Lived experiences with pre-exposure prophylaxis uptake and adherence among transgender women in Thailand: a qualitative study.

BACKGROUND: Transgender women (TGW) are disproportionately affected by HIV, and HIV prevalence among TGW in Thailand has been increasing. Although oral daily pre-exposure prophylaxis (PrEP) is effective for HIV prevention, PrEP uptake and persistence among TGW have been low. This study aimed to provide a deeper understanding of TGW's experiences with PrEP uptake and adherence, and to identify major barriers to PrEP use to inform intervention adaptation. METHODS: We interviewed 20 young TGW (six non-PrEP users, eight adherent, six non-adherent) and 10 health care providers from two HIV clinics in Bangkok, Thailand, in 2022. We focused on understanding challenges to PrEP use in this population using an interview guide based on a theoretical model of behaviour change and thematic content analysis. RESULTS: Thematic analysis identified major barriers to and facilitators of PrEP uptake and adherence. Barriers to PrEP initiation included low self-perceived HIV risk, concern about potential side-effects, patient burdens such as frequent HIV testing for prescription refills and social stigma against PrEP. Barriers to adherence included side-effects, inconvenient access to health services (especially during COVID-19 lockdowns), forgetfulness resulting from busy schedules and low self-perceived HIV risk. TGW also reported health care providers' stigma against PrEP users deterred them from seeking further PrEP services. TGW identified major facilitators of PrEP initiation, including awareness about the benefits of PrEP, concern about risks of HIV and supportive social networks of PrEP users. As to PrEP regimens, most TGW participants reported a clear preference for long-lasting, injectable PrEP over daily oral PrEP. TGW and health care providers largely agreed on barriers and facilitators of PrEP use, but they differed in perceptions of HIV risk. CONCLUSIONS: The results highlighted challenges and opportunities to improve the delivery of PrEP, as well as other sexually transmissable infection and mental health services, especially among TGW. Thus, there is an urgent need for developing effective intervention programs that could raise PrEP awareness and knowledge, reduce PrEP stigma, and improve PrEP delivery systems among TGW in Thailand.

Adapting Effective mHealth Interventions to Improve Uptake and Adherence to HIV Pre-Exposure Prophylaxis Among Thai Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial.

BACKGROUND: Young men who have sex with men (YMSM) are the fastest-growing HIV-positive population worldwide. Thailand has the highest adult HIV seroprevalence in Asia; over 25% of men having sex with men in Bangkok are HIV positive. Pre-exposure prophylaxis (PrEP) is an efficacious HIV prevention strategy recommended for all at-risk individuals. PrEP is highly effective when taken as prescribed, but PrEP utilization rate has been low, and adherence is often inadequate. OBJECTIVE: We propose to develop and pilot a multicomponent, technology-based intervention to promote motivation to begin PrEP ("uptake") and sustained adherence to PrEP among HIV-negative Thai YMSM. We will adapt an existing 2-session technology-delivered, motivational interviewing-based intervention to focus on PrEP use in YMSM in Thailand. The resulting intervention is called the Motivational Enhancement System for PrEP Uptake and Adherence (MES-PrEP). We will also develop motivational text messaging (MTM) to send two-way motivational messages to promote PrEP use. METHODS: The proposed study includes 3 phases. Phase 1 includes in-depth interviews with HIV-negative Thai YMSM and providers to explore barriers and facilitators of PrEP initiation and adherence, aiming to inform intervention content. Phase 2 consists of adapting and beta-testing MES-PrEP and MTM for functionality and feasibility using a youth advisory board of Thai YMSM. In Phase 3, we will conduct a pilot randomized controlled trial to evaluate the feasibility, acceptability, and preliminary efficacy of MES-PrEP and MTM to increase PrEP uptake and adherence among Thai YMSM. A total of 60 HIV-negative Thai YMSM who have not started PrEP and 60 YMSM who are on PrEP but not adherent to it will be randomized 2:1 to receive MES-PrEP and MTM (n=40) or standard PrEP counseling (n=20). The feasibility and acceptability of the intervention will be assessed through usage patterns and the System Usability Scale. The preliminary impact will be assessed by evaluating the proportion of PrEP initiation and level of adherence to PrEP. Participants will complete the assessments at baseline and at 1-, 3-, and 6-month postintervention. Biomarkers of adherence to PrEP and biomarkers of HIV and sexually transmitted infections will be collected. RESULTS: Recruitment for this study began in January 2022 for phase 1. Qualitative interviews were completed with 30 YMSM and 5 clinical providers in May 2022. Phase 3, the pilot feasibility and acceptability trial, began in July 2023. Upon project completion, we shall have developed a highly innovative mobile health intervention to support YMSM using PrEP, which will be ready for testing in a larger efficacy trial. CONCLUSIONS: This study addresses a critical problem (ie, high HIV incidence and low PrEP use) among Thai YMSM. We are developing 2 potentially synergistic technology-based, theory-driven interventions aimed at maximizing PrEP use. The proposed project has the potential to make significant contributions to advancing HIV prevention research and implementation science. TRIAL REGISTRATION: ClinicalTrials.gov NCT05243030; https://clinicaltrials.gov/ct2/show/NCT05243030. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46435.

