Barriers and motivators to pre-exposure prophylaxis uptake among Black and Latina transgender women in Los Angeles: perspectives of current PrEP users.

The purpose of this qualitative study was to identify barriers and motivators to PrEP uptake from the perspective of Black and Latina transgender women (TW) who are currently using PrEP to suggest intervention and outreach activities to increase PrEP uptake in this population. The Information-Motivation-Behavioral Skills Model guided the development of the semi-structured interview guide. A thematic analysis approach was used to analyze the data. Perceived barriers to PrEP uptake included structural and logistic barriers, language and cultural barriers to medical engagement, lack of transgender competent or gender-affirming care, and prioritizing hormone therapy over the use of PrEP. To increase PrEP uptake among BLTW, participants recommended disseminating PrEP information through a variety of methods, highlighting relationship and sexual health benefits of using PrEP, and developing effective patient-provider communication. Our findings highlight several ways to promote PrEP among BLTW. PrEP promotion should be integrated into gender-affirming care and supported by peer education and navigation services that reach BLTW in both clinic and community settings.

Experiences of Pre-Exposure Prophylaxis (PrEP)-Related Stigma among Black MSM PrEP Users in Los Angeles.

Black men who have sex with men (BMSM) are disproportionately affected by HIV infection in the USA. Pre-exposure prophylaxis (PrEP) is a proven efficacious biomedical prevention strategy with the potential to alter significantly the course of the epidemic in this population. However, the social stigma attached to PrEP and those who use it may act as a barrier to the uptake and continuation of PrEP among high-risk BMSM. In-depth, semi-structured qualitative interviews were conducted with 26 BMSM PrEP users to explore their experiences of stigma related to their PrEP use. BMSM reported multiple experiences or manifestations of PrEP-related stigma, which included (1) perception that PrEP users engage in elevated sexual risk behaviors; (2) conflicts in relationships attributed to PrEP; (3) experiences of discomfort or judgment from medical providers; (4) assumption that PrEP users are HIV-positive; and (5) gay stigma in families limiting PrEP disclosure. The experiences of stigma typically occur within the context of PrEP disclosure and have significant personal and social consequences for PrEP users. Efforts to address PrEP and other social-stigmas within the Black community may help facilitate PrEP uptake and continuation with BMSM.

Development and validation of a person-centered abortion scale: the experiences of care in private facilities in Kenya.

BACKGROUND: There is a need for a standardized way to measure person-centered care for abortion. This study developed and validated a measure of person-centered abortion care. METHODS: Items for person-centered abortion care were developed from literature reviews, expert review, and cognitive interviews, and administered with 371 women who received a safe abortion service from private health clinics in Nairobi, Kenya. Exploratory factor analyses were performed and stratified by surgical abortion procedures and medication abortion. Bivariate linear regressions assessed for criterion validity. RESULTS: We developed a 24-item unifying scale for person-centered abortion care including two sub-scales. The two sub-scales identified were: 1) Respectful and Supportive Care (14 items for medication abortion, 15 items for surgical abortion); and 2) Communication and Autonomy (9 items for both medication and surgical abortion). The person-centered abortion care scale had high content, construct, criterion validity, and reliability. CONCLUSIONS: This validated scale will facilitate measurement and further research to better understand women's experiences during abortion care and to improve the quality of women's overall reproductive health experiences to improve health outcomes.

Delivering PrEP to adults with "low" or "no" HIV risk and youth: experiences and perspectives of PrEP providers.

Health care providers have an important role to play in expanding PrEP uptake to populations disproportionately burdened by HIV. In this study, in-depth, semi-structured qualitative interviews were conducted with 20 PrEP providers in Los Angeles, California to explore their experiences and perspectives prescribing PrEP. Overall, the findings indicate that providers generally adhered to US CDC clinical guidelines in determining PrEP eligibility. However, they also identified special considerations with respect to adults with "low" or "no" HIV risk. Three themes were developed from the data related to the delivery of PrEP to such individuals: 1) patients may not disclose sexual behaviours; 2) patient autonomy and agency; and 3) the importance of PrEP in gay male monogamous relationships. Two additional themes were identified related to prescribing PrEP to young people under the age of consent: 4) the need for more PrEP and sexual health education with youth and 5) challenges in providing PrEP to youth without parental consent. Findings highlight the importance of providing PrEP to patients who could potentially benefit from adoption, whether or not they present with clear behavioural indicators for PrEP. Providers should also consider the potential barriers to delivering PrEP to youth to ensure successful adoption among members of this population.

