Barriers and facilitators to pre-exposure prophylaxis (PrEP) uptake and adherence among men who have sex with men (MSM) in Thailand: a qualitative study.

Young MSM (YMSM), aged 15-24, account for nearly half of new HIV infections in Thailand. Pre-exposure prophylaxis (PrEP) is an effective prevention medicine for populations at substantial HIV risk, yet YMSM frequently have suboptimal uptake of and adherence to PrEP. We conducted 35 in-depth interviews with YMSM to explore barriers and facilitators of both PrEP initiation and adherence. Interviews also elicited the perceptions and experiences of healthcare providers (HCPs) working with YMSM at three clinics in Bangkok. Primary barriers to PrEP initiation were limited accessibility, insufficient knowledge, and efficacy concerns; HCPs identified no-to-low self-perception of HIV risk, pre-existing health problems, fears of side effects, and living in distant provinces as barriers to PrEP initiation. YMSM primarily reported PrEP information and self-perceptions of elevated HIV risk as facilitators to PrEP initiation. Additionally, forgetfulness and low HIV risk awareness were common barriers to PrEP adherence. Reminders were a prominent facilitator of PrEP adherence alongside disclosure to close relationships, the routinization of regimens, and convenient facilities. HCPs regarded counseling as the leading facilitator of PrEP adherence. By understanding the barriers/facilitators of PrEP use, the current study seeks to help develop evidence-informed PrEP intervention programs among YMSM while considering cultural sensitivity.

Teachers' Perceptions of the Impact of the COVID-19 Pandemic and Their Implementation of an Evidence-based HIV Prevention Program in the Bahamas.

Information on how school-based programs is implemented and sustained during crises is limited. In this study, we assessed the impact of the COVID-19 pandemic on the implementation of a HIV prevention intervention in The Bahamas. Data were collected from 139 Grade 6 teachers in 2021-2022. Teachers attended virtual training and received implementation monitoring from coordinators. On average, teachers taught 26.4 (SD = 9.2) of the 35 core activities, and 7.4 (SD = 2.4) out of 9 sessions. More than half (58.3%) of teachers completed 28 or more core activities; 69.1% covered eight or all nine sessions, which is equivalent to 80% of the HIV intervention curriculum. Almost half of the teachers (43%) reported that the pandemic negatively impacted their ability to teach the program; 72% of teachers maintained that the program remained "very important" during times of crisis. Greater self-efficacy and supports increased implementation fidelity.

The influence of socioenvironmental risk factors on risk-taking behaviors among Bahamian adolescents: a structural equation modeling analysis.

Background: Adolescents' risk-taking behaviors can have profound impacts on their future health. Few studies have established a relationship between multiple social environmental factors and adolescent risk behaviors. We used structural equation modeling to examine the role of parental monitoring and environmental risks on adolescents' behavioral intentions and risk behaviors. Methods: Data were collected through the baseline survey of a national implementation project among 2205 Grade 6 students in 24 government schools in The Bahamas in 2019. Structural equation modeling examined relations among parental monitoring, environmental risk factors, behavioral intentions, and risk behaviors. Results: Students had engaged in various delinquent, substance use, and sexual risks. In the structural equation model, parental monitoring demonstrated direct negative (protective) effects on behavioral intentions and risk behaviors, whereas environmental risk factors had a direct positive effect on adolescent behavioral intentions and risk behaviors. The model had an R2 value of 0.57 for adolescent risk behaviors. Conclusion: Parental monitoring and environmental risk factors had strong influences on risk-taking behaviors of early adolescents. Future adolescent health behavior interventions should consider offering additional prevention resources to early adolescents who are exposed to multiple environmental risk factors.

Maintaining Program Fidelity in a Changing World: National Implementation of a School-Based HIV Prevention Program.

Large-scale, evidence-based interventions face challenges to program fidelity of implementation. We developed implementation strategies to support teachers implementing an evidence-based HIV prevention program in schools, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT) in The Bahamas. We examined the effects of these implementation strategies on teachers' implementation in the subsequent year after the initial implementation during the COVID-19 pandemic. Data were collected from 79 Grade 6 teachers in 24 government elementary schools. Teachers completed training workshops and a pre-implementation questionnaire to record their characteristics and perceptions that might affect their program fidelity. School coordinators and peer mentors provided teachers with monitoring, feedback, and mentoring. In Year 1, teachers on average taught 79.3% of the sessions and 80.8% of core activities; teachers in Year 2 covered 84.2% of sessions and 72.9% of the core activities. Teachers with "good" or "excellent" school coordinators in the second year taught significantly more sessions on average (7.8 vs. 7.0, t = 2.04, P < 0.05) and more core activities (26.3 vs. 23.0, t = 2.41, P < 0.05) than teachers with "satisfactory" coordinators. Teachers who had a "good" or "satisfactory" mentor taught more sessions than teachers who did not have a mentor (7.9 vs. 7.3; t = 2.22; P = 0.03). Two-level mixed-effects model analysis indicated that teachers' program fidelity in Year 1, confidence in the execution of core activities, and school coordinators' performance were significantly associated with Year 2 implementation dose. Implementation of FOYC + CImPACT was significantly associated with improved student outcomes. Teachers maintained high fidelity to a comprehensive HIV prevention program over 2 years during the COVID-19 pandemic. Future program implementers should consider additional implementation support to improve the implementation of school-based programs.

