Intersecting Stigma and the HIV Care Cascade: Qualitative Insights from Sex Workers, Men who have Sex with Men, and Transgender Women Living with HIV in Jamaica.

In Jamaica, stigma experiences of sex workers (SW), gay men and other men who have sex with men (MSM), and transgender women living with HIV remain understudied. To address this gap, we explored experiences of stigma and linkages with the HIV care cascade among key populations living with HIV in Jamaica, including cisgender women SW, MSM, and transgender women. This qualitative study involved n = 9 focus groups (FG), n = 1 FG per population living with HIV (SW, MSM, transgender women) in each of three sites (Kingston, St. Ann, Montego Bay). We also conducted key informant (KI) interviews. We applied thematic analysis informed by the Health Stigma and Discrimination (HSD) Framework. FG participants (n = 67) included SW (n = 18), MSM (n = 28), and trans women (n = 21); we interviewed n = 10 KI (n = 5 cisgender women, n = 5 cisgender men). Participant discussions revealed that stigma drivers included low HIV treatment literacy, notably misinformation about antiretroviral therapy (ART) benefits and HIV acquisition risks, and a lack of legal protection from discrimination. Stigma targets health (HIV) and intersecting social identities (sex work, LGBTQ identities, gender non-conformity, low socio-economic status). Stigma manifestations included enacted stigma in communities and families, and internalized stigma-including lateral violence. HIV care cascade impacts included reduced and/or delayed HIV care engagement and ART adherence challenges/disruptions. Participants discussed strategies to live positively with HIV, including ART adherence as stigma resistance; social support and solidarity; and accessing affirming institutional support. In addition to addressing intersecting stigma, future research and programing should bolster multi-level stigma-resistance strategies to live positively with HIV.

Exploring the Protective Value of Using Sexting for Condom Negotiation on Condom use Determinants and Practices Among Forcibly Displaced Adolescents in the Slums of Kampala, Uganda.

Given the global growth of adolescent texting, we evaluate texting-based sexual communication as a potential site for interventions encouraging condom use cascades, particularly among displaced adolescents-a population with disproportionate levels of sexually transmitted infections, including HIV. With data from 242 forcibly displaced adolescents in the slums of Kampala, Uganda, we used path analysis to examine pathways from gender/dating relationship to condom determinant (knowledge of where to access condoms) and practices (access/use of condoms), through sexting-based condom negotiation, controlling for sexting practices. We found direct pathways from gender (boys vs. girls) and from dating relationship (dating vs. not) to condom determinant. Sexting-based condom negotiation partially mediated the pathway from gender/dating relationship to condom determinant, and fully mediated the pathways from gender/dating relationship to condom practices. Future digital sexual health interventions should consider the utility of texting-based applications in promoting knowledge and use of condoms among adolescents.

RESUMEN: Dado el crecimiento global de los mensajes de texto de los adolescentes, evaluamos la comunicación sexual basada en mensajes de texto como un sitio potencial para intervenciones que fomenten el uso de condones en cascada, particularmente entre los adolescentes desplazados, una población con niveles desproporcionados de infecciones de transmisión sexual, incluido el VIH. Con datos de 242 adolescentes desplazados por la fuerza en los barrios marginales de Kampala, Uganda, utilizamos el análisis de caminos para examinar los caminos desde la relación de género/citas hasta el determinante del condón (conocimiento de dónde acceder a los condones) y las prácticas (acceso/uso de condones), a través del sexteo. -negociación basada en condones, controlando las prácticas de sexting. Encontramos caminos directos desde el género (niños vs. niñas) y desde la relación de noviazgo (citas vs. no) al determinante del condón. La negociación de condones basada en sexting medió parcialmente el camino de la relación de género/citas al determinante del condón, y medió completamente las vías de la relación de género/citas a las prácticas del condón. Las futuras intervenciones de salud sexual digital deben considerar la utilidad de las aplicaciones basadas en mensajes de texto para promover el conocimiento y el uso de condones entre los adolescentes.

PrEP eligibility, HIV risk perception, and willingness to use PrEP among high-risk men who have sex with men in India: A cross-sectional survey.