Experiences of Anticipated and Enacted Pre-exposure Prophylaxis (PrEP) Stigma Among Latino MSM in Los Angeles.

Latino men who have sex with men (MSM) are a group critically affected by HIV. Pre-exposure Prophylaxis (PrEP) is a biomedical prevention strategy that can help reduce new infections in this population. However, PrEP use may expose users to experiences of PrEP-related stigma. In-depth interviews conducted with Latino MSM PrEP users (N = 29) were analyzed using thematic analysis to explore experiences of PrEP stigma. Six themes emerged related to anticipated and enacted PrEP stigma: (1) Perception that PrEP users engage in risky sexual behaviors; (2) PrEP-induced conflict in relationships; (3) Perception that PrEP users are HIV-positive; (4) Generational differences in attitudes toward HIV prevention; (5) Experiences of discomfort, judgment, or homophobia from medical providers; and (6) Gay stigma related to PrEP disclosure to family. Manifestations of stigma included disapproving judgment, negative labeling, rejection, and devaluing individuals. The social consequences associated with using PrEP may deter uptake and persistence among Latino MSM.

Persistent stigmatizing and negative perceptions of pre-exposure prophylaxis (PrEP) users: implications for PrEP adoption among Latino men who have sex with men.

The Centers for Disease Control and Prevention (CDC) estimates the lifetime HIV risk is one in four for Latino men who have sex with men (MSM). Pre-Exposure Prophylaxis (PrEP) is an efficacious biomedical prevention strategy to help prevent the acquisition of HIV. At present, there has been limited uptake of PrEP by Latino MSM. Unfortunately, the negative perceptions and social stigma surrounding PrEP and those who use it may deter uptake of this novel prevention strategy, particularly among high-risk Latino MSM. In this qualitative study, we explore the experiences of using PrEP among Latino MSM. Participants were recruited using gay-oriented social and sexual networking apps to complete an interviewer-administered, semi-structured qualitative interview. Thematic analysis was used to identify emerging themes relating to perceptions of PrEP users and PrEP as an HIV prevention strategy. Major themes included: feelings of protection and sexual freedom; negative and stigmatizing labels associated with PrEP use; assumptions about sexual behaviors and perceptions of sexual risk taking and irresponsibility; and attitudes related to PrEP use in relationships. A striking but not prevalent theme was the perception reported by participants that monolingual Spanish-speaking Latino MSM are skeptical about the effectiveness of PrEP. These findings suggest that efforts are needed to address the stigmatizing and negative perceptions of PrEP that persist in the gay community that may deter adoption among Latino MSM.

Development of the Hypogonadism Impact of Symptoms Questionnaire Short Form: Qualitative Research.

INTRODUCTION: Hypogonadism in men is often associated with poor libido, erectile dysfunction, irritability, fatigue, and psychological and relationship problems. Many of these symptoms can be best assessed through patient report. The 28-item Hypogonadism Impact of Symptoms Questionnaire (HIS-Q) was developed to evaluate hypogonadism symptoms in men with low testosterone in the context of clinical trials. AIM: To develop a briefer version of the HIS-Q that could be practical for use in treatment settings. METHODS: Participants with low testosterone levels and symptoms consistent with hypogonadism were recruited through clinical sites. Focus groups and interviews were conducted to elicit symptom concepts and identify those that were most relevant to patients, including changes as a consequence of treatment. MAIN OUTCOME MEASURES: Systematic analysis of the qualitative data and expert clinician input were used to develop the HIS-Q short form (HIS-Q-SF). One-on-one cognitive interviews were conducted to confirm the content validity of the HIS-Q-SF. RESULTS: Thirty-five men participated in this qualitative research. Concept elicitation was conducted through focus group discussions (n = 18) and telephone interviews (n = 2); then, the draft HIS-Q-SF was evaluated through cognitive interviews (n = 15). The mean age of total sample was 53.2 ± 6.8 years, and the mean serum total testosterone level was 184.9 ± 55.2 ng/dL. Results suggest that the HIS-Q-SF has demonstrated content validity, including the content coverage, comprehensibility, and the appropriateness of the response options and recall period. The final version of the HIS-Q-SF includes 17 items and is aligned with the original longer version of the instrument. CONCLUSION: The HIS-Q-SF is a comprehensive measurement of hypogonadism symptom severity in men. Content coverage and content validity were confirmed. The instrument will be evaluated further to establish the psychometric characteristics and to assess the utility of the measurement in clinical treatment settings.

