Policymakers' and healthcare providers' perspectives on the introduction of oral pre-exposure prophylaxis for key populations in Ghana.

BACKGROUND: Key populations (KPs) such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID), and their partners contribute more than a quarter (27.5%) of new HIV infection in Ghana. Oral pre-exposure prophylaxis (PrEP) can substantially reduce HIV acquisition among this group. While the available research indicates KPs willingness to take PrEP in Ghana, little is known about the position of policymakers and healthcare providers on the introduction of PrEP for KPs. METHODS: Qualitative data were collected from September to October 2017 in the Greater Accra (GA) and Brong-Ahafo (BA) regions of Ghana. Key informant interviews were conducted with 20 regional and national policymakers and supplemented with In-depth Interviews with 23 healthcare providers to explore their level of support for PrEP and their perspectives on challenges and issues to consider for oral PrEP implementation in Ghana. Thematic content analysis was used to unearth the issues emerging from the interviews. RESULTS: Policymakers and healthcare providers in both regions expressed strong support for introducing PrEP for KPs. Key concerns regarding oral PrEP introduction included potential for behavioral disinhibition, non-adherence and side effects of medication, cost and long-term financial implications, and stigma related to HIV and key populations. Participants stressed the need to integrate PrEP into existing services and the provision of PrEP should start with high risk groups like sero-discordant couples, FSWs and MSM. CONCLUSIONS: Policymakers and providers recognize the value of PrEP in cubing new HIV infections but have concerns about disinhibition, non-adherence, and cost. Therefore, the Ghana health service should roll-out a range of strategies to address their concerns including: sensitization with providers to mitigate underlying stigma towards KPs, particularly MSM, integration of PrEP into existing services, and innovative strategies to improve continued use of PrEP.

A Layer Plus Approach to Implementation Research and Collaboration for Long-Acting Injectable Preexposure Prophylaxis for HIV Prevention.

In 2020, the HIV prevention clinical trials, HPTN (HIV Prevention Trials Network) 083 and 084, reported that long-acting injectable cabotegravir (CAB-LA) for HIV prevention was statistically superior to daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for pre-exposure prophylaxis (PrEP) in cisgender men and transgender women who have sex with men, and cisgender women. However, clinical efficacy does not translate to real-world effectiveness and clinical practice as evidenced by current global use of oral PrEP. There are ~626,000 users of PrEP, which is significantly below the 3 million goal set by UNAIDS for 2020. Implementation will be key to ensuring that CAB-LA reaches those who desire to use it. We describe the Layer Plus Approach for CAB-LA for PrEP dissemination and implementation. The "Layer" is focused on integrating CAB-LA into existing PrEP models of care and understanding the best delivery channels that could be established in existing programs. Important implications of layering include preparing health professionals to provide CAB-LA, improving access for potential users, and addressing existing PrEP structural and facility barriers. "Plus," which accounts for the existing disparities in PrEP access and use, means expanding CAB-LA to reach individuals for whom HIV prevention options have not been accessible or who have lapsed on oral PrEP. Implications for Plus include the development of new structures, systems, policies, and processes. A key aspect to the Approach is building collaborations to aid successful implementation. The Layer Plus Approach is a simple but strategic framework or a tailored approach to guide dissemination research and implementation.

Understanding Quality of Care and Satisfaction With Sexual and Reproductive Healthcare Among Young Men.

OBJECTIVE: Sexual and reproductive healthcare (SRHC) guidelines recommend the delivery of quality preventive SRHC to males beginning in adolescence. A quality of care (QOC) framework was used to examine factors associated with young male's perceptions of QOC and satisfaction with care, which can influence their engagement and use of SRHC. METHODS: Cross-sectional surveys were conducted from August 2014 to September 2016 with 385 male patients aged 15-24 years, recruited from primary care and sexually transmitted disease (STD) clinics. Surveys measured QOC received, satisfaction with care, and domains of a QOC framework. Poisson regression analyses examined associations between domains of quality and perceived QOC as well as satisfaction with care. RESULTS: Over half of males reported QOC as excellent (59%) and were very satisfied with the services (56.7%). Excellent QOC and high satisfaction with services was associated with timely care, higher Clinician-Client Centeredness, and being a bisexual male. Excellent QOC was also associated with greater comfort in the clinic, being tested for human immunodeficiency virus/STDs, attending primary care settings, and receipt of higher number of SRHC services. CONCLUSIONS: Using a QOC framework as part of providing SRHC to young males can be important in improving their perceptions of QOC and satisfaction with services.

