Salient beliefs related to secondary distribution of COVID-19 self-test kits within social networks.

Background: Widespread access to testing is critical to public health efforts to control the COVID-19 pandemic. Secondary distribution of COVID-19 self-test kits, where an individual distributes test kits to others in their social networks, is a potential strategy to improve access to testing. In this qualitative study, we identified salient beliefs about distributing and accepting COVID-19 self-test kits within one's social network, as well as ordering COVID-19 self-test kits from the government. Methods: We recruited 61 participants from a randomized controlled trial (NCT04797858) in Philadelphia, Pennsylvania to elicit beliefs about (1) distributing COVID-19 self-test kits within one's social network, (2) receiving test kits from social contacts, and (3) ordering self-test kits from the government. Using validated, open-ended question stems, we identified the most common set of beliefs underlying attitudes, perceived norms (or social referents), and perceived behavioral control (or self-efficacy) toward each of these behaviors. Results: Twenty-seven out of 30 (90%) of participants who received self-test kits reported distributing the kits to social contacts. These participants described altruistic beliefs about giving others access to testing, and felt approval from family members, friends, and others in their social networks. When receiving test kits from social network contacts, participants described advantages of test kit convenience, but some voiced concern about test kit tampering and confusing instructions. Participants also described perceived logistic barriers to distributing and receiving self-test kits, such as delivering or transporting test kits, or finding time to meet. Participants who ordered test kits from the government also described increased convenience of test access, but described different logistic barriers such as delays in test kit delivery, or not receiving test kits at all. Conclusion: In comparison with government-ordered test kits, the secondary distribution of COVID-19 self-test kits raised unique concerns about test kit quality and instructions, as well as distinctive logistic barriers related to distributing self-test kits to network contacts, which were not raised for test kits ordered from the government. This study demonstrates that beliefs may vary depending on the type of testing behavior, and behavioral interventions may benefit from developing messages tailored to specific testing strategies.

Do some prefer to pay? Identifying bias against free COVID-19 tests.

Objectives: In the United States, a federal emergency program has made SARS-CoV-2 self-test kits available at no cost. It is unclear how widely free tests are preferred. We conducted a survey to estimate the proportion of respondents who do not prefer a free test. We hypothesized that free tests would not be preferred universally, and that a preference for paying would be more common among those with conservative politics than with liberal politics, regardless of income. Design: Observational study design. Methods: A national sample of US adults completed an online survey. To reduce potential enrollment bias, the survey's focus was not specified beforehand. To prioritize a high-risk group, participation was limited to those who were unvaccinated or were incompletely vaccinated in the primary series against COVID-19. Participants reported their testing preferences and socio-demographic characteristics, including political affiliation. The main outcome assessed if a participant preferred to pay for a self-test or receive a free one (subsidized by the US government). Results: Among 1215 participants, (73%, n = 886) preferred free self-testing, while 27% (n = 329) preferred to pay for the same testing. After adjusting for income, the odds of preferring to pay for self-testing were 66% higher in "strong" Republicans compared to "strong" Democrats (odds ratio = 1.66, 95% confidence interval = 1.07-2.62). Conclusions: More than a quarter of individuals preferred paying for these tests. This preference was more likely among those with right-wing politics. Policy implications are discussed, along with future research directions.

HIV Self-testing and Risk Behaviors Among Men Who Have Sex With Men in 23 US Cities, 2017.