HIV pre-exposure prophylaxis (PrEP) is not yet included in India's national AIDS program, with demonstration projects for MSM in planning stages. In order to support PrEP roll-out for MSM, we assessed: (1) associations between guideline-informed PrEP eligibility, HIV risk perception, and perceived PrEP benefits and costs, with willingness to use PrEP (WTUP); and (2) correlates of non-WTUP among PrEP-eligible MSM. Data were collected from MSM (n = 197) sampled from cruising sites in Mumbai and Chennai. More than half (58.4%) reported inconsistent condom use with male partners, 88.3% >1 male partner, and 48.6% engaging in sex work (all past month). Overall, 76.6% reported they would "definitely use" PrEP. Among 92.9% deemed PrEP-eligible, 79.2% reported WTUP. In adjusted analyses, PrEP eligibility (aOR = 5.31, 95% CI 1.11, 25.45), medium (aOR = 2.41, 95% CI 1.03, 5.63) or high (aOR = 13.08, 95% CI 1.29, 132.27) perceived HIV risk, and greater perceived benefits (aOR = 1.13, 95% CI 1.03, 1.24) were associated with higher odds of WTUP. Among PrEP-eligible MSM, non-WTUP was associated with low HIV risk perception and lower perceived benefits. Facilitating accurate risk assessment and promoting awareness of PrEP benefits and eligibility criteria may increase PrEP uptake among MSM in India.

'No test, no disease': Multilevel barriers to HIV testing among young men who have sex with men and transgender women in three semi-urban areas in Thailand.

Young gay and other men who have sex with men and young transgender women in Thailand continue to be at high risk for HIV infection. We explored multilevel influences on HIV testing in order to inform the design of tailored interventions. We conducted four focus group discussions with 16-20-year-old gay men and transgender persons (n = 25) and 17 key informant interviews with healthcare providers, NGO leaders, and youth advocates. Focus groups and interviews were transcribed and reviewed using thematic analysis in Thai and English language by a bilingual team. We identified intersecting, culturally situated barriers at individual (lack of HIV knowledge, low HIV risk perception, denial), social (intersectional sexual- and HIV-related stigma, lack of family communication), institutional (inadequate and non-LGBT-inclusive sexual health education in schools, lack of youth-friendly clinics) and policy levels (parental consent requirements for HIV testing by minors). Multilevel and multisystem factors coalesce to form extensive barriers to HIV testing access and utilisation and promote disengagement from HIV prevention more broadly. Multicomponent, youth-engaged interventions informed by Thai sociocultural history and practices are needed in renewed approaches to HIV prevention and testing to end the epidemic among young gay and transgender people in Thailand.

Affirming and negotiating gender in family and social spaces: Stigma, mental health and resilience among transmasculine people in India.

Research on transmasculine people's health is scant globally, including in India. We explored transmasculine people's experiences in affirming their gender in family and social spaces, and how those experiences impact mental health. In 2019, we conducted four focus groups (n = 17 participants) and 10 in-depth interviews with transmasculine people in Mumbai and Chennai. Data analyses were guided by minority stress theory and the gender affirmation model. Within family, the pressure to conform to assigned gender roles and gender policing usually began in adolescence and increased over time. Some participants left parental homes due to violence. In educational settings, participants described the enforcement of gender-normative dress codes, lack of faculty support, and bullying victimisation, which led some to quit schooling. In the workplace, experiences varied depending on whether participants were visibly trans or had an incongruence between their identity documents and gender identity. Everyday discrimination experiences in diverse settings contributed to psychological distress. Amidst these challenges, participants reported resilience strategies, including self-acceptance, connecting with peers, strategic (non)disclosure, and circumventing gendered restrictions on dress and behaviour. Interventions at social-structural, institutional, family and individual levels are needed to reduce stigma and discrimination faced by transmasculine people in India and to promote their mental health.

Syndemic Conditions, Sexual Risk Behavior, and HIV Infection Among Men Who Have Sex with Men in Taiwan.