Challenges to and opportunities for the adoption and routine use of early warning indicators to monitor pediatric HIV drug resistance in Kenya.

BACKGROUND: Pediatric non-adherence to antiretroviral therapy (ART), loss to follow-up, and HIV drug resistance (HIVDR) are challenges to achieving UNAIDS' targets of 90% of those diagnosed HIV-positive receiving treatment, and 90% of those receiving treatment achieving viral suppression. In Kenya, the pediatric population represents 8% of total HIV infections and pediatric virological failure is estimated at 33%. The monitoring of early warning indicators (EWIs) for HIVDR can help to identify and correct gaps in ART program functioning to improve HIV care and treatment outcomes. However, EWIs have not been integrated into health systems. We assessed challenges to the use of EWIs and solutions to challenges identified by frontline health administrators. METHODS: We conducted key informant interviews with health administrators who were fully knowledgeable of the ART program at 23 pediatric ART sites in 18 counties across Kenya from May to June 2015. Thematic content analysis identified themes for three EWIs: on-time pill pick-up, retention in care, and virological suppression. RESULTS: Nine themes-six at the facility level and three at the patient level-emerged as major challenges to EWI monitoring. At the facility level, themes centered on system issues (e.g., slow return of viral load results), staff shortages and inadequate adherence counseling skills, lack of effective patient tracking and linkage systems, and lack of support for health personnel. At the patient level, themes focused on stigma, non-disclosure of HIV status to children who are age eligible, and little engagement of guardians in the children's care. Practical solutions identified included the use of lay health workers (e.g., peer educators, community health workers) to implement a variety of care and treatment tasks, whole facility approaches to adherence counseling, adolescent peer support groups, and working with children directly as soon as they are age eligible. DISCUSSION: The monitoring of EWIs has not been routine in health facilities in Kenya due to several challenges. However, facilities have implemented novel strategies to address some of these barriers. Future work is needed to assess whether scale-up of some of these approaches can aid in the effective use of EWIs and improving HIV care outcomes among the pediatric population.

Sexual and Reproductive Health Care Receipt Among Young Males Aged 15-24.

PURPOSE: This study aimed to describe young men's sexual and reproductive health care (SRHC) receipt by sexual behavior and factors associated with greater SRHC receipt. METHODS: There were 427 male patients aged 15-24 who were recruited from 3 primary care and 2 sexually transmitted disease (STD) clinics in 1 urban city. Immediately after the visit, the survey assessed receipt of 18 recommended SRHC services across four domains: screening history (sexual health, STD/HIV test, family planning); laboratories (STDs/HIV); condom products (condoms/lubrication); and counseling (STD/HIV risk reduction, family planning, condoms); in addition, demographic, sexual behavior, and visit characteristics were examined. Multivariable Poisson regressions examined factors associated with each SRHC subdomain adjusting for participant clustering within clinics. RESULTS: Of the participants, 90% were non-Hispanic black, 61% were aged 20-24, 90% were sexually active, 71% had female partners (FPs), and 20% had male or male and female partners (M/MFPs). Among sexually active males, 1 in 10 received all services. Half or more were asked about sexual health and STD/HIV tests, tested for STDs/HIV, and were counseled on STD/HIV risk reduction and correct condom use. Fewer were asked about family planning (23%), were provided condom products (32%), and were counseled about family planning (35%). Overall and for each subdomain, never sexually active males reported fewer services than sexually active males. Factors consistently associated with greater SRHC receipt across subdomains included having M/MFPs versus FPs, routine versus non-STD-acute visit, time alone with provider without parent, and seen at STD versus primary care clinic. Males having FPs versus M/MFPs reported greater family planning counseling. CONCLUSIONS: Findings have implications for improving young men's SRHC delivery beyond the narrow scope of STD/HIV care.