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.

Exploring effects of multi-level factors on transitions of risk-taking behaviors among middle-to-late adolescents.

Adolescents experiment with risk behaviors, including delinquency, substance use, and sexual activity. Multi-level social factors, such as having high-risk peers, neighborhood risks, and parental monitoring, influence adolescents' behaviors. We modeled transition patterns in Bahamian adolescents' risk behaviors across three high school years and examined the effects of multi-level factors. We collected data from 2,564 Bahamian adolescents in Grade 10 and follow-ups through Grade 12. We used latent transition model to identify adolescents' risk statuses. Further analyses used multinomial logistic regression to explore the effects of multi-level factors on assignment to those latent statuses and transitions. We identified four distinct statuses: "low risk" (47.9% of the sample at baseline), "alcohol use" (36.8%), "alcohol use and sexual activity" (5.5%), and "high risk" (9.8%). Males were more likely to be in higher-risk statuses at baseline and to transition from a lower-risk status in Grade 10 to a higher-risk status in Grade 11. Social risk factors were significantly associated with higher-risk statuses at baseline. Neighborhood risk and peer risk involvement continued to affect transitions from lower to higher risk; parental monitoring did not have a significant effect in later years. Our findings have important implications for developing targeted and developmentally appropriate interventions to prevent and reduce risk behaviors among middle-to-late adolescents.

Effects of Teacher Training and Continued Support on the Delivery of an Evidence-Based HIV Prevention Program: Findings From a National Implementation Study in the Bahamas.

BACKGROUND: Few studies have investigated the effects of teacher training and continued support on teachers' delivery of evidence-based HIV prevention programs. We examined these factors in a national implementation study of an evidence-based HIV risk reduction intervention for adolescents in the sixth grade in the Bahamas. METHODS: Data were collected from 126 grade 6 teachers and 3,118 students in 58 government elementary schools in the Bahamas in 2019-2021. This is a Hybrid Type III implementation study guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) model. Teachers attended 2-day training workshops. Trained school coordinators and peer mentors provided biweekly monitoring and mentorship. We used mixed-effects models to assess the effects of teacher training and continued support on implementation fidelity. RESULTS: Teachers who received training in-person or both in-person and online taught the most core activities (27.0 and 27.2 of 35), versus only online training (21.9) and no training (14.9) (F = 15.27, p < .001). Teachers with an "excellent" or "very good" school coordinator taught more core activities than those with a "satisfactory" coordinator or no coordinator (29.2 vs. 27.8 vs. 19.3 vs. 14.8, F = 29.20, p < .001). Teachers with a "very good" mentor taught more core activities and sessions than those with a "satisfactory" mentor or no mentor (30.4 vs. 25.0 vs. 23.1; F = 7.20; p < .01). Teacher training, implementation monitoring, peer mentoring, teachers' self-efficacy, and school-level support were associated with implementation fidelity, which in turn was associated with improved student outcomes (HIV/AIDS knowledge, preventive reproductive health skills, self-efficacy, and intention to use protection). CONCLUSION: Teachers receiving in-person training and those having higher-rated school coordinator and mentor support taught a larger number of HIV prevention core activities. Effective teacher training, implementation monitoring, and peer mentoring are critical for improving implementation fidelity and student outcomes.

Implementing a school-based HIV prevention program during public health emergencies: lessons learned in The Bahamas.