A qualitative examination of the content validity of the EQ-5D-5L in patients with type 2 diabetes.

BACKGROUND: The EQ-5D is frequently used to derive utilities for patients with type 2 diabetes (T2D). Despite widely available quantitative psychometric data on the EQ-5D, little is known about content validity in this population. Thus, the purpose of this qualitative study was to examine content validity of the EQ-5D in patients with T2D. METHODS: Patients with T2D in the UK completed concept elicitation interviews, followed by administration of the EQ-5D-5L and cognitive interviewing focused on the instrument's relevance, clarity, and comprehensiveness. RESULTS: A total of 25 participants completed interviews (52.0 % male; mean age = 53.5 years). Approximately half (52 %) reported that the EQ-5D-5L was relevant to their experience with T2D. When asked if each individual item was relevant to their experience with T2D, responses varied widely (24.0 % said the self-care item was relevant; 68.0 % said the anxiety/depression item was relevant). Participants frequently said items were not relevant to themselves, but could be relevant to patients with more severe diabetes. Most participants (92.0 %) reported that T2D and/or its treatment/monitoring requirements had an impact on their quality of life that was not captured by the EQ-5D-5L. Common missing concepts included food awareness/restriction (n = 13, 52.0 %); activities (n = 11, 44.0 %); emotional functioning other than depression/anxiety (n = 8, 32.0 %); and social/relationship functioning (n = 8, 32.0 %). CONCLUSIONS: The results highlight strengths and potential limitations of the EQ-5D-5L, including missing content that could be important for some patients with T2D. Suggestions for addressing limitations are provided.

Assessment of Parkinson's disease levodopa-induced dyskinesia: a qualitative research study.

BACKGROUND AND OBJECTIVES: The 26-item Parkinson disease dyskinesia scale (PDYS-26) was developed to assess the impact of Parkinson's disease levodopa-induced dyskinesias (PD-LID). The purpose of this qualitative research study was to assess the content validity of the PDYS-26 in an independent sample and to use the findings to suggest a conceptual framework around the impact of PD-LID. METHODS: PD patients experiencing LID and their caregivers were recruited from four US clinical sites. Stage I involved 22 qualitative concept elicitation interviews with patients and caregivers, and 11 qualitative cognitive interviews (CI) with patients about the PDYS-26. The PDYS-26 was modified based on Stage I findings. Stage II consisted of 13 CI on the Modified PDYS. RESULTS: Forty-six participants were interviewed across both stages of the study. Patient mean age was 67.3 (SD ± 9.55) years; 19 (54.3 %) female; 34 (97.1 %) white. The content validity of the PDYS-26 was generally supported. A revised conceptual framework with three hypothesized domains (body control, activities of daily living, social consequences) was developed. Modifications were made to the PDYS-26 (i.e., emphasizing LID in the instructions; response scale modification; deleting or modifying items), which resulted in the 22-item Modified PDYS. CONCLUSIONS: Stage I and II findings suggested a number of modifications to the scale in order to improve the content validity. Psychometric testing of the revised scale with a larger patient sample is suggested to evaluate item performance, establish scoring, and provide quantitative support for the conceptual framework.

The economic toll of COVID-19: A cohort study of prevalence and economic factors associated with postpartum depression in Kenya.

OBJECTIVE: The aim of the study is to examine the risk of postpartum depression (PPD) among women who delivered during the COVID-19 pandemic compared to women who delivered before the COVID-19 pandemic and how economic challenges are associated with PPD. METHODS: Data were collected from 2332 women. This includes 1197 women from healthcare facilities in 2019 who were followed up at 2-4 and 10 weeks postpartum. Additionally, we recruited 1135 women who delivered from March 16, 2020 onward when COVID-19 restrictions were mandated in Kenya in the same catchment areas as the original sample to compare PPD rates. RESULTS: Adjusting for covariates, women who delivered during COVID-19 had 2.5 times higher odds of screening positive for PPD than women who delivered before COVID-19 (95% confidence interval [CI] 1.92-3.15). Women who reported household food insecurity, required to pay a fee to cover the cost of PPE during labor and delivery and/or postnatal visit(s), and those who reported COVID-19 employment-related impacts had a higher likelihood of screening for PPD compared to those who did not report these experiences. CONCLUSION: The COVID-19 pandemic has greatly increased the economic vulnerability of women, resulting in increases in PPD.