Do Nonclinical Community-Based Youth-Serving Professionals Talk With Young Men About Sexual and Reproductive Health and Intend to Refer Them for Care?

Young men (ages 15-24) may benefit from community-based connections to care since many have sexual and reproductive health (SRH) needs and low care use. This study describes nonclinical community-based youth-serving professionals' (YSPs) SRH knowledge, confidence, past behaviors, and future intentions to talk with young men about SRH and refer them to care, and examines factors associated with care referral intentions. YSPs ( n = 158) from 22 settings in one mid-Atlantic city answered questions about the study's goal, their demographics and work environment from August 2014 to December 2015. Poisson regression assessed factors associated with YSPs' care referral intentions. On average, YSPs answered 58% of knowledge questions correctly, knew 5 of 8 SRH care dimensions of where to refer young men, and perceived being somewhat/very confident talking with young men about SRH (63%) and referring them to care (77%). During the past month, the majority (63%) talked with young men about SRH but only one-third made care referrals; the majority (66%) were somewhat/very likely to refer them to care in the next 3 months. Adjusted models indicated YSPs were more likely to refer young men if they had a very supportive work environment to talk about SRH (adjusted RR = 1.51, 95% CI [1.15, 1.98]), greater confidence in SRH care referral (1.28 [1.00, 1.62]), and greater SRH care referrals in the past month (1.16 [1.02, 1.33]). Nonclinical community-based YSPs have poor-to-moderate knowledge about young men's SRH care, and less than one-third reported referrals in the past month. Findings have implications for educating YSPs about young men's SRH care.

Prevalence of HIV Testing Provision at Community Organizations Serving Young People in a Mid-Atlantic City, 2013-2014.

OBJECTIVES: Little is known about the prevalence of human immunodeficiency virus (HIV) testing at community organizations or the organizational characteristics associated with testing. The objective of this study was to describe (1) the prevalence of HIV testing at community organizations serving young people in a mid-Atlantic urban city and (2) the characteristics associated with organizations that provide such testing. METHODS: We conducted telephone or in-person surveys between February 2013 and March 2014 with 51 directors and administrators of community organizations serving young people. We asked whether the organization provided HIV screening or testing, and we collected data on organizational characteristics (eg, setting, client, and staff member characteristics; services offered). We generated frequencies on measures and used Poisson regression analysis to examine the association between testing and organizational characteristics. RESULTS: Of the 51 organizations surveyed, 21 provided HIV testing. Of the 30 organizations that did not provide HIV testing, only 7 had a relationship with programs that did provide it. Characteristics associated with the provision of HIV testing included offering general health services (relative risk [RR] = 4.57; 95% confidence interval [CI], 1.68-12.48; P = .003) and referral services for sexually transmitted infection screening (RR = 5.77; 95% CI, 1.70-19.59; P = .005) and HIV care (RR = 4.78; 95% CI, 1.61-14.21; P = .005), as well as among administrators who perceived their staff members were comfortable talking with young people about sexual health (RR = 3.29; 95% CI, 1.28-8.49; P = .01). CONCLUSIONS: The prevalence of HIV testing provision at organizations serving young people in this mid-Atlantic city was low, and few organizations offered linkages to HIV testing. Strategies are needed to increase the provision of HIV testing at community organizations serving young people, whether through direct or linked approaches.

The Socioecology of Sexual and Reproductive Health Care Use Among Young Urban Minority Males.