Men who have sex with men (MSM) continue to constitute the majority of HIV incidence in Taiwan. This study examined the associations between five co-occurring psychosocial health conditions (PHCs)-childhood physical abuse (CPA), childhood sexual abuse (CSA), intimate partner violence (IPV), internalized homophobia (IH), and methamphetamine use (MU), and two outcomes (HIV infection and condomless anal sex) among a community sample of 1,000 Taiwanese MSM (mean age 28.5 years). Compared to MSM who had never experienced any PHC, MSM with one or more PHCs had greater than twofold higher odds of being HIV-positive, and those with three or more PHCs had twofold higher odds of having condomless anal sex. Interactive effects on HIV infection were identified from CPA + CSA + MU and CPA + IPV + MU. An interactive effect on condomless anal sex was detected between IH and MU. In order to control the escalating HIV epidemic among MSM in Taiwan, interventions are needed to address syndemic psychosocial health conditions.

RESUMEN: Los hombres que tienen sexo con hombres (HSH por sus siglas en inglés) continúan constituyendo la mayor parte de la incidencia del VIH en Taiwán. Este estudio examinó las asociaciones existentes entre cinco condiciones de salud psicosocial habituales en la sociedad (APS por sus siglas en inglés) -abuso fisico infantil (CPA), abuso sexual infantil (CSA), violencia en pareja (IPV), homofobia internalizada (IH), y el uso de metanfetamina (MU); y dos resultados de una muestra de 1.000 HSH de origen taiwanés (con una media de edad de 28,5 años) sobre infección por VIH y sexo anal sin condón. En comparación con aquellos HSH que nunca habían experimentado las APS anteriores, los HSH con una o más APS tenían más del doble de probabilidades de ser VIH positivos, y aquellos otros con tres o más APS tenían el doble de probabilidades de tener sexo anal sin condón. Se identificaron efectos interactivos de la infección por VIH a partir de CPA + CSA + MU y CPA + IPV + MU. Se detectó otro efecto interactivo cuyo origen es el sexo anal sin condón entre IH y MU. Con el fin de controlar la escalada de la epidemia del VIH entre los HSH en Taiwán se necesita realizar intervenciones para abordar las condiciones de salud psicosocial en sindemias.

Willingness to Use Pre-exposure Prophylaxis (PrEP) and Preferences Among Men Who have Sex with Men in Mumbai and Chennai, India: A Discrete Choice Experiment.

Pre-exposure prophylaxis (PrEP) programs are planned for key populations in India. We examined PrEP awareness and willingness to use PrEP in order to support products and services for MSM. From December 2016 to March 2017, we conducted a survey and discrete choice experiment (DCE)-a technique to quantify the strength of participants' trade-off preferences among various product attributes-to assess willingness to use PrEP and related preferences. MSM were recruited from cruising sites and HIV prevention services in Mumbai and Chennai. DCE data were analyzed using mixed logit regression models and estimated marginal willingness-to-pay, the relative value participants' place on different PrEP attributes. Overall, 76.6% indicated willingness to use PrEP. Efficacy had the greatest effect on choice (high vs. moderate, aOR = 19.9; 95% CI 13.0-30.4), followed by dosing frequency (intermittent vs. daily regimen, aOR = 2.02; 95% CI 1.8-2.2). Participants preferred no (vs. minor) side-effects, subsidized (vs. market) price, and government (vs. private) hospitals. Findings suggest that educational and social marketing interventions should emphasize PrEP's high efficacy and minimal side effects, and programs should provide government-subsidized PrEP with choices of intermittent or daily dosing delivered by government and private hospitals/clinics in order to optimize PrEP uptake among MSM in India.

LGBT+ inclusion and human rights in Thailand: a scoping review of the literature.