Beyond HIV prevention: Additional individual and community-level benefits of PrEP among Latino gay and bisexual men.

BACKGROUND: HIV infections disproportionately impact Latino gay and bisexual men (GBM) in the United States. Pre-Exposure Prophylaxis (PrEP) is a proven prevention strategy that can help reduce new HIV infections in this population. Unfortunately, PrEP adoption and persistence among Latino GBM remain low. The added benefits of using PrEP experienced by Latino GBM can provide important insights to inform the development of PrEP messaging to motivate this population to explore and consider PrEP as an appropriate and acceptable HIV prevention tool. METHODS: We conducted in-depth interviews with Latino GBM PrEP users to explore positive feelings and emotions, and additional benefits gained from using PrEP. Data were analyzed using thematic analysis. RESULTS: A total of 29 Latino GBM completed the study interview. The average age of participants was 30 years, and the mean length of time using PrEP was 17.1 months. Five themes were constructed from the data representing the additional benefits gained by Latino GBM PrEP users, and included: (1) reduced fear, anxiety, and stress about HIV, HIV testing, and sex; (2) feeling empowered and in control of their HIV risk; (3) greater awareness of sexual risk behaviors and sexual health; (4) greater sexual exploration and pleasure, and comfort having condomless sex; and (5) a greater connection to community and a feeling of contributing to the elimination of HIV. CONCLUSIONS: The added benefits identified in this study represent a range of social, emotional, and psychological benefits that Latino GBM experience while using PrEP. They speak to the complementary benefits that PrEP can bring to Latino GBM who decide to use the medication, that go beyond HIV prevention. These findings can inform the development of future PrEP messaging to help improve motivation for PrEP uptake and persistent use among Latino GBM.

Effects of the COVID-19 pandemic on antenatal care utilisation in Kenya: a cross-sectional study.

OBJECTIVE: The aim of this study was to assess the effects of COVID-19 on antenatal care (ANC) utilisation in Kenya, including women's reports of COVID-related barriers to ANC and correlates at the individual and household levels. DESIGN: Cross-sectional study. SETTING: Six public and private health facilities and associated catchment areas in Nairobi and Kiambu Counties in Kenya. PARTICIPANTS: Data were collected from 1729 women, including 1189 women who delivered in healthcare facilities before the COVID-19 pandemic (from September 2019-January 2020) and 540 women who delivered during the pandemic (from July through November 2020). Women who delivered during COVID-19 were sampled from the same catchment areas as the original sample of women who delivered before to compare ANC utilisation. PRIMARY AND SECONDARY OUTCOME MEASURES: Timing of ANC initiation, number of ANC visits and adequate ANC utilisation were primary outcome measures. Among only women who delivered during COVID-19 only, we explored women's reports of the pandemic having affected their ability to access or attend ANC as a secondary outcome of interest. RESULTS: Women who delivered during COVID-19 had significantly higher odds of delayed ANC initiation (ie, beginning ANC during the second vs first trimester) than women who delivered before (aOR 1.72, 95% CI 1.24 to 2.37), although no significant differences were detected in the odds of attending 4-7 or ≥8 ANC visits versus <4 ANC visits, respectively (aOR 1.12, 95% CI 0.86 to 1.44 and aOR 1.46, 95% CI 0.74 to 2.86). Nearly half (n=255/540; 47%) of women who delivered during COVID-19 reported that the pandemic affected their ability to access ANC. CONCLUSIONS: Strategies are needed to mitigate disruptions to ANC among pregnant women during pandemics and other public health, environmental, or political emergencies.

Improving stigma and psychosocial outcomes among post-abortion Kenyan women attending private clinics: A randomized controlled trial of a person-centered mobile phone-based intervention.

