Search

Background: According to the 2016-2017 Tanzania HIV Impact Survey, only 45% of men living with HIV (MLWH) were aware of their HIV status. In an effort to increase HIV testing in Tanzania, including among men, the Government of Tanzania passed a law in December 2019 allowing HIV self-testing (HIVST) to be included in the national testing strategies. The objective of this paper is to describe the development and pilot feasibility assessment of the Self-Testing Education and Promotion (STEP) intervention, which includes male peer education and demand creation for HIVST, and nurse-led distribution of HIVST kits in a community setting., Methods: The development and piloting processes were guided by the ADAPT-ITT model and informed by a national PEPFAR/USAID-funded HIV implementation science project called Sauti. The adapted STEP intervention included the following two components: 1) peer-based HIVST promotion; and 2) nurse-led HIVST distribution. For the feasibility assessment, 25 men were selected and trained as peer educators in 2019 to promote HIVST among their peers before recruiting 253 men who received instructions and an HIVST kit from a nurse at a community-based study tent site., Results: Of the 236 participants who completed the 1-month follow-up survey, 98.3% reported using the kit. The majority (92.4%) of participants reported a negative HIVST result while 4.2% (n = 10) received a positive result. Most (70%, n = 7) of the participants with a positive result sought follow-up services at a healthcare facility while 40.3% (n = 95) of the participants with a negative self-test result visited the community-based project site. Most of the men (53%, n = 129) did not visit a healthcare facility or the study site., Conclusion: The findings demonstrate that the combined peer-based promotion and nurse-led distribution of HIVST intervention was acceptable and feasible, though seeking follow-up services at healthcare facilities remained low. Future research should evaluate the effectiveness of offering nurse-led community-based clinical follow-up services in addition to HIVST rather than referral to facilities., (© 2024. The Author(s).)

Background: HIV self-testing (HIVST) offers an innovative and promising approach to increasing HIV testing among Black men in the United States, a population disproportionately affected by HIV. However, engaging Black men in traditional HIV prevention programs has been challenging due to stigma, medical mistrust, and limited access to preventive health services. This formative qualitative study aimed to explore the potential of utilizing barbershops as an example of a nontraditional healthcare venue to promote and distribute HIVST., Methods: Four virtual focus group discussions (FGDs) consisting of 19 participants in North Carolina were conducted with Black men, including barbershop business owners, barbers, and their customers, to assess perceptions of HIVST and the acceptability of partnering with barbershop businesses to promote HIVST. FGDs were digitally recorded, transcribed, and analyzed using a deductive coding approach to thematic analysis., Results: Participants reported that the trusting relationship between barbers and their customers, which may not exist between Black men and health care providers, is a facilitator of collaborating with barbershop businesses to reach Black men for HIVST distribution. Participants recommended providing education for barbers on the use of HIVST, as well as how to inform self-testers about linkage to care following HIVST to build the credibility of the barbers in delivering the intervention. Participants also raised the issue of the cost of HIVST to barbershop customers as a potential barrier to implementation, as well as the possibility that the implementation of such interventions could be seen as out of place in a barbershop business venue. Participants also expressed a strong belief that compensation to barbershops and their employees should accompany any intervention., Conclusion: These findings suggest that barbershop business venues may provide an appropriate venue for HIVST promotion and distribution, though factors like cost, training, and incentivization of implementers are necessary to consider in implementation planning. Furthermore, partnerships between public health actors and the business community must be built on equitable engagement to ensure the long-term viability of these critical initiatives., (© 2024. The Author(s).)

