Community Mitigation Strategies, Mobility, and COVID-19 Incidence Across Three Waves in the United States in 2020.

BACKGROUND: Summarizing the impact of community-based mitigation strategies and mobility on COVID-19 infections throughout the pandemic is critical for informing responses and future infectious disease outbreaks. Here, we employed time-series analyses to empirically investigate the relationships between mitigation strategies and mobility on COVID-19 incident cases across US states during the first three waves of infections. METHODS: We linked data on daily COVID-19 incidence by US state from March to December 2020 with the stringency index, a well-known index capturing the strictness of mitigation strategies, and the trip ratio, which measures the ratio of the number of trips taken per day compared with the same day in 2019. We utilized multilevel models to determine the relative impacts of policy stringency and the trip ratio on COVID-19 cumulative incidence and the effective reproduction number. We stratified analyses by three waves of infections. RESULTS: Every five-point increase in the stringency index was associated with 2.89% (95% confidence interval = 1.52, 4.26%) and 5.01% (3.02, 6.95%) reductions in COVID-19 incidence for the first and third waves, respectively. Reducing the number of trips taken by 50% compared with the same time in 2019 was associated with a 16.2% (-0.07, 35.2%) decline in COVID-19 incidence at the state level during the second wave and 19.3% (2.30, 39.0%) during the third wave. CONCLUSIONS: Mitigation strategies and reductions in mobility are associated with marked health gains through the reduction of COVID-19 infections, but we estimate variable impacts depending on policy stringency and levels of adherence.

Understanding Oral Prep Interest Among South African Adolescents: The Role of Perceived Parental Support and PrEP Stigma.

We examined oral PrEP interest among adolescents and its association with perceived parental support and PrEP stigma. Cross-sectional data were collected during baseline procedures of the "Our Family Our Future" intervention trial in South Africa. Adolescents (14-16 years) at elevated risk for acquiring HIV and their parents or caregivers were dyadically enrolled from 2018 to 2021. There were 879 complete adolescent-parent dyads. Among adolescents, 27% had heard about PrEP, 67% reported they would want to use PrEP, and 58% thought their parent would want them to use PrEP. Among parents, 33% had heard about PrEP and 85% reported they would want their adolescent to use PrEP. Adolescents who thought their parent would want them to use PrEP were more likely to be interested in PrEP than adolescents who thought their parent would not want them to use PrEP (adjusted prevalence ratio (aPR) = 2.11, 95% CI 1.82, 2.44). Further, adolescents with higher average PrEP stigma scores above the adolescent sample median were less likely to be interested in PrEP than adolescents with lower average PrEP stigma scores (aPR = 0.81, 95% CI 0.72, 0.91). In conclusion, parents were more supportive of their adolescent taking PrEP than adolescents perceived they would be, and perceptions of low parental support and greater PrEP stigma were associated with reduced PrEP interest among adolescents. Interventions should aim to improve adolescent-parent communication around sexual health and effective HIV prevention tools.

Associations between psychosocial wellbeing and experience of gender-based violence at community, household, and intimate-partner levels among a cross-sectional cohort of young people living with and without HIV during COVID-19 in Cape Town, South Africa.