PURPOSE: To explore perceptions of facilitators/barriers to sexual and reproductive health (SRH) care use among an urban sample of African-American and Hispanic young men aged 15-24 years, including sexual minorities. METHODS: Focus groups were conducted between April 2013 and May 2014 in one mid-Atlantic U.S. city. Young men aged 15-24 years were recruited from eight community settings to participate in 12 groups. Moderator guide explored facilitators/barriers to SRH care use. A brief pregroup self-administered survey assessed participants' sociodemographics and SRH information sources. Content analysis was conducted, and three investigators independently verified the themes that emerged. RESULTS: Participants included 70 males: 70% were aged 15-19 years, 66% African-American, 34% Hispanic, 83% heterosexual, and 16% gay/bisexual. Results indicated young men's perceptions of facilitators/barriers to their SRH care use come from multiple levels of their socioecology, including cultural, structural, social, and personal contexts, and dynamic inter-relationships existed across contexts. A health care culture focused on women's health and traditional masculinity scripts provided an overall background. Structural level concerns included cost, long visits, and confidentiality; social level concerns included stigma of being seen by community members and needs regarding health care provider interactions; and personal level concerns included self-risk assessments on decisions to seek care and fears/anxieties about sexually transmitted infection/HIV testing. Young men also discussed SRH care help-seeking sometimes involved family and/or other social network members and needs related to patient-provider interactions about SRH care. CONCLUSIONS: Study findings provide a foundation for better understanding young men's SRH care use and considering ways to engage them in care.

Multiple sexual partnerships among female adolescents in rural Uganda: the effects of family structure and school attendance.

BACKGROUND: A better understanding is needed of the contextual factors that influence HIV risk behaviors among female adolescents in sub-Saharan Africa. The objectives of this study were to assess the influence of family structure on lifetime sexual partners and on the number of sexual partners in the last year among female adolescents in rural Rakai, Uganda. In addition, the study assessed whether the influence of family structure on these outcomes differed by the school attendance status of the adolescents. METHODS: The sample consisted of 2337 unmarried adolescent girls, aged 15-19, enrolled in the Rakai Community Cohort Study. The last survey interview within the time period of 2001-2008 available for each girl was used. Analyses were stratified by age (15-17 year olds and 18-19 year olds) and school status. Multinomial logistic and poisson regressions were used. RESULTS: Living in a household with a biological father was protective against both outcomes. Family structure was not associated with the outcomes among in-school adolescents but it was significantly associated with the outcomes among out-of-school adolescents. CONCLUSION: The findings suggest that understanding the familial context in which female adolescents develop, as well as its interaction with school attendance, is important for HIV prevention efforts. Both research and programmatic initiatives must consider the interplay between the family and school domains when considering ways to reduce HIV acquisition among adolescent women.

Family structure effects on early sexual debut among adolescent girls in Rakai, Uganda.

This study assessed the association between household family structure and early sexual debut among adolescent girls, ages 15-19, in rural Rakai District, Uganda. Early sexual debut is associated with detrimental physical, emotional and social outcomes, including increased risk of HIV. However, research on the family's role on adolescents' sexual risk behaviors in sub-Sahara Africa has been minimal and rarely takes into account the varying family structures within which African adolescents develop. Using six rounds of survey data (2001-2008) from the Rakai Community Cohort Study, unmarried adolescent girls (n=1940) aged 15-17 at their baseline survey, were followed until age 19. Parametric survival models showed that compared to adolescent girls living with both biological parents, girls who headed their own household and girls living with step-fathers, grandparents, siblings, or other relatives had significantly higher hazards of early sexual debut before age 16. Adolescent girls were significantly more likely to debut sexually if neither parent resided in the household, either due to death or other reasons. In addition, absence of the living biological father from the home was associated with higher risk of sexual debut, regardless of the biological mother's presence in the home. Our study's findings suggest that family structure is important to adolescent girls' sexual behavior. There is need for research to understand the underlying processes, interactions and dynamics of both low and high risk family structures in order to devise and strategically target interventions targeted for specific types of family structures.

Clients' perceptions of service quality and satisfaction at their initial Title X family planning visit.

Family planning service quality and clients' satisfaction with services are important determinants of clients' contraceptive use and continuation. We examine women's experiences at family planning clinics on a range of dimensions, including patient-centered communication (PCC), and identify experiences associated with higher ratings of service quality and satisfaction. New female clients (n = 748), ages 18-35 years, from clinics in three major metropolitan areas completed computer-administered interviews between 2008 and 2009. Factors associated with primary outcomes of service quality and satisfaction were assessed using multinomial and ordinary logistic regression, respectively. Higher scores on a Clinician-Client Centeredness Scale, measuring whether clinicians were respectful, listened, and provided thoughtful explanations, were associated with perceptions of good quality care and being very satisfied. Higher scores on a Clinic Discomfort Scale, measuring staff and waiting-room experiences, were associated with reduced satisfaction. Clients' interactions with clinicians, especially PCC, influence their perceptions of service quality, whereas their satisfaction with services is also influenced by the facility environment. These measures are adaptable for agencies to identify the factors contributing to their own clients' satisfaction-dissatisfaction with care and perceptions of service quality.