Importance: HIV self-testing (HIVST) is a promising strategy to expand the HIV care continuum, particularly among priority populations at high risk of HIV infection. However, little is known about HIVST uptake among men who have sex with men (MSM) outside of clinical trial settings. Objective: To evaluate HIVST use among urban MSM in the US who reported testing within the past 12 months. Design, Setting, and Participants: A cross-sectional study of adult MSM in the 2017 National HIV Behavioral Surveillance system, which used venue-based sampling methods to collect data related to HIV testing, receipt of prevention services, and risk factors for HIV, was conducted at 588 venues in 23 urban areas in the contiguous US and Puerto Rico. All participants were offered HIV testing. Adult cisgender MSM who reported HIV-negative or unknown HIV status and obtained HIV testing in the past 12 months were included. Data for this study were collected between June 4, 2017, and December 22, 2017, and analyzed between October 23, 2020, and August 20, 2021. Main Outcomes and Measures: Self-reported HIVST in the past year. Adjusted prevalence ratios (aPRs) using survey weights were calculated to assess factors associated with HIVST. Results: A total of 6563 MSM in 23 urban areas met inclusion criteria, of whom 506 (7.7%) individuals reported HIVST in the past year. The median age of self-testers was 29 (IQR, 25-35) years, 52.8% had completed college, and 37.9% reported non-Hispanic White race. One self-tester reported seroconverting in the prior 12 months, and an additional 10 self-testers were diagnosed with HIV during the survey. HIVST was associated with sexual orientation disclosure (aPR, 10.27; 95% CI, 3.45-30.60; P < .001), perceived discrimination against people with HIV (aPR, 1.53; 95% CI, 1.09-2.03; P = .01), younger age (aPR, 0.74; 95% CI, 0.66-0.84; P < .001), higher educational level (aPR, 1.20; 95% CI, 1.04-1.37; P = .01), and higher income levels (aPR, 1.18; 95% CI, 1.04-1.32; P = .009). No association was noted with condomless anal sex (aPR, 0.96; 95% CI, 0.88-1.06, P = .88), sexually transmitted infections (aPR, 0.96; 95% CI, 0.70-1.30; P = .77), or preexposure prophylaxis use (aPR, 0.99; 95% CI, 0.75-1.30; P = .92). Conclusions and Relevance: In this study, HIVST was relatively uncommon in this sample of urban MSM. HIVST may not be reaching those with lower socioeconomic status or who have not disclosed their sexual identity. The findings of this study suggest that efforts to increase HIVST should focus on engaging underserved and vulnerable subgroups of MSM.

Adoption of HIV pre-exposure prophylaxis among women at high risk of HIV infection in Kenya.

In 2017, Kenya became one of the first African countries to provide pre-exposure prophylaxis (PrEP) in its national HIV prevention plan. We sought to characterize factors associated with PrEP uptake and persistence among a cohort of women at risk of HIV infection during the early stages of PrEP scale-up in Kenya. HIV-negative women ≥18 years with ≥2 sexual partners in the past 4 weeks were recruited as part of an ongoing cluster randomized trial of an HIV self-testing intervention. PrEP use was assessed at baseline and at 6- and 12-month follow-up visits. Between June 2017 and August 2018, 2,086 were enrolled and had complete baseline data. 138 (6.6%) reported PrEP use during the first year of the study. Although PrEP use increased, persistence on PrEP was low, and less than half of individuals reported continuing PrEP at follow-up visits. In multivariate analyses, PrEP use was associated with recent STIs, having an HIV-positive primary partner, having regular transactional sex in the past 12 months, and being a female sex worker. In the early stages of PrEP scale-up in Kenya, uptake increased modestly among women with risk factors for HIV infection, but overall uptake and persistence was low.

Brief Report: Nicotine Metabolism Ratio Increases in HIV-Positive Smokers on Effective Antiretroviral Therapy: A Cohort Study.

BACKGROUND: People with HIV (PWH) smoke tobacco at much higher rates than the general population. Previous research has shown that PWH have faster nicotine metabolism than HIV-uninfected individuals, which may underlie this disparity, but the cause is unknown. We investigated whether higher nicotine metabolite ratio (NMR; 3-hydroxycotinine:cotinine), a validated biomarker of nicotine metabolism through CYP2A6, was associated with antiretroviral use among HIV-infected smokers. METHODS: We conducted a retrospective cohort study of HIV-positive smokers in the University of Pennsylvania Center for AIDS Research cohort. We compared the NMR before viral suppression (>10,000 copies/mL) and after viral suppression on antiretroviral therapy (<200 copies/mL). We used mixed-effects linear regression to analyze the change in NMR after viral suppression and assessed for effect modification by efavirenz use. RESULTS: Eighty-nine individuals were included in the study. We observed effect modification by efavirenz use (interaction term for efavirenz use, P < 0.001). Among those on nonefavirenz regimens, the mean NMR increased by 0.14 (95% confidence interval: 0.05 to 0.23, P = 0.002). Among those on efavirenz-containing regimens, the mean NMR increased by 0.53 (95% confidence interval: 0.39-0.66, P < 0.001). CONCLUSIONS: We observed a clinically and statistically significant increase in NMR after viral suppression among smokers with HIV, which more than doubled among those on efavirenz-based regimens. Higher NMR among HIV-positive smokers on antiretroviral therapy may help explain the higher rates of tobacco use and lower quit rates among PWH in care. These findings suggest that regimen choice and other modifiable factors may be targets for future attempts to increase success rates for tobacco cessation among PWH.