BACKGROUND: Growing evidence indicates that gender-based violence (GBV) increased during COVID-19. We investigated self-reported impact of the pandemic on GBV at community, household and intimate partner (IPV) levels among young people and its associations with psychosocial wellbeing, i.e., COVID-related stressors and mental health. METHODS: Cross-sectional data were drawn from a survey with young people ages 13-24 (N = 536) living with HIV (YPLWH) and without HIV (YPLWoH), in peri-urban Cape Town, South Africa. The survey, conducted February-October 2021, examined the impact of the initial lockdown on experience and perceived changes in GBV at each level, and pandemic-related psychosocial wellbeing. Descriptive statistics and binomial and multinomial regression analyses were conducted to illustrate exposure and perceived changes in GBV since lockdown, and their association with COVID-related stress factors (e.g., social isolation, anxiety about COVID), mental health (e.g., depression, anxiety), and other risk factors (e.g., age, gender, socioeconomic status) by HIV status. RESULTS: Participants were 70% women with mean age 19 years; 40% were living with HIV. Since lockdown, YPLWoH were significantly more likely than YPLWH to perceive community violence as increasing (45% vs. 28%, p < 0.001), and to report household violence (37% vs. 23%, p = 0.006) and perceive it as increasing (56% vs. 27%, p = 0.002) (ref: decreasing violence). YPLWoH were also more likely to report IPV experience (19% vs. 15%, p = 0.41) and perception of IPV increasing (15% vs. 8%, p = 0.92). In adjusted models, COVID-related stressors and common mental health disorders were only associated with household violence. However, indicators of economic status such as living in informal housing (RRR = 2.07; 95% CI = 1.12-3.83) and food insecurity (Community violence: RRR = 1.79; 95% CI = 1.00-3.20; Household violence: RRR = 1.72; 95% CI = 1.15-2.60) emerged as significant risk factors for exposure to increased GBV particularly among YPLWoH. CONCLUSIONS: Findings suggest that for young people in this setting, GBV at community and household levels was more prevalent during COVID-19 compared to IPV, especially for YPLWoH. While we found limited associations between COVID-related stressors and GBV, the perceived increases in GBV since lockdown in a setting where GBV is endemic, and the association of household violence with mental health, is a concern for future pandemic responses and should be longitudinally assessed.

Access to Social Protection by People Living with, at Risk of, or Affected by HIV in Eswatini, Malawi, Tanzania, and Zambia: Results from Population-Based HIV Impact Assessments.

We aimed to measure social protection coverage among the general population, women and men living with HIV (WLHIV, MLHV), female and male sex workers (FSW, MSW), men who have sex with men (MSM), adolescent girls young women (AGYW), and orphans vulnerable children (OVC) in Eswatini, Malawi, Tanzania, and Zambia. We used Population-Based HIV Impact Assessment data. We operationalised social protection benefits as external economic support from private and public sources to the household in the last three or 12 months. We estimated survey-weighted proportions and 95% confidence intervals (CI) for each population receiving social protection benefits. The sample size ranged from 10,233 adults ages 15-59 years in Eswatini to 29,638 in Tanzania. In the surveyed countries, social protection coverage among the general population was lower than the global average of 45%, ranging from 7.7% (95% CI 6.7%-8.8%) in Zambia to 39.6% (95% CI 36.8%-42.5%) in Eswatini. In Malawi and Zambia, social protection coverage among OVC, AGYW, SW, MSM, and people living with HIV (PLHIV) was similar to the general population. In Eswatini, more AGWY reported receiving social projection benefits than older women and more men not living with HIV reported receiving social protection benefits than MLHIV. In Tanzania, more WLHIV than women not living with HIV, MLHIV than men not living with HIV, and FSW than women who were not sex workers reported receiving social protection benefits. More data on access to social protection benefits by PLHIV or affected by HIV are needed to estimate better their social protection coverage.

The Effect of PrEP Use Disclosure on Adherence in a Cohort of Adolescent Girls and Young Women in South Africa.

Effective strategies to support PrEP adherence among adolescent girls and young women (AGYW) are needed. We examined PrEP use disclosure and its effect on adherence among 200 AGYW ages 16-25 initiating PrEP in South Africa to help inform these  strategies. We estimated the relative prevalence of high adherence (intracellular tenofovir-diphosphate concentration ≥ 700 fmol/punch) 3- and 6-months after PrEP initiation among those who disclosed vs. did not disclose their PrEP use, both overall and by age. Most AGYW disclosed to a parent (58%), partner (58%), or friend (81%) by month 6. We did not observe a strong effect of disclosure on adherence overall; however, among younger AGYW (≤ 18 years), those who disclosed to a parent were 6.8 times as likely to have high adherence at month 6 than those who did not (95% CI 1.02, 45.56). More work is needed to understand parents' roles as allies and identify ways peers and partners can motivate PrEP use for AGYW.

