Dismantling Barriers and Transforming the Future of Pre-Exposure Prophylaxis Uptake in Young Black and Latinx Sexual Minority Men and Transgender Women.

Pre-exposure prophylaxis (PrEP) has the potential to transform HIV in young Black and Latinx sexual minority men (SMM) and transgender women (TW). Addressing low PrEP uptake in this population depends on the better understanding of barriers to PrEP use. This article uses an ecological framework to explore barriers to daily oral PrEP in a sample of young Black and Latinx SMM and TW in three geographically prioritized cities in the United States. In-depth interviews were completed with 33 young Black and Latinx SMM and TW (22 at risk for and 11 recently diagnosed with HIV), aged 17-24, participating in a randomized trial aimed at increasing PrEP and antiretroviral therapy (ART) uptake and adherence. Interviews were recorded and transcribed, and then analyzed using inductive and deductive coding. Coded transcripts were organized into individual, interpersonal, community, and structural categories, by PrEP use and HIV status. Among participants, nine reported having been prescribed PrEP, with five actively or recently taking PrEP, whereas only one participant diagnosed with HIV had been prescribed PrEP. Major themes related to barriers emerged across the individual, family, community, and structural level. Limited barriers related to partners, instead partners with HIV encouraged PrEP use. Participants commonly reported low perceived HIV risk, fear of disclosure, barriers relating to insurance/cost, and medication use as reasons for nonuse of PrEP. For youth to remain on a healthy life course, HIV preventative measures will need to be adopted early in adolescence for those at risk of HIV acquisition. Interventions need to simultaneously address multilevel barriers that contribute to nonuse in adolescents. Clinical trials registry site and number: ClinicalTrials.gov Identifier: NCT03194477.

Barriers and Facilitators to HIV Testing Among Adolescents and Young Adults in Washington, District of Columbia: Formative Research to Inform the Development of an mHealth Intervention.

BACKGROUND: Adolescents and young adults (AYA) in the United States, and in Washington, District of Columbia (DC), specifically, are disproportionately affected by HIV. Both the national Ending the HIV Epidemic initiative and DC-specific plans emphasize HIV testing, and innovative strategies to encourage testing among AYA are needed. OBJECTIVE: The purpose of this study is to identify sexual behaviors, HIV knowledge, HIV perceptions (eg, susceptibility and severity), and perceived barriers and facilitators to HIV testing among AYA at risk for HIV in DC. METHODS: This study was part of a larger study to determine the acceptability of using a life-and-dating simulation game to increase HIV testing among AYA. Focus groups and surveys stratified by self-reported sexual orientation were conducted among, and administered to, AYA aged 13-24 years in DC. HIV knowledge was explored during focus groups and measured using an adapted version of the Brief HIV Knowledge Questionnaire. Survey data were summarized using descriptive statistics and compared by self-reported sexual orientation. Transcripts were thematically analyzed. RESULTS: Of the 46 AYA who participated in the focus groups, 30 (65%) identified as heterosexual and 16 (35%) as lesbian, gay, bisexual, transgender, or queer. A higher proportion of lesbian, gay, bisexual, transgender, or queer AYA reported sexual activity (12/16, 75%, vs 18/30, 60%), condomless sex (11/12, 92%, vs 15/18, 83%), and HIV testing (13/16, 81%, vs 17/29, 58%) than heterosexual AYA. HIV prevention ("condoms" and "...PrEP") and transmission ("exchange of fluids") knowledge was high, and most (34/44, 77%) of the AYA perceived HIV testing as beneficial. However, the AYA also demonstrated some misinformation concerning HIV: an average of 67% (31/46; SD 0.474) of the participants believed that an HIV test could deliver accurate results 1 week after a potential exposure and an average of 72% (33/46; SD 0.455) believed that an HIV vaccine exists. The AYA also identified individual ("...people...are scared"), interpersonal ("it's an awkward conversation"), and structural ("...people don't...know where they can go") barriers to testing. Most of the AYA indicated that they were very likely to use the demonstrated game prototype to help with getting tested for HIV (median 3.0, IQR 2.0-3.0, using a scale ranging from 0 to 3, with 3 indicating high likelihood) and strongly agreed that the game was interesting (median 5.0, IQR 5.0-5.0), fun (median 5.0, IQR 4.0-5.0), and easy to learn (median 5.0, IQR 5.0-5.0, using a scale ranging from 1 to 5, with 5 indicating strong agreement). CONCLUSIONS: These results suggest a need for multilevel HIV testing interventions and informed the development of a mobile health intervention aiming to increase HIV knowledge and risk perception among AYA, while reducing barriers to testing at the individual and structural levels, supporting efforts to end the domestic HIV epidemic.