Sexual coercion among adolescent women in Rakai, Uganda: does family structure matter?

Studies on adolescent girls' vulnerability to sexual coercion in Sub-Saharan Africa have focused mainly on individual and partner risk factors, rarely investigating the role the family might play in their vulnerability. This study examined whether household family structure and parental vital status were associated with adolescent girls' risk of sexual coercion in Rakai, Uganda. Modified Poisson regression was used to estimate relative risk of sexual coercion in the prior 12 months among 1,985 unmarried and married adolescent girls aged 15 to 19 who were participants in the Rakai Community Cohort Study between 2001 and 2008. Among sexually active girls, 11% reported coercion in a given past year. Unexpectedly, living with a single mother was protective against experiencing coercion. As much as 4.1% of never-married girls living with single mothers reported coercion, compared to 7.8% of girls living with biological fathers (adj. relative risk [RR] = 2.24, 95% confidence interval [CI]: 0.98-5.08) and 20% of girls living in stepfather households (adj. RR = 4.73, 95% CI: 1.78-12.53). Ever-married girls whose mothers alone were deceased were more likely to report coercion than those with both parents alive (adj. RR = 1.56, 95% CI: 1.08-2.30). Protecting adolescent girls from sexual coercion requires prevention approaches that incorporate the family, with particular emphasis on including the men (e.g. fathers) who might play an influential role in young girls' sexual development. Understanding the family dynamics underlying the risk and protective effects of a given household structure might highlight new ways in which to prevent sexual coercion.

Adolescent mental and physical health in the English-speaking Caribbean.

OBJECTIVE: Bronfenbrenner's ecological systems theory, a multisystem framework, was used to identify risk and protective factors associated with adolescent mental and physical health (AMPH) in the English-speaking Caribbean. METHODS: A structured literature review, using the online databases of Medline, PsychInfo, and Scopus, was conducted to identify peer-reviewed studies published between January 1998 and July 2011 focused on adolescents ages 10-19 years. RESULTS: Sixty-eight articles were examined: 40 on adolescent mental health (AMH), 27 on adolescent physical health (APH), and 1 on both topics. Key individual factors included gender and age. Religiosity and engagement in other risk behaviors were associated with AMH, while the presence of other chronic illnesses affected APH. Significant determinants of AMH in the microsystem included family and school connectedness, family structure, and socioeconomic status. Maternal obesity, parental education, and school environment influenced APH. Studies that investigated macrosystem factors reported few consistent findings related to AMPH. A history of family mental health problems and physical and sexual abuse was significantly associated with AMH in the chronosystem, while a family history of diabetes and low birth weight were associated with APH. Studies did not examine the exosystem or the mesosystem. CONCLUSIONS: AMPH in the English-speaking Caribbean is affected by a variety factors in developing adolescents and their surroundings. Gender, family, and early exposure to negative environments are salient factors influencing AMPH and present potential avenues for prevention and intervention. A fuller understanding of AMPH in this region, however, requires scientifically rigorous studies that incorporate a multisystem approach.

Adolescent mental and physical health in the English-speaking Caribbean / Salud mental y física de los adolescentes en el Caribe de habla inglesa

