad de historia de infecciones de transmisión sexual. Ninguna interacción probada fue significativa. Conclusiones: Nuestros hallazgos resaltan la importancia de intervenciones integrales de salud mental para abordar la epidemia de VIH en Colombia

Objetivo: Examinar o papel desempenhado por quatro afeções psicossociais: sexo forçado, iniciação sexual precoce, uso inadequado de álcool e drogas ilícitas no risco de VIH e infeções de transmissão sexual, em Cali-Colômbia entre 2013-2015. Métodos: Utilizando dados duma campanha de aconselhamento e testes de VIH em Cali, Colômbia, testamos o efeito da acumulação e interações das quatro condições psicossociais na positividade ao VIH e a positividade a outras doenças de transmissão sexual. Resultados: 604 participantes das principais comunidades afetadas: homens que tem sexo com homens, mulheres transgênero e trabalhadoras sexuais. 733 participantes mulheres e homens heterossexuais. Só, abuso de drogas se associou com positividade VIH (Razão de prevalência = 2.3, IC 95%: 1.3­4.1), enquanto que, todas as condições psicossociais se associaram com história de infeções de transmissão sexual. Acumulação de condições sindémicas (palavra que reúne o social e o biológico) se relacionou com maior probabilidade de história de infeções de transmissão sexual. Nenhuma interação provada foi significativa. Conclusões: Nossos descobrimentos ressaltam a importância de intervenções integrais de saúde mental para abordar a epidemia de VIH na Colômbia.

Psychometric properties and validity of the Center for Epidemiological Studies Depression Scale (CES-D) in a population attending an HIV clinic in Cali, Colombia / Propiedades psicométricas y validez de la escala de depresión del Center for Epidemiological Studies (CES-D) en personas atendidas en una clínica de HIV en Cali, Colombia

INTRODUCTION: Depression in people living with HIV/AIDS is associated with poor health outcomes. Despite this, assessment of depressive symptoms is not a routine clinical practice in the care of people with HIV in Colombia. One reason could be the lack of validated depression screening scales for this population. OBJECTIVE: To test the reliability and construct validity of the 20- and 10-item-Center for Epidemiological Studies Depression Scale in patients attending an HIV clinic in Cali, Colombia. MATERIALS AND METHODS: A non-random sample of 105 adults was enrolled. The 20 item-CES-D (CES-D-20) scale was administered twice: At baseline and 2-4 weeks later. We calculated the Cronbach's alpha coefficient and the intraclass correlation coefficient. In addition, we used an exploratory and confirmatory factorial analysis, as well as the item response theory to assess the validity of the scale. RESULTS: Most participants were men (73%), with a mean age of 40 years, 53% of whom had not completed high school. Cronbach's coefficients were 0.92 and 0.94 at baseline and at the second interview, respectively. The intraclass correlation was 0.81 (95% CI: 0.72-0.88). Although all 20 items loaded distinctly in 4 factors, 5 items did not load as expected. The structure factor of the CES-D-20 was not confirmed, as 4 items had poor goodness of fit. The CES-D-10 appeared to perform better in this population. CONCLUSIONS: These results support the reliability and validity of the CES-D-10 instrument to screen for depressive symptoms in people living with HIV in Colombia.

Introducción. La depresión en personas con HIV/sida se asocia con resultados negativos para la salud. La evaluación de los síntomas depresivos no es una práctica clínica rutinaria en el cuidado de personas con HIV/sida en Colombia, lo cual puede deberse a la carencia de escalas validadas para la tamización de la depresión en esta población. Objetivo. Evaluar la reproducibilidad y validez de constructo de dos versiones de la escala de depresión del Center for Epidemiological Studies (CES-D), la de 20 ítems y la de 10 ítems, en personas con HIV/sida atendidas en una clínica de Cali, Colombia. Materiales y métodos. Se seleccionó una muestra no probabilística de 105 adultos con HIV/sida. La escala CES-D se utilizó dos veces (línea basal y 2 a 4 semanas después). La consistencia interna fue evaluada con el coeficiente alfa de Cronbach. La reproducibilidad se evaluó con el coeficiente de correlación intraclase. Para verificar la validez del constructo se utilizó un análisis factorial exploratorio y la teoría de respuesta al ítem. Resultados. El 73 % de la muestra correspondía a hombres, la edad promedio fue de 40 años y el 53 % tenía baja escolaridad. El coeficiente alfa de Cronbach fue de 0,92 (línea basal) y de 0,94 (segunda entrevista). El coeficiente de correlación intraclase fue de 0,81 (IC95% 0,72-0,88). Aunque en cuatro de los factores en la escala de 20 ítems claramente hubo carga factorial, cinco de los ítems no tuvieron un ajuste adecuado. La CES-D de 10 ítems parece funcionar mejor en esta población. Conclusiones. Los resultados respaldaron la reproducibilidad y la validez de la escala CES-D para la tamización de síntomas depresivos en personas con HIV/sida en Colombia.