Trajectories of PrEP Adherence Among Young Women Aged 16 to 25 in Cape Town, South Africa.

Despite demonstrated efficacy for HIV prevention, substantial challenges remain for the successful rollout of oral pre-exposure prophylaxis (PrEP), especially among adolescent girls and young women (AGYW). We characterized trajectories of PrEP adherence among 200 AGYW in South Africa and analyzed data from 22 qualitative interviews and 3 focus group discussions for explanatory purposes. Two adherence trajectory groups were identified: 52% with high early adherence that declined after month three and 48% with low adherence throughout. Adherence in the "consistently low" group was related to social support and logistical concerns, while the decrease in the "high declining" group corresponded to a change in the frequency of study visits from monthly to quarterly. PrEP support should be differentiated for those who need more frequent visits and adherence support initially versus later in PrEP use. Visits every month, when needed, should be considered for AGYW who need sustained support later into use.

Adolescent-Centered HIV Prevention: Perspectives on Acceptability of Oral Antiretroviral Pre-exposure Prophylaxis for Adolescents in a Global Priority Setting.

With oral antiretroviral pre-exposure prophylaxis (PrEP) rollout expanding to include adolescents in South Africa, research is needed to better understand perceptions of PrEP acceptability among adolescents and clinical service providers. We conducted an exploratory mixed-methods study among 57 adolescents, 16-17 years of age, living with and without HIV, and 25 clinical service providers in Cape Town, South Africa from 2015 to 2016. Cross-sectional survey and semi-structured qualitative interview data were used to explore (1) willingness to use PrEP and support partner PrEP use among adolescents living with and without HIV, (2) willingness to prescribe or support prescription of PrEP among service providers, and (3) perceptions of barriers and facilitators to PrEP implementation and interpretations of PrEP efficacy messaging for adolescent HIV prevention among all participants. Acceptability of PrEP among participants was high. Support for PrEP uptake was linked to messages that positively framed PrEP's protection potential (i.e., success- versus failure-framed messaging) among both adolescents and providers. Adolescents living without HIV endorsed high willingness to use PrEP and adolescents living with HIV endorsed high support for partner PrEP use. However, both groups noted that potential side effects, stigma, and PrEP's partial efficacy may hinder uptake. Clinical service providers endorsed PrEP for sexually active adolescents and shared stigma and efficacy concerns. Further, service providers expressed desire for adolescent-tailored training and integration of PrEP delivery into primary care and family planning services. Efforts to educate adolescents and service providers about PrEP should consider how message framing may influence acceptability. Community PrEP education and adolescent-friendly delivery should be prioritized to alleviate predicted PrEP stigma and facilitate uptake.

Self-Esteem as an Indicator of Transactional Sex Among Young Women in Rural South Africa (HPTN 068).

Transactional sex (TS) has been shown to contribute to the HIV epidemic in sub-Saharan Africa. Previous research has yet to identify psychosocial factors that make young women vulnerable to engaging in TS. This analysis examined the association between self-esteem and TS among young women in rural South Africa. A post hoc analysis of post-intervention survey data from HPTN 068 was conducted. Log-binomial regression was used to compute a prevalence ratio measure of association. Among 1942 young women, the prevalence of TS among those with lower self-esteem was 4.7 times the prevalence of TS among those with higher self-esteem (p < 0.001). Findings provide support for the association between lower self-esteem and TS in this context and may inform intervention development.

Recreational Use of HIV Antiretroviral Medication and Implications for HIV Pre-exposure Prophylaxis and Treatment.

Diversion of antiretroviral therapy (ART) for recreational use is concerning for countries with high HIV prevalence. This paper presents reports of recreational use of ART among adolescents from two HIV prevention studies in South Africa: (1) a cross-sectional survey of N = 200 adolescents and (2) a qualitative study of pre-exposure prophylaxis with N = 57 adolescents and N = 25 clinicians. Among adolescents, 3% used and 14% knew someone who used non-prescribed ART for recreational purposes. Administration included smoking (71%), snorting (15%), injecting (15%), ingesting (15%), and inserting (3%). Participants predicted increased crime as recreational use of ART increased. Future studies should investigate prevalence, composition, and diversion of ART from HIV prevention and treatment.