Optimizing an mHealth Intervention to Improve Uptake and Adherence to HIV Pre-exposure Prophylaxis in Young Transgender Women: Protocol for a Multi-Phase Trial.

BACKGROUND: Vulnerable adolescents and emerging adults (aged 18-29 years), particularly young transgender women, are among the fastest-growing HIV positive populations worldwide. Thailand has the highest adult HIV seroprevalence in Asia, with a rate of infection among this population of 18%. Widespread technology offers opportunities for innovative mobile health (mHealth) interventions. Pre-exposure prophylaxis (PrEP) is an efficacious HIV prevention strategy recommended for at-risk individuals. PrEP is highly effective when taken as prescribed, but uptake and adherence have been low, with high discontinuation rates among youth. OBJECTIVE: We propose to develop and pilot a multi-component, technology-based intervention to promote PrEP usage. We will adapt an existing 2-session, technology-delivered, motivational interviewing-based intervention to focus on PrEP use in transgender women in Thailand. We call this the Motivational Enhancement System for PrEP Uptake and Adherence (MES-PrEP). We will also refine and enhance YaCool, a mobile app with integrated text messaging developed and used clinically by our Thai team. The new version of the app is called Enhanced YaCool, and it enables self-management of gender and sexual health (including PrEP). Our primary aim is to develop and assess the preliminary efficacy of this mHealth intervention. METHODS: We will utilize a multiphase optimization strategy (MOST) to identify the most effective intervention component or combination of components to improve PrEP usage in Thai transgender women. The study includes two phases: phase I (R21) includes qualitative interviews with key stakeholders to explore barriers and facilitators of PrEP usage through thematic analysis to inform intervention adaptation. Following this, we will adapt and beta-test MES-PrEP and Enhanced YaCool for functionality and feasibility using a community advisory board of HIV-negative Thai transgender women. In phase II (R33), we will conduct a MOST design-based trial to evaluate the feasibility, acceptability, and preliminary efficacy of MES-PrEP and Enhanced YaCool. Eighty HIV-negative participants who are currently taking PrEP and 80 participants who are not will be randomized to four conditions: (1) standard PrEP counseling (the control condition); (2) MES-PrEP and standard PrEP counseling; (3) Enhanced YaCool and standard PrEP counseling; and (4) MES-PrEP, Enhanced YaCool, and standard PrEP counseling. Feasibility and acceptability of the intervention will be assessed through usage patterns and the System Usability Scale. Preliminary impact will be assessed by evaluating the proportion of participants who initiate PrEP and their level of adherence to PrEP. Assessments will be at baseline and 1, 3, 6, 9, and 12 months postintervention. Biomarkers of adherence to PrEP, HIV, and other sexually transmitted infections will be collected. RESULTS: Upon project completion, we will have an optimized mHealth intervention to support the use of PrEP by transgender women that will be ready for testing in a larger efficacy trial. CONCLUSIONS: Even though transgender women in Thailand face increasing risks of HIV, few interventions have targeted them. Effective developmentally and culturally tailored interventions are needed to prevent HIV transmission in this high-risk population. TRIAL REGISTRATION: ClinicalTrials.gov NCT05262426; https://clinicaltrials.gov/ct2/show/NCT05262426. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37659.