Psychometric properties and validity of the Center for Epidemiological Studies Depression Scale (CES-D) in a population attending an HIV clinic in Cali,Colombia / Propiedades psicométricas y validez de la escala de depresión del Center for Epidemiological Studies (CES-D) en personas atendidas en una clínica de HIV en Cali, Colombia

Abstract Introduction: Depression in people living with HIV/AIDS is associated with poor health outcomes. Despite this, assessment of depressive symptoms is not a routine clinical practice in the care of people with HIV in Colombia. One reason could be the lack of validated depression screening scales for this population. Objective: To test the reliability and construct validity of the 20- and 10-item-Center for Epidemiological Studies Depression Scale in patients attending an HIV clinic in Cali, Colombia. Materials and methods: A non-random sample of 105 adults was enrolled. The 20 item- CES-D (CES-D-20) scale was administered twice: At baseline and 2-4 weeks later. We calculated the Cronbach's alpha coefficient and the intraclass correlation coefficient. In addition, we used an exploratory and confirmatory factorial analysis, as well as the item response theory to assess the validity of the scale. Results: Most participants were men (73%), with a mean age of 40 years, 53% of whom had not completed high school. Cronbach's coefficients were 0.92 and 0.94 at baseline and at the second interview, respectively. The intraclass correlation was 0.81 (95% CI: 0.72- 0.88). Although all 20 items loaded distinctly in 4 factors, 5 items did not load as expected. The structure factor of the CES-D-20 was not confirmed, as 4 items had poor goodness of fit. The CES-D-10 appeared to perform better in this population. Conclusions: These results support the reliability and validity of the CES-D-10 instrument to screen for depressive symptoms in people living with HIV in Colombia.

Resumen Introducción: La depresión en personas con HIV/sida se asocia con resultados negativos para la salud. La evaluación de los síntomas depresivos no es una práctica clínica rutinaria en el cuidado de personas con HIV/sida en Colombia, lo cual puede deberse a la carencia de escalas validadas para la tamización de la depresión en esta población. Objetivo. Evaluar la reproducibilidad y validez de constructo de dos versiones de la escala de depresión del Center for Epidemiological Studies (CES-D), la de 20 ítems y la de 10 ítems, en personas con HIV/sida atendidas en una clínica de Cali, Colombia. Materiales y métodos. Se seleccionó una muestra no probabilística de 105 adultos con HIV/sida. La escala CES-D se utilizó dos veces (línea basal y 2 a 4 semanas después). La consistencia interna fue evaluada con el coeficiente alfa de Cronbach. La reproducibilidad se evaluó con el coeficiente de correlación intraclase. Para verificar la validez del constructo se utilizó un análisis factorial exploratorio y la teoría de respuesta al ítem. Resultados. El 73 % de la muestra correspondía a hombres, la edad promedio fue de 40 años y el 53 % tenía baja escolaridad. El coeficiente alfa de Cronbach fue de 0,92 (línea basal) y de 0,94 (segunda entrevista). El coeficiente de correlación intraclase fue de 0,81 (IC95% 0,72-0,88). Aunque en cuatro de los factores en la escala de 20 ítems claramente hubo carga factorial, cinco de los ítems no tuvieron un ajuste adecuado. La CES-D de 10 ítems parece funcionar mejor en esta población. Conclusiones. Los resultados respaldaron la reproducibilidad y la validez de la escala CES-D para la tamización de síntomas depresivos en personas con HIV/sida en Colombia.

Individual- and regional-level determinants of human papillomavirus (HPV) vaccine refusal: the Ontario Grade 8 HPV vaccine cohort study.