Recruitment of Youth Living With HIV to Optimize Adherence and Virologic Suppression: Testing the Design of Technology-Based Community Health Nursing to Improve Antiretroviral Therapy (ART) Clinical Trials.

BACKGROUND: Despite advances in HIV diagnosis and treatment, adolescents and young adults 12-25 years old have high HIV incidence, poor engagement and retention in treatment, and low rates of adherence and virologic suppression when compared to their older counterparts. HIV has emerged as a chronic disease for which antiretroviral therapy (ART) adherence is critical for virologic suppression and long-term survival. Virologic suppression has been elusive for many youth with HIV (YHIV). Novel strategies designed to facilitate health care systems' support for YHIV between medical visits are essential for improving ART adherence, virologic suppression, and long-term survival. OBJECTIVE: The aim of this study is to compare the effectiveness of a technology-enhanced community health nursing intervention (TECH2CHECK) to a standard of care (SOC) control group for improving ART adherence and subsequent viral suppression using a randomized trial design. The objectives are to assess the feasibility, acceptability, and cost-effectiveness of TECH2CHECK as compared to SOC for management of HIV in the outpatient setting and to examine the sustainability of self-care behavior, adherence, and virologic suppression among youth following the intervention period. METHODS: We will recruit 120 adherence-challenged YHIV being followed at clinics specializing in HIV care in the Baltimore-Washington metropolitan area and in Jacksonville. Eligible participants complete an audio, computer-assisted self-interview and are randomized to either TECH2CHECK intervention or the SOC (60 participants in each arm). The primary outcome of interest is virologic suppression (viral load <20 copies/mL) and improved treatment adherence. Participants in the intervention arm receive community health nursing visits at 2 weeks, 6 weeks, 10 weeks, 14 weeks, and 26 weeks. The intervention arm also receives SMS messaging comprising daily adherence and appointment reminders and positive reinforcement for medication adherence daily for 2 weeks, on alternate days for 2 weeks, thrice weekly for 1 month, weekly for 3 months, and every 2 weeks for the rest of the study duration. The control group receives appointment reminders and SOC per clinic protocol. Exploratory analysis will be conducted to determine differences in medication adherence and virologic suppression in the 2 arms and to assess cost-effectiveness and study feasibility and acceptability. RESULTS: In the first 23 months of the study (July 2018-April 2020), 56 (55%) of 102 eligible patients were enrolled and randomized. At present, participating youths are primarily African American (53/56, 95%), male (37/56, 66%), and ≥18 years old (53/56, 95%). Follow-up study visits, as required per the protocol, have been completed by 77% (43/56), 94% (45/48), 95% (37/39), 96% (24/25), and 100% (10/10) of participants at the 1-month, 3-month, 6-month, 12-month, and 18-month follow-ups, respectively. CONCLUSIONS: Preliminary accrual and retention data suggest that TECH2CHECK is feasible and acceptable. TRIAL REGISTRATION: ClinicalTrials.gov NCT03600103 https://clinicaltrials.gov/ct2/show/NCT03600103. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/23480.

Providing Unique Support for Health Study Among Young Black and Latinx Men Who Have Sex With Men and Young Black and Latinx Transgender Women Living in 3 Urban Cities in the United States: Protocol for a Coach-Based Mobile-Enhanced Randomized Control Trial.