"I'm doing this test so I can benefit from PrEP": exploring HIV testing barriers/facilitators and implementation of pre-exposure prophylaxis among South African adolescents.

In South Africa, adolescents are a key population in the HIV epidemic that can benefit from increased access to oral pre-exposure prophylaxis (PrEP). HIV testing is an integral component of the PrEP care continuum but adolescents in South Africa have generally low HIV testing rates; therefore, adolescents' HIV testing attitudes and behaviours must be understood to develop strategies for effective PrEP implementation. Ten focus groups were conducted with adolescents living with HIV and HIV-uninfected adolescents (n = 55), and in-depth interviews were conducted with service providers (n = 25), adolescents living with HIV (n = 10) and HIV-uninfected adolescents (n = 25). Data were collected in the Western Cape province of South Africa from 2015-2016. Thematic framework analysis was used to understand dynamics by which South African adolescents' attitudes toward HIV testing might influence intended uptake of PrEP and, reciprocally, to explore the implications of adolescents' perceptions about PrEP availability for their willingness to engage in HIV testing. While South African adolescents' current HIV testing attitudes and behaviours present barriers to intended PrEP implementation in this population, increased access to PrEP has the potential to improve their initial HIV testing rates and decrease stigma and fear around HIV testing. However, implementation of PrEP must consider specific HIV testing barriers for adolescent boys and girls, respectively. As PrEP becomes more widely available for adolescents, possible challenges noted by participants may include the potential for adolescents to reduce continued HIV testing behaviours while on PrEP and to share/use unprescribed PrEP medications among peers.

Patterns of Health Information Technology Use according to Sexual Orientation among US Adults Aged 50 and Older: Findings from a National Representative Sample-National Health Interview Survey 2013-2014.

Health disparities among sexual minority adults ages 50 and older have been documented. Factors such as lifetime discrimination and internalized stigma may deter sexual minority individuals from seeking health services. Several studies suggest that health information technology may facilitate health education and outreach to populations whose health behaviors are affected by stigma such as older sexual minority people. This study examined the role of sexual minority identity as a factor that is associated with health information technology use. Data from the 2013-2014 National Health Interview Survey (NHIS) were analyzed. Multivariate logistic regressions were used to compare the odds of using technology as a resource for health information between sexual minority versus heterosexual US adults aged 50 and older. Adjusting for sociodemographic variables and health variables, sexual minority participants had increased odds of using computers to look up health information on the Internet (OR = 2.01, 95% CI 1.53-2.64), using computers to fill a prescription (OR = 1.97, 95% CI 1.36-2.85), and using computers to communicate with health-care provider by e-mail (OR = 2.13, 95% CI 1.55-2.92), compared with heterosexuals. Findings reveal greater use of health information technology among older sexual minority adults when compared to their heterosexual counterparts. While sensitive, competent providers and culturally appropriate prevention services are essential to meeting the needs of aging sexual minority populations, health information technology use may be an innovative means of reducing disparities in information access as structural changes are implemented.

Serum Insulin Levels Are Reduced by Intravenous Ghrelin Administration but Do Not Correlate with Alcohol Craving in Alcohol-Dependent Individuals.