OBJECTIVES: The objective of this study was to evaluate a person-centered abortion care mobile-based intervention on perceived social stigma, social support, mental health and post-abortion care experiences among Kenyan women who received abortion services at private clinics. METHODS: This randomized controlled study enrolled women who obtained an abortion from private clinics in Nairobi county, Kenya and randomized them into one of three study arms: 1) standard of care (follow-up by service provider call center); 2) post-abortion phone follow-up by a peer counselor (a woman who has had an abortion herself and is trained in person-centered abortion care); or 3) post-abortion phone follow-up by a nurse (a nurse who is trained in person-centered abortion care). All participants were followed-up at two- and four-weeks post-abortion to evaluate intervention effects on mental health, social support, and abortion-related stigma scores. A Kruskal-Wallis one-way ANOVA test was used to assess the effect of each intervention compared to the control group. In total, 371 women participated at baseline and were each randomized to the study arms. RESULTS: Using Kruskal-Wallis tests, the nurse arm improved mental health scores from baseline to week two; however this was only marginally significant (p = 0.059). The nurse arm also lowered stigma scores from baseline to week four, and this was marginally significant (p = 0.099). No other differences were found between the study arms. This person-centered mobile phone-based intervention may improve mental health and decrease perceived stigma among Kenyan women who received abortion services in private clinics. CONCLUSIONS: Nurses trained in person-centered abortion care, in particular, may improve women's experiences post-abortion and potentially reduce feelings of shame and stigma and improve mental health in this context.

Redefining communities: The association between deferred action, online and offline social capital and depressive symptoms among undocumented young adults.

An explosion in Internet use, social networking sites, and COVID-19 has promoted a new concept in health - online social capital, defined as linkages to online social networks that promote trust and group norms. Particularly for the 1.3 million undocumented young adult immigrants who "live in the shadows," the Internet may serve as a place of support and information. This study examines the association between documentation status (defined as Deferred Action for Childhood Arrivals (DACA) status), offline social capital, online social capital, and depressive symptoms among foreign-born Latino and Asian and Pacific Islander young adults in California (N = 208) using data from an internet-based survey conducted in 2017. This study found that those without DACA status had higher online social capital (p < 0.001) and increased depressive symptoms (p = 0.01) than those with DACA status. Using linear regression, we found evidence of online social capital potentially mediating the relationship between DACA status and depressive symptoms. This study also found that as offline social capital increases, the association between online social capital on depressive symptoms decreases. This study points to the power of offline communities and the importance of increasing access to community resources, particularly to those without documentation status who may only have online social networks.

Person-centered maternity care and postnatal health: associations with maternal and newborn health outcomes.

BACKGROUND: Limited evidence exists on how women's experiences of care, specifically person-centered maternity care during childbirth, influence maternal and newborn health outcomes. OBJECTIVE: This study aimed to examine the associations between person-centered maternity care and maternal and newborn health outcomes. STUDY DESIGN: Longitudinal data were collected with 1014 women who completed baseline at a health facility and followed up at 2 weeks and 10 weeks after birth. A validated 30-item person-centered maternity care scale was administered to postpartum women within 48 hours after childbirth. The person-centered maternity care scale has 3 subscales: dignity and respect, communication and autonomy, and supportive care. Bivariate and multivariable log Poisson regressions were used to examine the relationship between person-centered maternity care and reported maternal complications, newborn complications, postpartum depression, postpartum family planning uptake, exclusive breastfeeding, and newborn immunizations. RESULTS: Controlling for demographic characteristics, women with high total person-centered maternity care score at baseline had significantly lower risk of reporting maternal complications (adjusted relative risk, 0.63; 95% confidence interval, 0.42-0.95), screening positive for depression (adjusted relative risk, 0.55; 95% confidence interval, 0.38-0.81), and reporting newborn complications (adjusted relative risk, 0.74; 95% confidence interval, 0.56-0.97), respectively, than women with low total person-centered maternity care scores. Women with high scores on the supportive care subscale had significantly lower risk of reporting maternal and newborn complications than women with low scores on these subscales (adjusted relative risk, 0.52 [95% confidence interval, 0.42-0.65] and 0.74 [95% confidence interval, 0.60-0.91], respectively). Significant associations were found between all 3 subscale scores and screening positive for depression. Women with high total person-centered maternity care scores were also more likely to adopt a family planning method than those with low scores (adjusted relative risk, 1.25; 95% confidence interval, 1.02-1.52). In particular, women with high scores on the communication and autonomy subscale had significantly higher odds of adopting a family planning method than women with low scores (risk ratio, 1.15; 95% confidence interval, 1.08-1.23). CONCLUSION: Improving person-centered maternity care may improve maternal and newborn health outcomes. Specifically, improving supportive care may decrease the risk of maternal and newborn complications, whereas improving communication and autonomy may increase postpartum family planning uptake.