BACKGROUND: Studies on the determinants of human papillomavirus (HPV) vaccine use have generally focused on individual-level characteristics, despite the potentially important influence of regional-level characteristics. Therefore, we undertook a population-based, retrospective cohort study to identify individual- and regional-level determinants of HPV vaccine refusal (non-receipt) in Ontario's (Canada) Grade 8 HPV Immunization Program. METHODS: Ontario's administrative health and immunization databases were used to identify girls eligible for free HPV vaccination in 2007-2011 and to ascertain individual-level characteristics of cohort members (socio-demographics, vaccination history, health care utilization, medical history). The social and material characteristics of the girl's region (health unit) were derived from the 2006 Canadian Census. Generalized estimating equations (binomial distribution, logit link) were used to estimate the population-average effects of individual- and regional-level characteristics on HPV vaccine refusal. RESULTS: Our cohort consisted of 144,047 girls, 49.3% of whom refused HPV vaccination. Factors associated with refusal included a previous diagnosis of Down's syndrome (OR = 1.37, 95% CI 1.16-1.63) or autism (OR = 1.60, 95% CI 1.34-1.90), few physician visits (OR = 1.45, 95% CI 1.35-1.55), and previous refusal of mandatory (OR = 2.23, 95% CI 2.07-2.40) and optional (OR = 3.96, 95% CI 3.87-4.05) vaccines. Refusal was highest among the lowest and highest income levels. Finally, a previous diagnosis of obesity and living in an area of high deprivation were associated with lower refusal (OR = 0.87, 95% CI 0.83-0.92 and OR = 0.82 95%, CI 0.79-0.86, respectively). CONCLUSIONS: Studies on HPV vaccine determinants should consider regional-level factors. Efforts to increase HPV vaccine acceptance should include vulnerable populations (such as girls of low income) and girls with limited contact with the healthcare system.

HIV Testing and Counselling in Colombia: Local Experience on Two Different Recruitment Strategies to Better Reach Low Socioeconomic Status Communities.

HIV testing rates remain very low in Colombia, with only 20% of individuals at risk ever tested. In order to tackle this issue, the Corporacion de Lucha Contra el Sida (CLS) has implemented a multidisciplinary, provider-initiated, population-based HIV testing/counselling strategy named BAFI. In this report, we describe the experience of CLS at reaching populations from low socioeconomic backgrounds in 2008-2009. Two different approaches were used: one led by CLS and local health care providers (BAFI-1) and the other by CLS and community leaders (BAFI-2). Both approaches included the following: consented HIV screening test, a demographic questionnaire, self-reported HIV knowledge and behaviour questionnaires, pre- and posttest counselling, confirmatory HIV tests, clinical follow-up, access to comprehensive care and antiretroviral treatment. A total of 2085 individuals were enrolled in BAFI-1 and 363 in BAFI-2. The effectiveness indicators for BAFI-1 and BAFI-2, respectively, were HIV positive-confirmed prevalence = 0.29% and 3.86%, return rate for confirmatory results = 62.5% and 93.7%, return rate for comprehensive care = 83.3% and 92.8%, and ART initiation rate = 20% and 76.9%. Although more people were reached with BAFI-1, the community-led BAFI-2 was more effective at reaching individuals with a higher prevalence of behavioural risk factors for HIV infection.

Income and economic exclusion: do they measure the same concept?

INTRODUCTION: In this paper, we create an index of economic exclusion based on validated questionnaires of economic hardship and material deprivation, and examine its association with health in Canada. The main study objective is to determine the extent to which income and this index of economic exclusion index are overlapping measurements of the same concept. METHODS: We used the Canadian Household Panel Survey Pilot and performed multilevel analysis using a sample of 1588 individuals aged 25 to 64, nested within 975 households. RESULTS: While economic exclusion is inversely correlated with both individual and household income, these are not perfectly overlapping constructs. Indeed, not only these indicators weakly correlated, but they also point to slightly different sociodemographic groups at risk of low income and economic exclusion. Furthermore, the respective associations with health are of comparable magnitude, but when these income and economic exclusion indicators are included together in the same model, they point to independent and cumulative, not redundant effects. CONCLUSIONS: We explicitly distinguish, both conceptually and empirically, between income and economic exclusion, one of the main dimensions of social exclusion. Our results suggest that the economic exclusion index we use measures additional aspects of material deprivation that are not captured by income, such as the effective hardship or level of economic 'well-being'.