COVID-19 in Children: Clinical Manifestations and Pharmacologic Interventions Including Vaccine Trials.

Children usually present with milder symptoms of COVID-19 as compared with adults. Supportive care alone is appropriate for most children with COVID-19. Antiviral therapy may be required for those with severe or critical diseases. Currently there has been a rapid development of vaccines globally to prevent COVID-19 and several vaccines are being evaluated in children and adolescents. Currently, only the Pfizer-BioNTech messenger RNA vaccine is approved for emergency authorization use in the pediatric population ages 16 years and older.

Clinical Characteristics of 204 Children With Human Adenovirus Type 7 Pneumonia Identified by Whole Genome Sequencing in Liuzhou, China.

BACKGROUND: Clinical knowledge of human adenovirus type 7 (HAdV-7) pneumonia in children remains limited. Moreover, predictors for disease severity are largely unknown. METHODS: This is a retrospective study of children hospitalized at Liuzhou Maternal and Child Health Hospital, China, with HAdV-7 pneumonia in 2018-2019. Demographics, clinical characteristics, laboratory results, and imaging data were collected. HAdV-7 was identified in plasma using whole genome sequencing, which yielded quantitative HAdV-7 sequence numbers. RESULTS: There were 204 children; 145 (71%) were <2 years of age. There were 68 children with severe pneumonia (SP) and 136 with nonsevere pneumonia (NSP). Up to 43% in SP group with respiratory failure (SP-RF) were <12 months of age. Median duration of fever before hospitalization was shorter in NSP group than SP groups (P < 0.01). Fourteen (6.9%) underwent mechanical ventilation. There was a significant difference in mean plasma HAdV-7 sequence numbers among SP-RF, SP without respiratory failure (SP-NRF), and NSP groups (2485 ± 165, 2034 ± 124, and 286 ± 35, respectively) (P < 0.01). In a logistic regression analysis, we found that elevated plasma HAdV-7 sequence numbers significantly increased the risk of severe HAdV-7 pneumonia (OR 1.80, 95% confidence interval: 1.59-2.60, P < 0.01) after adjusting for age, fever duration, platelet counts, and serum lactate dehydrogenase levels. CONCLUSIONS: Over two-thirds of children hospitalized with HAdV-7 pneumonia were <2 years of age. Approximately 40% of those with SP associated with respiratory failure were <12 months of age. Those with SP exhibited higher plasma HAdV-7 sequence numbers. Thus, plasma HAdV-7 sequence numbers have a potential in predicting severity of HAdV-7 pneumonia in children.

Update on Coccidioidomycosis in the United States and Beyond.

Coccidioidomycosis is a fungal infection that is prevalent in western United States, Central America, and South America. The infection is acquired by inhalation. It can affect persons of all ages including infants and children. The majority of cases are asymptomatic and the incidence of infection is greater during a dry summer season after heavy rainfall in prior winter. For those with symptoms, they may experience a self-limiting influenza-like illness. However, some may progress toward pneumonia or disseminated diseases involving skeletal system and central nervous system. The diagnosis is based mainly on various serology testing. Antifungal treatment is generally not required for those with mild symptoms. For those with moderate to severe infections, the mainstay of treatment is azole, with fluconazole being often considered as the first line therapy. Currently there is no effective solution to prevent coccidioidomycosis. Those who work in high-risk conditions should be given appropriate protective equipment as well as education on proper precaution.