BACKGROUND: Increasing evidence supports a role for appetite-regulating pathways like ghrelin, insulin, and leptin in alcoholism. We previously reported that intravenous (i.v.) exogenous ghrelin increases alcohol craving. We also reported i.v. ghrelin reduces endogenous serum leptin, whose levels, in turn, negatively correlated with alcohol craving. Exogenous ghrelin administration decreases insulin secretion both in vitro and in vivo experiments. This study tested the hypothesis that i.v. ghrelin may also decrease endogenous serum insulin levels in alcoholic individuals. Additionally, we explored possible correlations between serum insulin and alcohol craving, since a correlation between insulin and alcohol craving was previously reported. METHODS: This was a double-blind, placebo-controlled human laboratory study ( n =43). Non-treatment-seeking, alcohol-dependent, heavy drinkers were randomized to receive i.v. ghrelin or placebo, followed by an alcohol cue-reactivity procedure. RESULTS: There was a main effect for i.v. ghrelin, compared to placebo in reducing serum insulin ( P <.05). There was also a time effect ( P <.001) but not ghrelin x time interaction ( P >.05). We did not find a correlation between the reduction of serum insulin and alcohol craving ( P >.05). The change in serum insulin was consistent with a parallel reduction in serum connective-peptide in the ghrelin group compared with placebo, although this difference did not reach statistical significance ( P =.076). No similar effects were found for other glucose-regulating hormones analyzed i.e. glucagon, glucagon-like peptide-1, and gastric inhibitory peptide ( P s>.05). CONCLUSIONS: These findings indicate i.v. ghrelin administration has an effect on reducing serum insulin in alcohol-dependent individuals; however, the reduction of insulin did not correlate with changes in alcohol cue-elicited craving. We speculate that, unlike for leptin, the interactions between ghrelin and insulin relationship are limited at the peripheral level. However, mechanistic studies are needed to investigate this hypothesis.

The Acceptability, Feasibility, and Preliminary Effectiveness of a Courier HIV-Treatment Delivery and SMS Support Intervention for Young People Living With HIV in South Africa.

BACKGROUND: Young people living with HIV (YPLWH) experience poorer rates of virological suppression compared with adults. Differentiated service delivery models for YPLWH are urgently needed to address this disparity. SETTING: Participants were recruited from an HIV treatment clinic near Cape Town, South Africa. METHODS: We conducted a longitudinal pilot study to examine the acceptability, feasibility, and preliminary effectiveness of a courier ART delivery and SMS support intervention to retain YPLWH (13-24 years) in care during COVID-19. YPLWH had the option to enroll in the courier service and were randomized 1:1 to receive adherence support via a weekly SMS. Modified Poisson regression was used to estimate the preliminary effectiveness of the courier intervention on viral suppression (HIV-1 RNA <200 copies/mL) at months 3 and 6. RESULTS: Among 215 participants, 82% elected to enroll in the courier ART service at baseline, 41% reported receiving a delivery in the past 3 months at month 3, and 49% reported receiving a delivery in the past 3 months at month 6. Among those who received a delivery, most (91%-100%) rated the intervention as acceptable. Participants who reported receiving a delivery in the past 3 months at month 3 were 1.26 (95% CI: 1.05, 1.54) times as likely to have a suppressed viral load at month 3 and 1.21 (0.99, 1.48) times as likely at month 6, controlling for potential confounders. CONCLUSIONS: Findings reveal high uptake and acceptability of a courier ART delivery intervention among YPLWH and promising evidence for its effectiveness in increasing the probability of viral suppression. A fully powered trial is warranted.

Access to sexual and reproductive health services among South African young people living with and without HIV during the COVID-19 pandemic.

OBJECTIVE: To examine sexual and reproductive health (SRH) service access among South African young people during the COVID-19 pandemic. STUDY DESIGN: We utilized cross-sectional data collected from February to October 2021 in Cape Town among young people 13-24 years of age living with and without HIV. RESULTS: Two hundred and fifteen young people living with HIV (YPLWH) and 320 young people living without HIV were included. Young people reported an unmet need for SRH services during COVID-19, and 28% of YPLWH reported missing an HIV care appointment during the COVID-19 lockdowns. CONCLUSIONS: Expanding access to SRH services for young people during disruptive events is critical to reduce disparities in HIV and other SRH outcomes.

Socioeconomic inequalities in the 90-90-90 target, among people living with HIV in 12 sub-Saharan African countries - Implications for achieving the 95-95-95 target - Analysis of population-based surveys.