BACKGROUND: Natural disasters and public health crises can disrupt communities' capacities to implement important public health programs. A nationwide implementation of an evidence-based HIV prevention program, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT), in The Bahamas was disrupted by Hurricane Dorian and the COVID-19 pandemic, especially in its more remote, Family Islands. We explored the teacher- and school-level factors that affected implementation of the program in these islands during those disruptions. METHODS: Data were collected from 47 Grade 6 teachers and 984 students in 34 government elementary schools during the 2020-2021 school year. Teachers completed a pre-implementation questionnaire to record their characteristics and perceptions that might affect their implementation fidelity and an annual program training workshop. School coordinators and high-performing teachers acting as mentors received additional training to provide teachers with monitoring, feedback, and additional support. Teachers submitted data on their completion of the 9 sessions and 35 core activities of FOYC + CImPACT. The fidelity outcomes were the number of sessions and core activities taught by teachers. RESULTS: On average, teachers taught 60% of sessions and 53% of core activities. Teachers with "very good" school coordinators (34% of teachers) taught more activities than those with "satisfactory" (43%) or no (34%) school coordinator (27.5 vs. 16.8 vs. 14.8, F = 12.86, P < 0.001). Teachers who had attended online training or both online and in-person training taught more sessions (6.1 vs. 6.2 vs. 3.6, F = 4.76, P < 0.01) and more core activities (21.1 vs. 20.8 vs. 12.6, F = 3.35, P < 0.05) than those who received no training. Teachers' implementation was associated with improved student outcomes (preventive reproductive health skills, self-efficacy, and intention). CONCLUSIONS: The Hurricane Dorian and the COVID-19 pandemic greatly disrupted education in The Bahamas Family Islands and affected implementation of FOYC + CImPACT. However, we identified several strategies that supported teachers' implementation following these events. Teacher training and implementation monitoring increased implementation fidelity despite external challenges, and students achieved the desired learning outcomes. These strategies can better support teachers' implementation of school-based interventions during future crises.

Investigating a key structural determinant of health, racism, and related social determinants of health in Massachusetts during the COVID-19 pandemic.

A disproportionate burden of the ongoing COVID-19 pandemic is being shouldered by members of racial and ethnic minorities and socially disadvantaged communities. Structural and social determinants of health have been recognized as key contributors to the inequalities observed. Racism, a major structural determinant of health that patterns related social determinants of health, in the USA, warrants further investigation. In this perspective piece we provide an overview of the historical context of racism, followed by preliminary findings from the ongoing COVIDStory study-a cross-sectional study addressing perceptions of COVID-19 and COVID-19 research-that highlights the experiences of non-Hispanic Black and Hispanic identifying adult participants, residing in Worcester Massachusetts, during the COVID-19 pandemic. We then discuss these findings in the context of current and past research considering racism and relevant social determinants of health. Our study results suggest that racism and its residuals (residential segregation, economic insecurity, discrimination, bias, and vigilance) are modern challenges for non-Hispanic Black and Hispanic participants, and these findings are supported by the existing literature. It is our hope that this perspective piece provides additional evidence for action on structural and social determinants affecting the health of minoritized people, especially those living in Massachusetts.

Adverse Side Effects of Psychotropic Medication and Challenging Behavior: Pilot Work Assessing Impact.

Psychotropic medications are often prescribed to reduce challenging behavior in individuals with intellectual and developmental disabilities (IDD). Functional analyses (FAs) have demonstrated utility in assessing medication impact on behavior; however, the impact of adverse side effects (ASE) on challenging behavior is under-assessed. The purpose of this study was to develop a methodology, similar to FAs, to explore potential medication ASE impact on challenging behavior in seven individuals with IDD. Results revealed response rate differences in designed ASE conditions for most participants. Outcomes support further development and use of this methodology to assess the presence and impact of ASEs.

Assessing the Impact of Psychotropic Medication Changes on Challenging Behavior of Individuals with Intellectual Disabilities.

OBJECTIVE: The use of psychotropic medication to address challenging behavior in individuals diagnosed with intellectual disabilities is common practice; however, very few studies have examined how multiple medication use (or combination treatment) impacts the behaviors these medications are prescribed to treat. METHOD: The current study followed eight individuals over a two-year period as they experienced changes in their psychotropic medication regimens. During that time, data from functional analyses and indirect assessments of challenging behavior were collected. RESULTS: The results suggest that changes in psychotropic medication regimens can produce changes in functional assessment outcomes, suggesting a need for continued behavioral assessment to better inform medication practices and behavioral treatment. Of the eight participants in the study, five participants' behaviors varied in rate of responding in FAs across all medication changes. Additionally, three participants' FAs produced changes in outcomes; however, those changes were not consistent across all medication changes, that is, not every medication change yielded different outcomes from previous assessments. CONCLUSION: This study demonstrates how the outcome of an FA can be used to monitor the effects of psychotropic medication changes, specifically when medications are combined, on challenging behavior in individuals with intellectual and developmental disabilities.