Extrapulmonary Coccidioidomycosis Among Children in Central California: A Retrospective Review.

BACKGROUND: The literature on pediatric extrapulmonary coccidioidomycosis is limited. We reviewed the clinical course, diagnostic studies, treatment and outcomes of children with extrapulmonary coccidioidomycosis followed at a tertiary care center in central California. METHODS: Retrospective study of 78 patients ≤21 years old with extrapulmonary coccidioidomycosis diagnosed over 10 years (1/1/07-12/31/16). RESULTS: The median age was 9.7 years (interquartile range, 4.5-14.8). The majority of patients were males (55%), Hispanic (65%) and without comorbid conditions (85%). Over two-thirds (68%) had concurrent pulmonary disease. Organ involvements included bones and joints (33%), mediastinum (19%), central nervous system (19%), cervical lymph nodes (15%), larynx (6%) and skin (5%). Most cases (84%) resolved and/or became stable on maintenance therapy, 14% experienced relapse and/or progressive disease, and 2% were fatal. Children ≥10 years of age tended to have >1 site of involvement (47% vs. 25%, P = 0.06), and more relapsed/progressive/fatal disease (21% vs. 5%, P = 0.06) compared with those <10 years. They also required longer durations of treatment (median, 611 vs. 349 days, P = 0.02). Non-Hispanics were more likely to require >1 drug therapy (85% vs. 70%, P = 0.04) and tended to have Coccidioides complement fixation titers ≥1:32 (89% vs. 72%, P = 0.04) compared with Hispanics. CONCLUSIONS: Extrapulmonary coccidioidomycosis in children can be severe and spread to multiple sites and requires prolonged treatment. Non-Hispanics and those ≥10 years of age are more likely to experience severe disease, suggesting a need for early recognition and intervention in these populations.

Growth of HIV-Exposed Infants in Southwest China: A Comparative Study.

Objectives. Prevention of mother-to-child HIV transmission has been globally successful leading to a decline in HIV-infected infants. Thus, the number of HIV-exposed, but uninfected, infants is increasing. As growth is an important indicator of child health, this study aimed to evaluate growth parameters of HIV-exposed Chinese infants. Methods. A prospective study was conducted among HIV-exposed (HIV-infected and uninfected) infants born during 2007 to 2015 in Liuzhou, China. Their weight and length were assessed longitudinally from birth to 18 months of age and compared with HIV-unexposed, uninfected (HUU) infants from the same region. Results. There were 467 HIV-exposed infants. Four percent of infants were HIV-infected. The mean weight-for-age (WAZ) and length-for-age (LAZ) z scores of HIV-infected infants were significantly lower than those of HIV-exposed but uninfected (HEU) infants during 9 to 18 months and 12 to 18 months of age, respectively. Additionally, the mean WAZ and LAZ scores of HIV-infected infants were significantly lower than HUU infants during the first 12 months and 18 months of life, respectively. The mean WAZ and LAZ scores of HEU infants were significantly lower than HUU infants during the first 12 months and 6 months of life, respectively. HEU infants also had a lower mean weight-for-length z score than HUU infants during the first 6 months. Conclusion. We demonstrated poor growth among HIV-exposed Chinese infants, including HIV-uninfected, compared with HUU infants. The results emphasize the need for nutritional monitoring and interventions for HIV-exposed infants regardless of HIV infection status. Research is needed on long-term growth trajectories and factors affecting growth of HIV-exposed infants in China.

Epidemiology of birth defects based on surveillance data from 2011-2015 in Guangxi, China: comparison across five major ethnic groups.