BACKGROUND: Globally, LGBT+ people continue to struggle to achieve full realization of their human rights. Amid reported health and mental health disparities, and economic insecurity, we conducted a scoping review to explore the breadth of the literature, map and summarize the evidence, and identify knowledge gaps on LGBT+ inclusion and human rights in Thailand. METHODS: We conducted a scoping review in accordance with the methodology developed by the Joanna Briggs Institute and PRISMA-ScR guidelines. We systematically searched 16 databases for peer-reviewed literature, and government and nongovernmental organization websites for grey literature, published in English or Thai from January 1, 2000-August 21, 2020. Two reviewers independently screened studies according to pre-set criteria. We abstracted and analyzed data on publication characteristics and focal populations, and synthesized findings in six domains of LGBT+ inclusion: political and civic participation, education, family, personal security and violence, economic well-being, and health. RESULTS: The review captured 3327 results in total, which was scoped to 76 peer-reviewed articles and 39 grey literature sources, the majority published after 2010. Gay men and transgender women were the primary focal populations in the peer-reviewed literature, LGBT+ people as a whole in the grey literature. Health was the predominant domain across publications. Key findings include the absence of generalized antidiscrimination legislation for LGBT+ individuals and lack of recourse for transgender individuals to change their legal gender; multifaceted stigma and discrimination in the educational system; social isolation and exclusion in families; disproportionate prevalence of sexual violence and reluctance to report to police; discrimination and marginalization in employment; and LGBT+ disparities in health and mental health. CONCLUSIONS: Future research and programmatic initiatives on LGBT+ inclusion in Thailand should aim to address: 1) understudied populations-lesbian and bisexual women, transmasculine persons; 2) underrepresented topics, including constraints to LGBT+ advocacy; 3) strategic policy initiatives around anti-discrimination laws and legal recognition of same-sex marriage and families; and 4) the need for consistent collection of disaggregated data on LGBT+ persons in education, family, economic, personal security/violence, and health domains in order to assess indicators of inclusion and progress in advancing human rights for LGBT+ people in Thailand.

Virality, desire and health assemblages: mapping (dis)continuities in the response to and management of HIV and COVID-19.

In this paper, we explore the relationship between "viral load" as a virological, immunological, epidemiological and social category and how it links the four decades-long global HIV pandemic to the ongoing response to COVID-19. We argue, metaphorically, that the response to SARS-CoV-2 contains 'genetic' material from HIV, which has (as a result of the digital age which reproduces error-filled data at incredible speed) mutated and is being transmitted into the social and political body. Using sexual health and substance use as focal points, we turn to Deleuzoguattarian theoretical insights about the assemblage of desire, affect and material factors that produce epidemics. Contrasting historical and contemporary scenes and issues, we explore the complex assemblage created by viral loads, medical and public health protocols, conceptions of risk, responsibility and fear that connect both pandemics. Finally, we consider the goal of viral eradication and related militaristic metaphors, alongside the increasing convergence of medicine, public health, the law and corporate interests, and contrast this with community responses that engage with what it means to be living and dying in viral times.

Pre-Exposure Prophylaxis (PrEP) Implementation for Gay, Bisexual, and Other Men Who Have Sex with Men: Implications for Social Work Practice.

Social workers have been critical in the response to HIV from its inception, in HIV prevention, support, and advocacy for stigmatized populations including gay, bisexual, and other men who have sex with men (GBM). Recently, social workers have been tasked with working in an era of increasingly biomedicalized HIV prevention, including pre-exposure prophylaxis (PrEP), a safe and highly effective new prevention technology. However, disparities in PrEP access due to structural barriers, including lack of health insurance coverage, and complex decision-making pathways and processes of engagement present substantial challenges for PrEP implementation. Ensuring equitable access to resources and supporting informed decision making are paramount to social work values, yet scant published literature has considered PrEP social work intervention. This article draws on qualitative data from 29 GBM respondents to highlight gaps in PrEP decision-making support and access that may be amenable to social work intervention. Authors describe opportunities for individual, interpersonal, organizational, and structural social work interventions to address multilevel gaps in PrEP implementation. Findings illuminate the complexity of individual experiences and social discourses regarding PrEP and their impact on GBM and raise important issues for social workers to consider in working with GBM clients, service providers, and administrators.

A qualitative study of resilience among transgender women living with HIV in response to stigma in healthcare.