Background: Inequalities undermine efforts to end AIDS by 2030. We examined socioeconomic inequalities in the 90-90-90 target among people living with HIV (PLHIV) -men (MLHIV), women (WLHIV) and adolescents (ALHIV). Methods: We analysed the available Population HIV Impact Assessment (PHIA) survey data for each of the 12 sub-Saharan African countries, collected between 2015 and 2018 to estimate the attainment of each step of the 90-90-90 target by wealth quintiles. We constructed concentration curves, computed concentration indices (CIX) -a negative (positive) CIX indicated pro-poor (pro-rich) inequalities- and identified factors associated with, and contributing to inequality. Findings: Socioeconomic inequalities in achieving the 90-90-90 target components among PLHIV were noted in 11 of the 12 countries surveyed: not in Rwanda. Awareness of HIV positive status was pro-rich in 5/12 countries (Côte d'Ivoire, Tanzania, Uganda, Malawi, and Zambia) ranging from CIX=0·085 (p< 0·05) in Tanzania for PLHIV, to CIX = 0·378 (p<0·1) in Côte d'Ivoire for ALHIV. It was pro-poor in 5/12 countries (Côte d'Ivoire, Ethiopia, Malawi, Namibia and Eswatini), ranging from CIX = -0·076 (p<0·05) for PLHIV in Eswatini, and CIX = -0·192 (p<0·05) for WLHIV in Ethiopia. Inequalities in accessing ART were pro-rich in 5/12 countries (Cameroun, Tanzania, Uganda, Malawi and Zambia) ranging from CIX=0·101 (p<0·05) among PLHIV in Zambia to CIX=0·774 (p<0·1) among ALHIV in Cameroun and pro-poor in 4/12 countries (Tanzania, Zimbabwe, Lesotho and Eswatini), ranging from CIX = -0·072 (p<0·1) among PLHIV in Zimbabwe to CIX = -0·203 (p<0·05) among WLHIV in Tanzania. Inequalities in HIV viral load suppression were pro-rich in 3/12 countries (Ethiopia, Uganda, and Lesotho), ranging from CIX = 0·089 (p< 0·1) among PLHIV in Uganda to CIX = 0·275 (p<0·01) among WLHIV in Ethiopia. Three countries (Tanzania CIX = 0·069 (p< 0·5), Uganda CIX = 0·077 (p< 0·1), and Zambia CIX = 0·116 (p< 0·1)) reported pro-rich and three countries (Côte d'Ivoire CIX = -0·125 (p< 0·1), Namibia CIX = -0·076 (p< 0·05), and Eswatini CIX = -0·050 (p< 0·05) pro-poor inequalities for the cumulative CIX for HIV viral load suppression. The decomposition analysis showed that age, rural-urban residence, education, and wealth were associated with and contributed the most to inequalities observed in achieving the 90-90-90 target. Interpretation: Some PLHIV in 11 of 12 countries were not receiving life-saving HIV testing, treatment, or achieving HIV viral load suppression due to socioeconomic inequalities. Socioeconomic factors were associated with and explained the inequalities observed in the 90-90-90 target among PLHIV. Governments should scale up equitable 95-95-95 target interventions, prioritizing the reduction of age, rural-urban, education and wealth-related inequalities. Research is needed to understand interventions to reduce socioeconomic inequities in achieving the 95-95-95 target. Funding: This study was supported by the Swiss National Science Foundation (grant 202660).

Social isolation and psychological distress among southern U.S. college students in the era of COVID-19.

