Online-Mediated HIV Pre-exposure Prophylaxis Care and Reduced Monitoring Frequency for Men Who Have Sex With Men: Protocol for a Randomized Controlled Noninferiority Trial (EZI-PrEP Study).

BACKGROUND: Daily and event-driven HIV pre-exposure prophylaxis (PrEP) with oral tenofovir-emtricitabine is highly effective to prevent HIV in men who have sex with men (MSM). PrEP care generally consists of in-clinic monitoring every 3 months that includes PrEP dispensing, counseling, and screening for HIV and sexually transmitted infections (STIs). However, the optimal frequency for monitoring remains undetermined. Attending a clinic every 3 months for monitoring may be a barrier for PrEP. Online-mediated PrEP care and reduced frequency of monitoring may lower this barrier. OBJECTIVE: The primary objective of this study is to establish the noninferiority of online PrEP care (vs in-clinic care) and monitoring every 6 months (vs every 3 months). The secondary objectives are to (1) examine differences between PrEP care modalities regarding incidences of STIs, HIV infection, and hepatitis C virus infection; retention in PrEP care; intracellular tenofovir-diphosphate concentration; and satisfaction, usability, and acceptability of PrEP care modalities; and (2) evaluate associations of these study outcomes with sociodemographic, behavioral, and psychological characteristics. METHODS: This study is a 2×2 factorial, 4-arm, open-label, multi-center, randomized, controlled, noninferiority trial. The 4 arms are (1) in-clinic monitoring every 3 months, (2) in-clinic monitoring every 6 months, (3) online monitoring every 3 months, and (4) online monitoring every 6 months. The primary outcome is a condomless anal sex act with a casual partner not covered or insufficiently covered by PrEP (ie, "unprotected act") as a proxy for HIV infection risk. Eligible individuals are MSM, and transgender and gender diverse people aged ≥18 years who are eligible for PrEP care at 1 of 4 participating sexual health centers in the Netherlands. The required sample size is 442 participants, and the planned observation time is 24 months. All study participants will receive access to a smartphone app, which contains a diary. Participants are requested to complete the diary on a daily basis during the first 18 months of participation. Participants will complete questionnaires at baseline and 6, 12, 18, and 24 months. Dried blood spots will be collected at 6 and 12 months for assessment of intracellular tenofovir-diphosphate concentration. Incidence rates of unprotected acts will be compared between the online and in-clinic arms, and between the 6-month and 3-month arms. Noninferiority will be concluded if the upper limit of the 2-sided 97.5% CI of the incidence rate ratio is <1.8. RESULTS: The results of the main analysis are expected in 2024. CONCLUSIONS: This trial will demonstrate whether online PrEP care and monitoring every 6 months is noninferior to standard PrEP care in terms of PrEP adherence. If noninferiority is established, these modalities may lower barriers for initiating and continuing PrEP use and potentially reduce the systemic burden for PrEP providers. TRIAL REGISTRATION: ClinicalTrials.gov NCT05093036; https://tinyurl.com/28b8ndvj. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/51023.

Assessing stigma in low- and middle-income countries: A systematic review of scales used with children and adolescents.

INTRODUCTION: Stigmatization contributes to health inequalities, impacting the wellbeing of children and adolescents negatively. Addressing stigmatization requires adequate measurement. Our systematic review synthesizes the content of scales used with children and adolescents in low- and middle-income countries (LMICs) across stigmas, and examines their comparability and level of cultural adaptation. METHODS: Ten databases were systematically searched combining three sets of search terms: (i) stigma, (ii) scales, and (iii) LMICs. Studies conducted in LMICs, with a sample with mean age below 18 and reporting a minimum of one stigma scale, were eligible. We allocated scale items to four frameworks: (i) dimensions, or drivers of stigmatization; (ii) target variants, or types of stigmatization; (iii) socio-ecological levels, and (iv) cross-cultural equivalence, or scale adaptation to context/population. Based on percentages, we compared scale content per age cohort, stigma status, region, and stigma category. RESULTS: Out of 14,348 records, we included 93 articles (112 scales). Most studies focused on adolescents (12-18 years). Twelve scales were used more than once, seven were used across regions, and four were employed for multiple stigmas. Physical health stigma, and HIV/AIDS-related stigma in particular, was measured most; mental health and multiple/generic stigmas least. Physical and mental health scales were generally more comprehensive, i.e., measuring more stigma facets. In general, scales consistently measured two of the 21 included stigma facets, namely the disruptiveness dimension and the community level. Cross-cultural equivalence was moderate; conceptual and measurement equivalence were high. DISCUSSION: Although scales were largely comparable in how they measure stigma, they failed to reflect the complexity of the stigmatization process and fell short of existing stigma frameworks and qualitative research. Stigma research with children should work towards cross-culturally validated stigma scale sets which incorporate more facets of existing stigma frameworks, thus facilitating comparability across cultural contexts and informing intervention development and evaluation.

Similarity attracts: The role of personality in similarity perceptions and children's attitudes towards refugees.