Stigma in healthcare is a pervasive adversity experienced by transgender (trans) women living with HIV (WLWH). Resilience is described as individual and collective processes of navigating and overcoming adversity. This qualitative study sought to explore resilience exhibited by trans WLWH in response to stigma in healthcare. Semi-structured, individual interviews were conducted in 2017-2018 with a purposive sample of trans WLWH (n = 11) participating in a community-based cohort study. Framework analysis was used to identify key themes, patterns within themes between participants, and patterns across themes among participants. Three overarching themes were identified. (1) Resilient responses to stigma in healthcare. Participants exhibited resilient personality traits and processes of resistance and transformation in response to stigma. (2) Motivations, benefits, and consequences of responding. Participants experienced self and altruistic driven motivations. Benefits included increased self-worth, economic resources, and leverage for better healthcare treatment, and reduced internalized stigma and isolation. Negative consequences included defensive provider reactions, being further stereotyped, and decreased physical and mental health. (3) Recommendations for systemic change. Participants recommended trans inclusion in service delivery, development, and management, as well as increased provider education. Providers can leverage trans WLWH's personal and collective strengths while working in solidarity to reduce stigma in healthcare settings.

Syndemics and HIV-related sexual risk among men who have sex with men in India: influences of stigma and resilience.

Using syndemics theory as a framework, we explored the experience of men who have sex with men in India in relation to four syndemic conditions (depression, alcohol use, internalised homonegativity and violence victimisation) and to understand their resilience resources. Five focus groups were conducted among a purposive sample of diverse men along with seven key informant interviews with HIV service providers. Participants' narratives suggested various pathways by which syndemic conditions interact with one another to sequentially or concurrently increase HIV risk. Experiences of discrimination and violence from a range of perpetrators (family, ruffians and police) contributed to internalised homonegativity and/or depression, which in turn led some men to use alcohol as a coping strategy. Stigma related to same-sex sexuality, gender non-conformity and sex work contributed to the production of one or more syndemic conditions. While rejection by family and male regular partners contributed to depression/alcohol use, support from family, regular partners and peers served as resources of resilience. In India, HIV prevention and health promotion efforts among men who have sex with men could be strengthened by multi-level multi-component interventions to reduce intersectional/intersecting stigma, address syndemic conditions and foster resilience - especially by promoting family acceptance and peer support.

Gender-affirming healthcare experiences and medical transition among transgender women living with HIV: a mixed-methods study.

Background Transgender (trans) women are overrepresented among people living with HIV, yet trans women living with HIV (WLWH) experience lower access to HIV care. Access to medical transition may facilitate access to HIV care among trans WLWH. This study sought to describe barriers and facilitators to access to medical transition among trans WLWH. METHODS: This convergent parallel mixed-methods study drew on cross-sectional quantitative data from 48 trans WLWH analysed using descriptive and bivariate analyses, as well as qualitative semistructured interview data from a subsample of 11 participants analysed using framework analysis. The primary outcome was self-reported transition experience (completed or in the process of medical transition vs planning to but have not begun medical transition). Quantitative and qualitative results were merged and analysed for convergence, divergence and/or expansion of understanding. RESULTS: Just over half the participants reported being fully completed medical transition or in the process of medical transition (52.1% (25/48); 95% confidence interval (CI) 37.5-67.6%), with one-fifth reporting planning to but not having begun medical transition (18.8% (9/48); 95% CI 8.3-29.2%). Factors significantly associated with not having begun one's medical transition included housing instability, transphobia, HIV-related stigma and barriers in access to care. Qualitative findings revealed varied transition experiences, influenced by community norms, passing and class privilege, HIV and structural barriers. Mixed-methods results showed positive relationships between trans WLWH and HIV care providers in terms of trans and HIV health care. CONCLUSIONS: HIV-related stigma and social determinants of health limit access to medical transition for trans WLWH. Stigma must be addressed in a broad range of healthcare settings, in addition to structural barriers, to increase access to gender-affirming HIV care and medical transition for trans WLWH.

Factors Associated With Syphilis Testing and a History of Syphilis Infection Among a Sample of Transgender Women in Jamaica.