Analysis of State-Level Immigrant Policies and Preterm Births by Race/Ethnicity Among Women Born in the US and Women Born Outside the US.

Importance: Criminalizing immigrant policies, a form of structural racism, are associated with preterm birth; however, to date, few population studies have examined this association by race and nativity status or examined the association of inclusive immigrant policies with preterm birth. Objective: To assess the extent to which variation in preterm birth by race/ethnicity and nativity status is associated with state-level criminalizing vs inclusive immigrant policies. Design, Setting, and Participants: This retrospective, cross-sectional study analyzed birth record data from all 50 states and the District of Columbia in 2018, as well as state-level indicators of inclusive and criminalizing immigrant policies. White, Black, Asian, and Latina women who had singleton births were included in the study. Statistical analysis was performed from June 1, 2020, to February 5, 2021. Two continuous variables were created to capture the number of criminalizing vs inclusive immigrant policies in effect as of 2017 in each state. Main Outcomes and Measures: The main outcome measure was preterm birth (<37 weeks' gestation). Results: Among the 3 455 514 live births that occurred in 2018, 10.0% were preterm, and 23.2% were to mothers born outside the US. Overall, for women born outside the US, each additional state-level inclusive policy was associated with a 2% decrease in preterm birth (adjusted odds ratio [aOR], 0.98 [95% CI, 0.96-1.00]); there were no significant associations between inclusive policies and preterm birth among women born in the US. In models examining the combined associations of criminalizing and inclusive immigrant policies with preterm birth, each additional criminalizing policy was associated with a 5% increase in preterm birth among Black women born outside the US (aOR, 1.05 [95% CI, 1.00-1.10]). Each additional inclusive immigrant policy was associated with a lower likelihood of preterm birth for Asian women born in the US (aOR, 0.95 [95% CI, 0.93-0.98]) and White women born outside the US (aOR, 0.97 [95% CI, 0.95-0.99]). No significant associations were found among other groups. Conclusions and Relevance: This study suggests that criminalizing immigrant policies are associated with an increase in preterm birth specifically for Black women born outside the US. Inclusive immigrant policies are associated with a decrease in preterm birth for immigrants overall, Asian women born in the US, and White women born outside the US. No associations were found between criminalizing or inclusive immigrant policies and preterm birth among Latina women.

Contraceptive Need, Intimate Partner Violence, and Reproductive Coercion Among Women Attending a Syringe Exchange Program.

OBJECTIVE: Women who use drugs are at high risk of unintended pregnancy. This study describes contraceptive need, explores relationships between contraceptive use, intimate partner violence (IPV) and reproductive coercion, and unintended pregnancy, and assesses the acceptability of receiving contraceptive care at a syringe exchange program (SEP). METHODS: Between August and October, 2017, written surveys were administered to 96 reproductive-aged women attending an SEP in Santa Ana, California. Data were analyzed using descriptive, bivariate, and multivariate statistics. RESULTS: Most women used methamphetamines (79%) and/or heroin (74%). The majority (62%) did not use contraception during last sex with a man. Half (50%) reported a history of unintended pregnancy. Many (62%) experienced IPV or reproductive coercion in the previous 3 months. Experiencing IPV or reproductive coercion was not associated with contraceptive use or unintended pregnancy. The majority (56%) were interested in receiving contraceptive care from the SEP; history of unintended pregnancy (adjusted odds ratio [aOR] 3.5, 95% confidence interval [CI] 1.3-10.0) and depression (aOR 4.55, 95% CI 1.24-16.69) were associated with interest in contraceptive services. CONCLUSIONS: Our findings suggest that referrals for contraceptive care and direct provision of contraceptive methods at SEPs may be an acceptable approach to addressing the unmet family planning needs of women who use substances. Innovative approaches like these have the potential to impact the high prevalence of unintended pregnancy among this population; however, high prevalence of IPV and reproductive coercion must also be acknowledged by providers when providing counseling for contraceptive services.

PrEP discontinuation among Latino/a and Black MSM and transgender women: A need for PrEP support services.