BACKGROUND: College students are at heightened risk for negative psychological outcomes due to COVID-19. We examined the prevalence of psychological distress and its association with social isolation among public university students in the southern United States. METHODS: A cross-sectional survey was emailed to all University of North Carolina-Chapel Hill students in June 2020 and was open for two weeks. Students self-reported if they were self-isolating none, some, most, or all of the time. Validated screening instruments were used to assess clinically significant symptoms of depression, loneliness, and increased perceived stress. The data was weighted to the complete student population. RESULTS: 7,012 completed surveys were included. Almost two-thirds (64%) of the students reported clinically significant depressive symptoms and 65% were categorized as lonely. An estimated 64% of students reported self-isolating most or all of the time. Compared to those self-isolating none of the time, students self-isolating some of the time were 1.78 (95% CI 1.37, 2.30) times as likely to report clinically significant depressive symptoms, and students self-isolating most or all of the time were 2.12 (95% CI 1.64, 2.74) and 2.27 (95% CI 1.75, 2.94) times as likely to report clinically significant depressive symptoms, respectively. Similar associations between self-isolation and loneliness and perceived stress were observed. CONCLUSIONS: The prevalence of adverse mental health indicators among this sample of university students in June 2020 was exceptionally high. University responses to the COVID-19 pandemic should prioritize student mental health and prepare a range of support services to mitigate mental health consequences as the pandemic continues to evolve.

Pre-exposure prophylaxis as an opportunity for engagement in HIV prevention among South African adolescents.

Pre-exposure prophylaxis (PrEP) offers a potential biomedical strategy to reduce HIV incidence among adolescent populations disproportionately affected by HIV. There is limited evidence on the social and clinical implications, including engagement in HIV prevention efforts, of PrEP for South African adolescents, who face high HIV risk. We conducted a mixed-methods study in Western Cape, South Africa from 2015 to 2016. Adolescents (N = 35) aged 16-17 and clinical service providers working with adolescents (N = 25) were recruited from community and clinic settings. Adolescents and service providers completed a survey about their overall perceptions of PrEP and completed interviews guided by semi-structured protocols. We performed descriptive analysis of quantitative data using SPSS and thematic analysis of qualitative data using NVivo. The majority of adolescents endorsed future PrEP use for themselves and partners, and all clinical service providers endorsed future PrEP use for sexually active adolescents. Both adolescents and service providers identified PrEP as an opportunity to engage youth as active participants in HIV prevention. Service providers also viewed PrEP as a potential mechanism for shifting life trajectories. Findings from this study enhance our understanding of the considerations needed to engage adolescents and clinical service providers in the roll-out of oral PrEP in South Africa.

Oral pre-exposure prophylaxis uptake, adherence, and adverse events among South African men who have sex with men and transgender women.

Background: HIV prevention programmes that include pre-exposure prophylaxis (PrEP) for men who have sex with men (MSM) and transgender women (TGW) in South Africa have not been widely implemented. Objectives: The authors examined oral PrEP uptake, adherence, and adverse events among HIV-uninfected MSM and TGW to inform intervention acceptability and feasibility. Method: In 2015, MSM and TGW in two South African cities were offered a comprehensive package of HIV prevention services, including daily oral PrEP, and were followed for one year. Different models of PrEP delivery were used at each site. Adherence was measured using self-report and pill-count data and tenofovir-diphosphate (TFV-DP) concentrations. Results: Among 135 participants who were eligible for PrEP, 82 (61%) initiated PrEP, of whom 67 (82%) were on PrEP at study end. Participants were on PrEP for a median of 294 out of 314.5 possible days (93% protected days). The median time from PrEP initiation to discontinuation or study end was 305 days (interquartile range: 232-325 days). Across the follow-up time points, 57% - 72% of participants self-reported taking protective levels of PrEP and 59% - 74% were adherent to PrEP as indicated by pill counts. Fewer (≤ 18%) achieved protective TFV-DP concentrations of ≥ 700 fmol/punch in dried blood spots. Side effects, while typically mild, were the most commonly cited reason by participants for early PrEP discontinuation. Conclusion: Many MSM and TGW initiated and maintained PrEP, demonstrating that PrEP can be successfully delivered to South African MSM and TGW in diverse programmatic contexts. Biologic adherence measures suggest MSM and TGW may experience challenges taking PrEP regularly. Counselling for coping with side effects and motivating daily pill taking is recommended to support South African MSM and TGW in achieving protection with PrEP.

Intimate partner violence and oral HIV pre-exposure prophylaxis adherence among young African women.