BACKGROUND: The US National HIV/AIDS Strategy 2020 calls for increasing access to care, improving outcomes of people living with HIV, and targeting biomedical prevention efforts, including access to pre-exposure prophylaxis (PrEP) in communities where HIV is most heavily concentrated. The cities of Baltimore, Maryland (MD); Washington, DC; and Philadelphia, Pennsylvania (PA) are disproportionately burdened by high rates of new cases of HIV infection, with high prevalence among young Black and Latinx men who have sex with men (YBLMSM) and young Black and Latinx transgender women (YBLTW) aged 15-24 years. OBJECTIVE: This study aims (1) to identify and recruit YBLMSM and YBLTW who are at risk or living with HIV in Baltimore, MD; Philadelphia, PA; and Washington, DC, using respondent-driven sampling (RDS) with targeted seed selection, and (2) to assess the efficacy of a coach-based mobile-enhanced intervention (MEI) compared with standard of care (SOC) to increase successful engagement and retention into HIV, PrEP, and substance use treatment care across the HIV care and prevention continua in 3 Mid-Atlantic cities. This paper describes the protocol and progress as of October 20, 2019. METHODS: This study uses a multiphase mixed methods design. The first phase is a formative, qualitative research with focus group discussions and key informant interviews. The second phase consists of evaluating the ability of RDS with targeted seed selection. The third phase includes 2 embedded randomized controlled trials (RCTs), where participants complete a baseline sociobehavioral survey, rapid HIV testing, and eligible youth enroll in parallel status-dependent RCTs that randomize the participant to 1 of 2 study arms: MEI with coach or SOC. Participants are asked to complete a web-based survey and provide biologic specimens-HIV-1 RNA (viral load) or HIV-1 antibody test and urine drug screen-at baseline and at 3, 6, and 12 months, and an exit interview at 18 months. RESULTS: A formative qualitative research was conducted in February 2017 and May 2018, and this led to further refinement of recruitment and study methods. Aim 1 recruitment began in September 2017 with subsequent enrollment into the RCTs. Recruitment is ongoing with 520 participants screened and 402 (77.3%) enrolled in aim 1 by October 2020. Of these, 159 are enrolled in the 2 randomized trials: 36 (22.6%) HIV-positive not virally suppressed (aim 2) and 123 (77.4%) high-risk HIV-negative (aim 3). CONCLUSIONS: This study has the potential to significantly impact the medical and substance use services provided to YBLMSM and YBLTW in the United States by providing rigorous scientific evidence outlining approaches and strategies that improve the uptake and engagement of YBLMSM and YBLTW in the HIV treatment and prevention continuum. TRIAL REGISTRATION: ClinicalTrials.gov NCT03194477; https://clinicaltrials.gov/ct2/show/NCT03194477. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17269.

"When Should I Tell?": Perspectives on Disclosure to Their Children among Parents with Perinatally Acquired HIV.

Adolescents and young adults (AYA) with perinatally acquired HIV (PHIV) engage in developmentally expected behaviors, such as establishing relationships and having children. Previous research has focused on pregnancy management/outcomes of AYA with PHIV. However, little research has focused on the parenting experiences of this emerging cohort and on their views of disclosure to their offspring. This article examines data from a pilot study of five AYA parents with PHIV on disclosure to their child(ren) (n = 7, 6 HIV-negative). Disclosure of their own HIV status to their children is on the minds of parents with PHIV. However, few currently have children old enough to understand the parent's diagnosis. Three parents indicated they would disclose their HIV status when their child was "old enough to understand" so that their child would be knowledgeable about HIV. One father also noted that he currently had more pressing parenting responsibilities beyond disclosure. When discussing their perspectives on disclosure, many referenced their personal stories indicating a link between their decision to disclose/not disclose to their child and their own disclosure narrative. One mother cited she did not plan to reveal her diagnosis to her son because he was uninfected, while another mother explained she did not want to worry her child. The mother of the only infected child "did not want to wait like my mother did" and planned to tell her son at an earlier age than when she learned of her own diagnosis. Clinical implications related to disclosure will be discussed and future areas of research identified.