OBJECTIVE: Bronfenbrenner's ecological systems theory, a multisystem framework, was used to identify risk and protective factors associated with adolescent mental and physical health (AMPH) in the English-speaking Caribbean. METHODS: A structured literature review, using the online databases of Medline, PsychInfo, and Scopus, was conducted to identify peer-reviewed studies published between January 1998 and July 2011 focused on adolescents ages 10-19 years. RESULTS: Sixty-eight articles were examined: 40 on adolescent mental health (AMH), 27 on adolescent physical health (APH), and 1 on both topics. Key individual factors included gender and age. Religiosity and engagement in other risk behaviors were associated with AMH, while the presence of other chronic illnesses affected APH. Significant determinants of AMH in the microsystem included family and school connectedness, family structure, and socioeconomic status. Maternal obesity, parental education, and school environment influenced APH. Studies that investigated macrosystem factors reported few consistent findings related to AMPH. A history of family mental health problems and physical and sexual abuse was significantly associated with AMH in the chronosystem, while a family history of diabetes and low birth weight were associated with APH. Studies did not examine the exosystem or the mesosystem. CONCLUSIONS: AMPH in the English-speaking Caribbean is affected by a variety factors in developing adolescents and their surroundings. Gender, family, and early exposure to negative environments are salient factors influencing AMPH and present potential avenues for prevention and intervention. A fuller understanding of AMPH in this region, however, requires scientifically rigorous studies that incorporate a multisystem approach.

OBJETIVO: Se empleó la teoría de sistemas ecológicos de Bronfenbrenner, un marco conceptual multisistémico, para identificar los factores de riesgo y de protección asociados con la salud mental y física de los adolescentes en el Caribe de habla inglesa. MÉTODOS: Se llevó a cabo una revisión bibliográfica estructurada usando las bases de datos en línea MEDLINE, PsychInfo y Scopus, para identificar estudios con revisión externa publicados entre enero de 1998 y julio del 2011 centrados en adolescentes de 10 a 19 años. RESULTADO: Se examinaron 68 artículos: 40 sobre salud mental en adolescentes, 27 sobre salud física en adolescentes y 1 sobre ambos temas. Los factores individuales clave incluyeron el sexo y la edad. La religiosidad y la participación en otros comportamientos de riesgo se asociaron con la salud mental, mientras que la presencia de otras enfermedades crónicas afectó a la salud física. Los determinantes significativos de la salud mental en el microsistema incluyeron la vinculación con la familia y la escuela, la estructura familiar y la situación socioeconómica. La obesidad materna, la educación parental y el ambiente escolar influyeron en la salud física. Los estudios que investigaron los factores del macrosistema informaron pocos resultados consistentes relacionados con la salud mental y física en los adolescentes. Los antecedentes familiares de problemas de salud mental, y el maltrato físico y el abuso sexual presentaron una asociación significativa con la salud mental en el cronosistema, mientras que los antecedentes familiares de diabetes y peso bajo al nacer se asociaron con la salud física. Los estudios no examinaron el exosistema o el mesosistema. CONCLUSIONES: La salud mental y física de los adolescentes en el Caribe de habla inglesa está afectada por varios factores de su desarrollo y su entorno. El género, la familia y la exposición temprana a un entorno negativo son factores destacados que influyen en la salud mental y física de los adolescentes y representan posibles caminos para la prevención y la intervención. No obstante, para alcanzar una comprensión más integral de la salud mental y física de los adolescentes en esta región se requieren estudios científicamente rigurosos que incorporen un enfoque multisistémico.

Protective and risk factors associated with adolescent sexual and reproductive health in the English-speaking Caribbean: a literature review.

PURPOSE: To identify risk and protective factors associated with adolescent sexual and reproductive health (ASRH) in the English-speaking Caribbean through a structured literature review. METHODS: Peer-reviewed articles published between January 1998 and December 2009 focused on the sexual and reproductive health of adolescents, aged 10-19 years, were included in this review. Articles were organized according to Bronfenbrenner's ecological systems theory. Research gaps were also identified. RESULTS: A total of 30 studies assessed ASRH. At the individual level, gender, psychosocial well-being, and mental health were key factors associated with ASRH. Within the microsystem, the quality of the parent-adolescent relationship, the presence of violence, substance abuse or mental health problems in the family, and peer relationships were important determinants of ASRH. Within the macrosystem, cultural attitudes had an effect on youth's sexual behavior and generally, safer sex practices appear to be increasing. Within the chronosystem, a history of physical and sexual abuse was associated with several ASRH outcomes. CONCLUSION: A research agenda that incorporates a multisystem approach and advocates for the inclusion of socially marginalized youth is needed to fully understand and adequately address ASRH in the Caribbean.