The COVID-19 Self-Testing through Rapid Network Distribution (C-STRAND) trial: A randomized controlled trial to increase COVID-19 testing in underserved populations.

Background Widely available population testing is critical to public health efforts to control the ongoing COVID-19 pandemic. However, COVID-19 testing has been low in underserved communities disproportionately affected by COVID-19. One approach to increase testing rates is through the secondary distribution of self-collection kits, where an individual distributes test kits to contacts in their social network and encourages them to self-collect test specimens. We outline a randomized clinical trial, COVID-19 Self-testing Through Rapid Network Distribution (C-STRAND), and a cohort study of individuals with COVID-19, to determine the impact of a secondary distribution strategy on COVID-19 testing among medically underserved populations. Methods The clinical trial will seek to enroll 1048 adult index participants from federally health qualified centers in Philadelphia, PA seeking COVID-19 testing. Eligible participants will be randomized 1:1 to receive multiple self-collection test kits or multiple referrals for standard clinic-based tests to distribute to contacts within their social network. The primary outcome will be testing among at least two network contacts at 8 weeks. Index participants and network contacts who test positive for COVID-19 from C-STRAND will be eligible to join the COVID-19 Close Contact Self-testing Study (CloseST), assessing the secondary distribution of self-collection test kits among individuals with COVID-19. The primary outcome of this cohort will be the number of close contacts who test positive at 8 weeks. Conclusion Novel strategies to promote COVID-19 testing are necessary, particularly among underserved populations most affected by COVID-19. We will determine the efficacy of a self-testing secondary distribution strategy. The results may inform efforts to increase testing rates during the current pandemic.

Brief Report: Financial Incentives and Real-Time Adherence Monitoring to Promote Daily Adherence to HIV Treatment and Viral Suppression Among People Living With HIV: A Pilot Study.

BACKGROUND: Interventions to promote medication adherence and viral suppression are needed among HIV-positive individuals. We aimed to determine the feasibility, acceptability, and preliminary impact of daily financial incentives linked to real-time adherence monitoring among treatment-experienced individuals. METHODS: At an HIV clinic in Philadelphia, we conducted a pilot randomized trial among treatment-experienced HIV-positive adults with unsuppressed viral loads (>400 copies/mL). Participants randomized to the intervention group were eligible for daily lottery-based financial rewards dependent on antiretroviral therapy (ART) adherence, measured by a wireless-enabled electronic pill bottle. Participants also received a financial incentive for achieving viral suppression at 3 months. The control group received the standard of care. We measured acceptance and feasibility through follow-up survey at 3 months, viral suppression at 3 months, and adherence. RESULTS: Among 29 participants, 28 (93%) completed 3-month follow-up, and 24 (83%) completed a 3-month laboratory visit. Electronic pill bottles were highly acceptable to participants, with most strongly agreeing that they worked well, were reliable, and easy to use. Among those who received the intervention, 77% were very satisfied with their experience. Among those who completed the 3-month laboratory visit, viral suppression was achieved by 40% in the intervention group and 29% in the control group. ART adherence ≥80% was achieved by 36% and 25% in the intervention and control groups, respectively. CONCLUSIONS: Daily financial incentives coupled with real-time adherence monitoring are a promising strategy to support ART adherence among HIV-positive individuals who are not virally suppressed. This novel approach warrants testing in a larger trial.

Persistent Disparities in Smoking Rates Among PLWH Compared to the General Population in Philadelphia, 2009-2014.

Despite reductions in smoking rates in the general population, little is known about recent smoking trends among people living with HIV (PLWH). We compared the risk for smoking and temporal trends in smoking among PLWH and the general population in the Philadelphia metropolitan area between 2009 and 2014. We used weighted logistic regression to assess the relation between HIV and smoking, and examined temporal smoking trends. The adjusted odds ratio (OR) for smoking comparing PLWH to the general population was 1.80 (95% CI 1.55-2.09) after adjusting for socio-economic, demographic, and mental health diagnosis variables. Smoking prevalence decreased in both the PLWH and general populations during the study period, and we did not observe a significant difference in rates of decline between groups (P = 0.54). Despite overall progress in smoking cessation, a disparity persisted in smoking rates between PLWH and the general population, with and without adjustment for socio-economic, demographic, and mental health variables. Further research is needed to understand the mechanisms linking HIV and tobacco use in order to inform public health efforts to reduce smoking among PLWH.