Previous research has shown that children's intergroup similarity judgements are based not only on ethnicity but also on other dimensions such as sports interest. The present research investigates the role of personality in perceived similarity between ingroup children and refugee outgroup children. A study was conducted among 9- to 12-year-old children (N = 124) at two elementary schools in the Netherlands. It was predicted and found that children take into account ethnicity as well as personality (whether a child is introverted or extraverted) when judging similarity of ingroup (Dutch) and outgroup (refugee) children. Furthermore, we predicted and found that greater perceived similarity between Dutch children and refugee children was associated with more positive attitudes towards refugee children. Finally, children felt lower levels of anxiety towards an extraverted compared to an introverted refugee child. Lower anxiety, in turn, was associated with more positive attitudes towards refugee children. Theoretical and practical implications are discussed. Statement of contribution What is already known? McGlothlin et al. (2005, British Journal of Developmental Psychology, 23, 227) found that similarity ratings are based not only on ethnicity but also on sports interest. Studies among adults show that extraversion is negatively related to anxiety and positively to cross-group friendships. What does this study add? The present study shows that children also base similarity ratings on the personality trait extraversion. Higher similarity between self/ingroup and refugee children is related to positive outgroup attitudes. This study shows that extraverted children feel less anxiety to an extraverted refugee child. Lower anxiety in children is related to more positive attitudes to refugee children in general.

When Is Humiliation More Intense? The Role of Audience Laughter and Threats to the Self.

In personal accounts, humiliation is often reported as a very intense, painful, negative emotion. We report two scenario studies in which we explored two factors that may contribute to the intense character of humiliation: (1) unwanted, negative public exposure, and (2) a threat to central aspects of one's identity. Study 1 (N = 115) assessed emotional reactions to a public insult when an audience responded with either laughter or not and when someone from the audience offered support after the insult or no support was offered. Results showed that the intensity of humiliation increased when people laughed after the insult. However, support offered after the insult had no effect on reported humiliation. Study 2 (N = 99) focused on threats to different self-related values and showed stronger reports of humiliation when central self-related values were threatened than when less central self-related values were threatened. Study 2 also replicated the audience-effect from Study 1, but only when central self-related values were threatened and not when less central self-related values were threatened. Limitations of these studies (e.g., the use of scenarios) and potential avenues for future research, such as the (long-term) consequences of humiliation and humiliation in the context of social media, are discussed.

Withdraw or affiliate? The role of humiliation during initiation rituals.

Initiation rituals can take different forms and empirical evidence is inconsistent as to whether these rituals promote affiliation among novices. We argue that experienced humiliation during initiations leads to less affiliation among novices, in particular when one is initiated as sole group member rather than as part of the group. We examined this hypothesis in three studies, using different paradigms. In Study 1 (N = 123), perceived severity of an initiation in the past was associated with lower affiliation with other novices; this relationship was mediated by experienced humiliation. Study 2 (N = 64) showed that public derogation in the lab led to more humiliation when participants were the only victim than when they were derogated as a group. Study 3 (N = 248), a vignette study, showed that a similar effect of social context was mediated by expected support from other novices. We conclude that severe initiations may, due to experienced humiliation, result in less rather than more affiliation with fellow novices.

Subjective social status and intergroup attitudes among ethnic majority and minority children in Portugal.

A measure of subjective social status (SSS) was examined among high (White), and low (Black and Roma) ethnic status children in Portugal within a developmental design including 6-8-year-old and 9-12-year-old children. White children favoured their in-group over the Black and Roma out-groups on the SSS measure, social preferences and positive as well as negative trait attributions. Generally, the Black and Roma showed equal SSS, preferences and trait attribution for their in-group and the high status White out-group, but not the other low-status out-group. With age White children generally demonstrated higher SSS for Black and Roma, preferred them more and attributed more positive traits. For low-status groups, an age effect was found only for Black children who preferred the Roma more with age and attributed more positive traits. Changes on preferences and trait attribution depending on age-group were mediated by SSS. It is concluded that minority group's SSS does not parallel the objective status hierarchy but, rather, is a dynamic reorganisation of group's relative positions serving strategies to cope with their minority condition.

From extreme emotions to extreme actions: explaining non-normative collective action and reconciliation.

A key argument of Dixon et al. in the target article is that prejudice reduction through intergroup contact and collective action work in opposite ways. We argue for a complementary approach focusing on extreme emotions to understand why people turn to nonnormative collective action and to understand when and under what conditions extreme emotions may influence positive effects of contact on reconciliation.

Direct and extended friendship effects on minority and majority children's interethnic attitudes: a longitudinal study.

Longitudinal direct and extended cross-ethnic friendship effects on out-group evaluations among German (majority status, N = 76) and Turkish (minority status, N = 73) children (age 7-11 years) in ethnically heterogeneous elementary schools were examined at the beginning and end of the school year (time lag: 7 months). The results showed that among majority status children, but not minority status children, direct cross-ethnic friendship predicted over time positive out-group evaluations. This association was partly mediated by perceived social norms about cross-ethnic friendship relations. No longitudinal effects of extended cross-ethnic friendship were found. These results suggest that in ethnically heterogeneous contexts, direct friendship is more effective in changing intergroup attitudes than extended friendship and that social status moderates direct friendship effects.