BACKGROUND: Globally, social inequalities contribute to elevated sexually transmitted infections (STIs) rates among transgender women. High syphilis prevalence has been documented among transgender women in Latin America. Little is known, however, of syphilis testing uptake among transgender women in Jamaica, where homosexuality is criminalized. The study objective was to understand factors associated with opting-in for syphilis testing and a syphilis infection history among transgender women in Jamaica. METHODS: We conducted a cross-sectional tablet-based survey of 137 transgender women between March and November 2015 in Jamaica. Bivariate analyses were used to assess differences across sociodemographic, intrapersonal, interpersonal, and structural factors based on syphilis infection history. We conducted univariable and multivariable logistic regression to determine the odds ratio for opting-in for syphilis testing for all factors associated with testing uptake at a P value of less than 0.05 in bivariate analyses, controlling for sociodemographic characteristics. RESULTS: Among 137 participants, 83 (60.6%) opted in for syphilis screening and 8 (9.6%) had positive rapid test results. One quarter of participants (n = 26; 25.2%) reported being HIV positive. Opting-in for syphilis testing was associated with the following: 1 health (HIV-positive serostatus: adjusted odds ratio [AOR], 4.33; 95% confidence interval [CI], 1.31-14.26), 1 intrapersonal (perceived STI risk: AOR, 1.58; 95% CI, 1.04-2.40), 1 interpersonal (childhood sexual abuse: AOR, 2.80; 95% CI, 1.03-7.62), and 1 structural (incarceration: AOR, 0.27; 95% CI, 0.11-0.71) factor. CONCLUSIONS: This study identified factors (HIV-positive serostatus, perceived STI risk, childhood sexual abuse, no incarceration history) associated with syphilis testing uptake among transgender women. Findings can inform multilevel STI testing, prevention, and care strategies tailored for transgender women in Jamaica.

"Like Holding an Umbrella Before It Rains": Acceptability of Future Rectal Microbicides Among Men Who Have Sex With Men in India-A Modified Technology Acceptance Model.

Topical rectal microbicides (RMs) are a new prevention technology in development that aims to reduce the risk of HIV acquisition from anal sex. We examined RM acceptability among men who have sex with men (MSM) in India. We conducted a qualitative exploratory study guided by a modified Technology Acceptance Model, with 10 focus groups ( n = 61) of MSM and 10 key informant interviews. Data were explored using framework analysis. RM acceptability was influenced by technological contexts: perceived usefulness of RMs, perceived ease of use of RM and applicator, and habits around condom and lubricant use; individual and interpersonal contexts: perceived relevance and preferences for product formulation and dosing frequency; and MSM community/social contexts: perceived social approval, RM-related stigma, social support. Implementation of RMs for MSM in India may be supported by multi-level interventions that engage community-based organizations in destigmatizing and distributing RMs, ideally gel-based products that enable on-demand use before sex.

Acceptability and Preferences for Hypothetical Rectal Microbicides among a Community Sample of Young Men Who Have Sex with Men and Transgender Women in Thailand: A Discrete Choice Experiment.

Rectal microbicides (RMs) may offer substantial benefits in expanding HIV prevention options for key populations. From April to August 2013, we conducted Tablet-Assisted Survey Interviewing, including a discrete choice experiment, with participants recruited from gay entertainment venues and community-based organizations in Chiang Mai and Pattaya, Thailand. Among 408 participants, 74.5 % were young men who have sex with men, 25.5 % transgender women, with mean age = 24.3 years. One-third (35.5 %) had ≤9th grade education; 63.4 % engaged in sex work. Overall, 83.4 % reported they would definitely use a RM, with more than 2-fold higher odds of choice of a RM with 99 versus 50 % efficacy, and significantly higher odds of choosing gel versus suppository, intermittent versus daily dosing, and prescription versus over-the-counter. Sex workers were significantly more likely to use a RM immediately upon availability, with greater tolerance for moderate efficacy and daily dosing. Engaging key populations in assessing RM preferences may support biomedical research and evidence-informed interventions to optimize the effectiveness of RMs in HIV prevention.

HIV testing among clients in high HIV prevalence venues: disparities between older and younger adults.