Providing competent, comprehensive and inclusive sexual health services for men who have sex with men in low- and middle-income countries: a scoping review.

Although men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmissible infections, sexual health services for MSM in low- and middle-income countries (LMIC) remain under-resourced and are poorly understood. A scoping review of literature on MSM sexual health in LMIC was conducted in order to identify key clinical services and gaps in knowledge. Three databases were searched, in addition to hand-reviewing key journals and bulletins, to identify literature with a focus on MSM sexual health. Key services related to providing care to MSM in LMIC that emerged from our review are described. These services include creation of safe and confidential clinic environments, HIV testing services, behavioural interventions, HIV pre-exposure prophylaxis (PrEP), rapid antiretroviral therapy (ART) initiation and STI services. Compared with high-income settings, major differences in LMIC include lack of diagnostic technology, unfavourable legal environments and lack of funding for MSM health. Innovative approaches to healthcare delivery, such as harnessing mobile technology, self-testing and crowdsourcing interventions, can improve health services among MSM in LMIC. There are gaps in the evidence about how best to provide sexual health services for MSM in LMIC settings. Implementation research and scale-up of existing biomedical and behavioural interventions, such as HIV/STI testing services, PrEP and early antiretroviral initiation are urgently needed in LMIC.

PrEP in the Real World: Predictors of 6-Month Retention in a Diverse Urban Cohort.

The effectiveness of HIV pre-exposure prophylaxis (PrEP) depends on adherence, which requires retention in PrEP care. We sought to examine factors associated with six-month retention in PrEP care among individuals prescribed PrEP between 2011 and 2015 in a large, academic health system in the Bronx, New York. We used multivariable logistic regression to identify factors independently associated with six-month retention. Among 107 patients, retention at 6 months was 42%. In the multivariable analysis, heterosexual individuals were less likely to be retained in PrEP care at 6 months, but individuals who received prescriptions from attending physicians were more likely to be retained in care. Larger prospective studies are needed to better evaluate the individual and health system factors associated with long-term engagement in PrEP care.

Identifying MSM-competent physicians in China: a national online cross-sectional survey among physicians who see male HIV/STI patients.

BACKGROUND: Men who have sex with men (MSM) are at high risk of human immunodeficiency virus (HIV) infection and sexually transmitted infection (STI) in China. Inadequate clinical services and poor clinical competency among physicians are major barriers to improving the sexual health of MSM. This study aims to understand physician clinical competency in providing MSM health services in China. METHODS: We conducted an online cross-sectional survey among Chinese physicians who have seen male patients for STI complaints in the past year. We obtained information on individual demographics, clinical practice, attitudes toward MSM, and interest in contributing to MSM clinical services. We defined an MSM-competent physician as one who asked male patients about sexual orientation, sexual practices, and recommended HIV/ STI testing during a clinic visit. We conducted multivariable logistic regression to identify factors associated with MSM competency. RESULTS: In total, 501 physicians completed the survey. The most common subspecialties were dermatovenereology (33.1%), urology (30.1%), and general medicine (14.4%). Roughly half (n = 267, 53.3%) reported seeing MSM in the past 12 months. Among physicians who saw MSM in the past 12 months, 60.3% (n = 161) met criteria as MSM-competent physicians, and most (n = 234, 87.6%) MSM-competent physicians reported positive or neutral attitudes towards MSM. Over 60% of all physicians were willing to participate in activities for improving MSM services, such as training and being on a list of physicians willing to serve MSM. MSM-competent physicians showed no sociodemographic differences compared with non MSM-competent physicians. MSM-competent physicians were more willing to have their medical institution named on a public clinic list capable of serving MSM (aOR: 1.70, 95%CI: 1.01-2.86) and being on a public physician list capable of serving MSM (aOR: 1.77, 95%CI: 1.03-3.03). CONCLUSIONS: MSM-competent physicians included a broad range of individuals that practiced in diverse clinical settings. Most physicians were interested in improving and expanding MSM clinical services, despite having neutral attitudes toward same-sex behavior. Future interventions should focus on developing MSM clinical competency and expanding services that meet the needs of MSM.