PURPOSE: Disparities persist in HIV infection among Black and Latino men who have sex with men (BLMSM) and Black and Latina transgender women (BLTW). Increasing uptake and subsequent consistent use of pre-exposure prophylaxis (PrEP), an effective biomedical strategy for preventing HIV acquisition, can dramatically reduce HIV incidence in these populations. The purpose of this study was to explore reasons for PrEP discontinuation among BLMSM and BLTW living in Los Angeles County to inform the development of support services for these populations to remain persistent with their PrEP regimen. METHODS: In-depth, semi-structured interviews were conducted with 15 BLMSM and 7 BLTW who reported either temporary or indefinite PrEP discontinuation. A thematic analysis approach was used to analyze qualitative data. RESULTS: Four themes emerged related to reasons for PrEP discontinuation, including: (1) lower perceived HIV risk related to changes in sexual behavior; (2) structural or logistical barriers (e.g., lapse or loss of health insurance, cost, difficulty navigating complex medical systems); (3) anticipated and experienced medication side effects, with a sub-theme of interactions between PrEP and feminizing hormone medications; and (4) challenges with medication adherence. CONCLUSIONS: PrEP is an important prevention tool for BLMSM and BLTW, particularly during periods of heightened HIV risk. However, both individual (e.g., inability to adhere to medication, changes in HIV sexual risk behaviors) and structural/logistical (e.g., loss of insurance, navigating complex medical systems) factors can cause temporary or indefinite PrEP discontinuation. Additional support services, beyond those offered by medical providers, are needed to help BLMSM and BLTW PrEP users overcome barriers to discontinuation and assist them to remain persistent with their PrEP regimen. We describe potential options for support services such as PrEP case management, expanded PrEP navigation services, or text messaging services.

Do you need to pay for quality care? Associations between bribes and out-of-pocket expenditures on quality of care during childbirth in India.

While it is mandated that reproductive and child health services be provided for free at public facilities in India, qualitative evidence suggests it is common for facilities to request bribes and other informal payments for medicines, medical tests or equipment. This article examines the prevalence of bribe requests, total out-of-pocket expenditures (OOPEs) and associations between bribe requests and total OOPEs on the experience of quality of care and maternal complications during childbirth. Women who delivered in public facilities in Uttar Pradesh, India were administered a survey on sociodemographic characteristics, bribe requests, total OOPEs, types of health checks received and experience of maternal complications. Data were analysed using descriptive, bivariate and multivariate statistics. Among the 2018 women who completed the survey, 43% were asked to pay a bribe and 73% incurred OOPEs. Bribe requests were associated with lower odds of receiving all health checks upon arrival to the facility (aOR = 0.49; 95% CI: 0.24-0.98) and during labour and delivery (aOR = 0.44; 95% CI: 0.25-0.76), lower odds of receiving most or all health checks after delivery (aOR = 0.44; 95% CI: 0.31-0.62) and higher odds of experiencing maternal complications (aOR = 1.45; 95% CI: 1.13-1.87). Although it is mandated that maternity care be provided for free in public facilities in India, these findings suggest that OOPEs are high, and bribes/tips contribute significantly. Interventions centred on improving person-centred care (particularly guidelines around bribes), health system conditions and women's expectations of care are needed.

Association between person-centered maternity care and newborn complications in Kenya.

OBJECTIVE: Despite the recognized importance of person-centered care, very little information exists on how person-centered maternity care (PCMC) impacts newborn health. METHODS: Baseline and follow-up data were collected from women who delivered in government health facilities in Nairobi and Kiambu counties in Kenya between August 2016 and February 2017. The final analytic sample included 413 respondents who completed the baseline survey and at least one follow-up survey at 2, 6, 8, and/or 10 weeks. Data were analyzed using descriptive, bivariate, and multivariate statistics. Logistic regression was used to assess the relationship between PCMC scores and outcomes of interest. RESULTS: In multivariate analyses, women with high PCMC scores were significantly less likely to report newborn complications than women with low PCMC scores (adjusted odds ratio [aOR] 0.39, 95% confidence interval [CI] 0.16-0.98). Women reporting high PCMC scores also had significantly higher odds of reporting a willingness to return to the facility for their next delivery than women with low PCMC score (aOR 12.72, 95% CI 2.26-71.63). The domains of Respect/Dignity and Supportive Care were associated with fewer newborn complications and willingness to return to a facility. CONCLUSION: PCMC could improve not just the experience of the mother during childbirth, but also the health of her newborn and future health-seeking behavior.