The Centers for Disease Control and Prevention recommends routine human immunodeficiency virus (HIV) testing of every client presenting for services in venues where HIV prevalence is high. Because older adults (aged ≥50 years) have particularly poor prognosis if they receive their diagnosis late in the course of HIV disease, any screening provided to younger adults in these venues should also be provided to older adults. We examined aging-related disparities in recent (past 12 months) and ever HIV testing in a probability sample of at-risk adults (N = 1238) seeking services in needle exchange sites, sexually transmitted disease clinics, and Latino community clinics that provide HIV testing. Using multiple logistic regression with generalized estimating equations, we estimated associations between age category (<50 years vs. ≥50 years) and each HIV testing outcome. Even after controlling for covariates such as recent injection drug use, older adults had 40% lower odds than younger adults did of having tested in the past 12 months (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.40-0.90) or ever (OR = 0.6; 95% CI = 0.40-0.90). Aging-related disparities in HIV testing exist among clients of these high HIV prevalence venues and may contribute to known aging-related disparities in late diagnosis of HIV infection and poor long-term prognosis.

Barriers to antiretroviral treatment access for injecting drug users living with HIV in Chennai, South India.

India's National AIDS Control Organization provides free antiretroviral treatment (ART) to people living with HIV (PLHIV), including members of marginalized groups such as injecting drug users (IDUs). To help inform development of interventions to enhance ART access, we explored barriers to free ART access at government ART centers for IDUs living with HIV in Chennai by conducting three focus groups (n = 19 IDUs) and four key informant interviews. Data were explored using framework analysis to identify categories and derive themes. We found interrelated barriers at the family and social, health-care system, and individual levels. Family and social level barriers included lack of family support and fear of societal discrimination, as well as unmet basic needs, including food and shelter. Health-care system barriers included actual or perceived unfriendly hospital environment and procedures such as requiring proof of address and identity from PLHIV, including homeless IDUs; provider perception that IDUs will not adhere to ART, resulting in ART not being initiated; actual or perceived inadequate counseling services and lack of confidentiality; and lack of effective linkages between ART centers, needle/syringe programs, and drug dependence treatment centers. Individual-level barriers included active drug use, lack of self-efficacy in ART adherence, low motivation to initiate ART stemming from a fatalistic attitude, and inadequate knowledge about ART. These findings indicate that to facilitate IDUs gaining access to ART, systemic changes are needed, including steps to make the environment and procedures at government ART centers more IDU-friendly and steps to decrease HIV- and drug use-related stigma and discrimination faced by IDUs from the general public and health-care providers. Housing support for homeless IDUs and linkage of IDUs with drug dependence treatment are also essential.

Endorsement of compulsory HIV vaccination policy among populations at high risk of HIV exposure (LA VOICES).

Compulsory vaccination is a frequently implemented policy option for ensuring comprehensive vaccine coverage. Ongoing controversies around human papillomavirus vaccine dissemination, and suboptimal coverage, suggest the value of assessing acceptability of compulsory vaccinations-particularly among likely target populations-in advance of their public availability to support evidence-informed interventions. With the first HIV vaccine to demonstrate partial efficacy in a large-scale clinical trial, we examined individual characteristics and attitudes associated with support for compulsory HIV vaccination policy among a diverse, representative sample of adults attending probable HIV vaccine dissemination venues in a large urban county. Participants were recruited using three-stage probability sampling from likely venues for future HIV vaccine dissemination. We used Audio-CASI to administer a 60-min structured questionnaire. Items included endorsement of compulsory HIV vaccination policy, sociodemographic characteristics, injecting drug use, vaccine attitudes and perceived HIV risk. Among 1,225 participants (mean age = 36.8 years; 55.6 % males, 37.6 % non-English speaking Hispanic, 78.8 % heterosexual, 25.7 % injection drug users), almost half (48.2 %) endorsed a compulsory HIV vaccination policy. Non-English speaking Hispanics compared to whites, participants with less than high school education, higher positive vaccine attitude scores and higher perceived HIV risk were significantly more likely, and people who inject drugs significantly less likely to endorse compulsory HIV vaccination. Public health interventions to promote positive vaccine attitudes and accurate perceptions of HIV risk among vulnerable populations, and strategies tailored for people who inject drugs, may build support for compulsory HIV vaccination policy and promote broad HIV vaccine coverage.