BACKGROUND: The causes of birth defects (BDs) are complex and include genetic and environmental factors and/or their interactions. More research is needed to describe the epidemiology of BDs within specific regions of China. This study focused on differences in the prevalence of BDs based on ethnicity in a large city in Guangxi Province, China. METHODS: Surveillance data of infants born in 114 registered hospitals in Liuzhou between 2011 and 2015 were analyzed to determine the epidemiology of BDs across five major ethnic groups. We calculated the prevalence of BDs and relative risk of BDs by ethnicity. RESULTS: There were 260,722 perinatal infants of which 6581 had BDs, with the average prevalence of 25.24 per 1000 perinatal infants (PIs). Prevalence data showed an obvious uptrend over the past 5 years. Han had the highest prevalence of total BDs (28.98‰), followed by Zhuang (25.19‰), Yao (18.50‰), Miao (15.78‰) and Dong (14.24‰). Relative to the Han; Zhuang, Miao, Yao, and Dong had a lower risk of musculoskeletal and urogenital malformations; Miao and Yao had a lower risk of cardiovascular malformation; and Dong had a lower risk of cardiovascular and craniofacial malformation. Several maternal risk factors were found to be associated with BDs (e.g., maternal and gestational age, number of antenatal care visits). CONCLUSION: This study provided a comprehensive description of ethnic differences in the risk of BDs in Liuzhou City, China. Observed ethnic differences in the risk of BDs may be related to genetic susceptibilities, environment, cultural customs, or to potential combinations of these factors.

Group B streptococcal colonization in mothers and infants in western China: prevalences and risk factors.

BACKGROUND: The epidemiology of maternal and infant Group B streptococcus (GBS) colonization is poorly understood in China. The aim of this study is to explore the prevalence and risk factors associated with maternal and infant GBS colonization in Western China. METHODS: From January 2017 to June 2017, a prospective study was conducted to estimate the maternal and infant GBS colonization rate by maternal rectovaginal and infant nasopharynx, ear canal and umbilical swab culture. Patient demographics, clinical characteristics and outcomes were collected. Chi-square and logistic regression analyses were used to examine the risk factors associated with GBS colonization of mothers and infants. RESULTS: The GBS colonization rate in mothers and infants was 6.1 and 0.7%, respectively. The vertical transmission rate was 7.6%. The early onset GBS infection rate was 0.58 per 1000 live births and mortality was 0.29 per 1000 live births. Age younger than 40 years (p = 0.040) and minority ethnic status (p = 0.049) were associated with higher GBS colonization rate in pregnant women. Positive GBS status in the mother prior to delivery (p < 0.001) as well as longer duration of membrane rupture (≥12 h) (p < 0.001) and longer labor (≥4 h) (p < 0.001) were all significant risk factors for GBS colonization in infants. Compared to infants without GBS colonization, infants colonized with GBS were more likely to have had a temperature of ≥38 °C (p < 0.001), developed early onset infection (EOD) (p < 0.001), and been prescribed antibiotics (p < 0.001). Furthermore, infants with GBS were more likely to have been admitted to neonatal intensive unit (NICU) (p < 0.001) with a longer hospital length of stay (LOS) (p < 0.001). CONCLUSIONS: Maternal GBS colonization, longer duration of membrane rupture and labor were all major risk factors associated with GBS colonization in Chinese infants. Infant GBS colonization was associated with increased risk of EOD and NICU admission as well as longer LOS.

Extrapulmonary Aspergillus infection in patients with CARD9 deficiency.