OBJECTIVE: To estimate the effect of intimate partner violence (IPV) on oral pre-exposure prophylaxis (PrEP) adherence among adolescent girls and young women (AGYW). DESIGN: We conducted a secondary analysis of data from HIV Prevention Trials Network 082 (HPTN 082), a multisite prospective study designed to assess oral PrEP adherence among AGYW in southern Africa. METHODS: We estimated the relative prevalence of high PrEP adherence 3 and 6 months after initiation among AGYW 16-25 years who reported a history of any IPV in the past year at enrollment versus AGYW who did not, both overall and by age. High adherence was defined as an intracellular tenofovir-diphosphate concentration at least 700 fmol/punch or more dried blood spots. RESULTS: Among 409 PrEP-initiating AGYW, half (49%) reported experiencing any IPV by a current/recent partner in the year prior to enrollment. Overall, a similar proportion of AGYW who reported IPV had high PrEP adherence at months 3 and 6 as AGYW who did not report IPV. There was, however, evidence of effect modification by age at month 3: among AGYW less than 21 years old, those who reported IPV were less than half as likely to have high adherence [adjusted PR (aPR) = 0.43, 95% confidence interval (CI) 0.22-0.86]; among AGYW aged 21 years or older, those who reported IPV were more than twice as likely to have high adherence (aPR = 2.21, 95% CI 1.34-3.66). At month 6, effect estimates within each age stratum were consistent in direction to those at month 3. CONCLUSION: IPV events may either impede or motivate PrEP adherence among African AGYW, with age appearing to be an important consideration for IPV-related adherence interventions.

Adapting technology-based HIV prevention and care interventions for youth: lessons learned across five U.S. Adolescent Trials Network studies.

BACKGROUND: U.S. sexual and gender minority youth experience individual, interpersonal, and structural-level barriers to HIV prevention and care. Innovative, youth-driven approaches to mobile and electronic interventions that support use of new biomedical prevention, testing, and treatment options may address these barriers. Adapting evidence-based interventions for youth must balance core intervention components with responsiveness to the distinct needs of end-users. METHODS: The UNC/Emory Center for Innovative Technology (iTech) adapts and evaluates technology-based interventions for youth living with or at risk for HIV. We analyzed formative research (focus groups and individual usability sessions) across five iTech studies: two apps promoting HIV testing and pre-exposure prophylaxis (PrEP), one app promoting behavioral risk reduction and PrEP, one PrEP adherence app, and one mobile-optimized website for increasing viral suppression, with the aim of informing best practices for technology-based intervention development. Each study presented prototypes of adapted mHealth interventions to samples of their target end-user population for use and/or evaluation. RESULTS: One hundred and thirty-eight youth across seven geographically diverse sites provided feedback during the intervention adaptation process. We found high interest in and acceptability of all five intervention prototypes. Cross-study themes included: (I) Desire for multiple privacy protections (e.g., password, fingerprint) to keep HIV status, sexual identity, and sexual behavior confidential. (II) Strong but varied preferences for the look and feel of platforms. Imagery should be discrete but representative. Participants valued customizable platforms and positive themes, motivational language, and humor. Youth wanted information presented using multiple modalities (e.g., text, video, image) to increase engagement. (III) Youth preferred engagement features and functions consistent with familiar platforms (e.g., Snapchat, Instagram). Gamification features that resulted in tangible versus virtual rewards were predicted to increase engagement. Intervention messaging functions were perceived as useful; customization was desired as a way to control frequency, mode (e.g., SMS, in-app message, push notification), and content. (IV) Youth voiced varied preferences for platform content including: featuring young role models from the lesbian, gay, bisexual, transgender, queer and/or questioning (LGBTQ) community, incorporating mental health resources, and maintaining a holistic health-focus (not HIV-centric). CONCLUSIONS: We found high acceptability and consistent feedback in youths' evaluations of these mHealth interventions; divergence was most commonly found in preferred content versus features and functions. Identifying broadly accepted aspects of mHealth interventions for youth supports the feasibility of adaptation (versus de novo creation) and should guide the focus of future formative research phases. Continued research is needed to better understand how to balance usability preferences with finite resources for customization.