Invasive pulmonary aspergillosis is a life-threatening mycosis that only affects patients with immunosuppression, chemotherapy-induced neutropenia, transplantation, or congenital immunodeficiency. We studied the clinical, genetic, histological, and immunological features of 2 unrelated patients without known immunodeficiency who developed extrapulmonary invasive aspergillosis at the ages of 8 and 18. One patient died at age 12 with progressive intra-abdominal aspergillosis. The other patient had presented with intra-abdominal candidiasis at age 9, and developed central nervous system aspergillosis at age 18 and intra-abdominal aspergillosis at age 25. Neither patient developed Aspergillus infection of the lungs. One patient had homozygous M1I CARD9 (caspase recruitment domain family member 9) mutation, while the other had homozygous Q295X CARD9 mutation; both patients lacked CARD9 protein expression. The patients had normal monocyte and Th17 cell numbers in peripheral blood, but their mononuclear cells exhibited impaired production of proinflammatory cytokines upon fungus-specific stimulation. Neutrophil phagocytosis, killing, and oxidative burst against Aspergillus fumigatus were intact, but neither patient accumulated neutrophils in infected tissue despite normal neutrophil numbers in peripheral blood. The neutrophil tissue accumulation defect was not caused by defective neutrophil-intrinsic chemotaxis, indicating that production of neutrophil chemoattractants in extrapulmonary tissue is impaired in CARD9 deficiency. Taken together, our results show that CARD9 deficiency is the first known inherited or acquired condition that predisposes to extrapulmonary Aspergillus infection with sparing of the lungs, associated with impaired neutrophil recruitment to the site of infection.

Motivational interviewing targeting risky sex in HIV-positive young Thai men who have sex with men.

Motivational interviewing (MI) has been shown to reduce sexual risks among HIV-positive men who have sex with men (HMSM) in the US. We conducted a randomized trial of Healthy Choices, a 4-session MI intervention, targeting sexual risks among 110 HIV-positive youth ages 16-25 years in Thailand. Risk assessments were conducted at baseline, 1 month, and 6 months post-intervention. This report presents the analysis of 74 HMSM in the study. There were 37 HMSM in the Intervention group and 37 in the control group. The proportions of participants having anal sex and having sex with either HIV-uninfected or unknown partners in past 30 days were significantly lower in Intervention group than in Control group at 6 months post-intervention (38 vs. 65 %, p = .04; and 27 vs. 62 %, p < .01, respectively). There were no significant differences in general mental health scores and HIV stigma scores between the two groups at any study visit. Thirty-five (95 %) HMSM in the Intervention group vs. 31 (84 %) in control group attended ≥ 3 sessions. Loss to follow-up was 8 and 30 %, respectively (p = .04). Healthy Choices for young Thai HMSM was associated with sexual risk reduction. Improvements in mental health were noted in Intervention group. Healthy Choices is a promising behavioral intervention and should be further developed to serve the needs of young HMSM in resource-limited countries.

Retroperitoneal aspergilloma.

We report a previously healthy 8-year-old boy who presented to the hospital with a palpable abdominal mass, fever and abdominal pain. CT and MRI scans confirmed a large mass that was centered in the retroperitoneum. The lesion was biopsied and the histology showed branching hyphae. Tissue cultures grew Aspergillus fumigatus and a diagnosis of aspergilloma was made. The immunological work-up did not reveal an immunodeficiency. This case is a unique presentation of aspergilloma presenting in an unusual location and in an immunocompetent patient.

Motivational interviewing targeting risk behaviors for youth living with HIV in Thailand.

Healthy Choices, a four-session motivational interviewing-based intervention, reduces risk behaviors among US youth living with HIV (YLWH). We randomized 110 Thai YLWH (16-25 years) to receive either Healthy Choices or time-matched health education (Control) over 12 weeks. Risk behaviors were assessed at baseline, 1, and 6 months post-session. The pilot study was not powered for between-group differences; there were no statistical differences in sexual risks, alcohol use, and antiretroviral adherence between the two groups at any visit. In within-group analyses, Healthy Choices group demonstrated decreases in the proportion of HIV-negative partners (20 vs 8.2%, P = 0.03) and HIV sexual risk scores (4.3 vs 3.3, P = 0.04), and increased trends in the proportion of protected sex (57 vs 76.3%, P = 0.07) from baseline to 1 month post-session. These changes were not sustained 6 months later. No changes were observed in Control group. Healthy Choices has potential to improve sexual risks among Thai YLWH.