Globally, men are less likely to access HIV services, and addressing HIV service challenges among men is crucial to the global HIV/AIDS response. HIV self-testing (HIVST) has been shown to be a potentially effective strategy in improving HIV testing coverage among men. This study assessed and identified factors influencing willingness to receive HIVST kits from sexual partners among men in Tanzania. Data are from the baseline survey of the Self-Testing Education and Promotion (STEP) project, a five-year study comprising male participants aged 18 or older who self-reported as HIV-negative. Logistic regression models were used to assess factors associated with men's willingness to receive HIVST kits from their sexual partners. There were 505 heterosexual male participants enrolled in the study with an average age of 29 years, of whom 69% reported being willing to receive HIVST kits from their sexual partner. Logistic regression models demonstrated that willingness to receive HIVST kits from sexual partners was significantly associated with number of sexual partners within 12 months (aOR = 1.2, 95% CI [1.1-1.3]), awareness of HIVST (aOR = 5.6, 95% CI [3.2-9.5]), previous discussion of HIVST with sexual partners aOR = 14.0, 95% CI [8.0-24.6]), and previous testing for HIV with sexual partners not (aOR = 2.5, 95% CI [1.3-4.7]). These findings suggest additional promotional strategies to improve men's awareness of HIVST and support open conversations about HIVST and HIV testing with sexual partners could improve men's willingness to receive HIVST kits when distributed through their sexual partners., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Poverty and economic insecurity are driving forces in entering sex work among women in low resource areas. This increases their risk for HIV by influencing the decision-making process for high-risk behaviors. Few studies examine financial behaviors and capacities of women engaged in sex work (WESW). This paper describes the methodology used in a financial diary study aimed at characterizing women's spending patterns within a larger prevention intervention trial among WESW in Uganda. From June 2019 to March 2020, a subsample of 150 women randomized to the combination HIV prevention and economic empowerment treatment were asked to complete financial diaries to monitor daily expenditures in real time. Two hundred forty financial diaries were distributed to study participants during the financial literacy sessions at 8 sites. A total of 26,919 expense entries were recorded over 6 months. Sex work related expenses comprised approximately 20.01% of the total. The process of obtaining quality and consistent data was challenging due to the transient and stigmatized nature of sex work coupled with women's varying levels of education. Frequent check-ins, using peer support, code word or visuals, and a shorter timeframe would allow for a more accurate collection of high frequency data. Moreover, the ability of women to complete the financial diaries despite numerous challenges speaks to their potential value as a data collection tool, and also as an organizing tool for finances., Competing Interests: Competing interests None declared.

Intimate partner violence (IPV) is a significant global public health problem that results in high social and economic costs to individuals and communities. Compared to women in the general population, women engaged in sex work (WESW) are more likely to experience physical, emotional, and sexual IPV. This study examines the correlates of IPV among young WESW with their intimate partners in Southern Uganda. We used baseline data from the Kyaterekera project , a 5 year NIH-funded longitudinal study aimed at reducing HIV risks among 542 WESW in Southern Uganda. To examine the factors associated with IPV, we fitted three separate multi-level Poisson regression models for physical, emotional, and sexual IPV, respectively. Average age was 31.4 years, and 54% of the women reported being victims of at least one form of IPV from their intimate partners. Model one assessed correlates of sexual IPV. Being married women (β = .71, 95% CI [0.24, 1.17]), divorced/separated/widowed (β = .52, [0.02, 1.02]), depressed (β = .04, [0.02, 0.05]), and having any sexually transmitted infections (STIs) (β = .58, [0.14, 1.01]) were associated with sexual IPV. Model two assessed correlates of physical IPV. Experience of childhood sexual abuse (β = .12, [0.04, 0.19]) was associated with an increase in physical IPV, and increasing age reduced its occurrence (β = -.02, [-0.04, -0.001]). Finally, model three assessed emotional IPV. Women with higher education (β = .49, [0.14, 0.85]) and symptoms of depression (β = .02, [0.001, 0.04]) had higher risks for emotional IPV. For WESW, IPV presents an additional potential pathway for HIV and STIs acquisition and transmission through a lack of negotiating power for safe sex. Efforts to reduce violence against WESW should be prioritized as a strategy for enhancing the well-being of WESW.

Self-administered HIV testing may be a promising strategy to improve testing in hard-to-reach young adults, provided they are aware of and willing to use oral HIV self-testing (HIVST). This study examined awareness of and willingness to use oral HIVST among 350 high-risk young adults, aged 18-22, living in Kenya's informal urban settlements. Bivariate and multivariate logistic regressions were used to examine differences in HIVST awareness and willingness by demographic and sexual risk factors. Findings showed that most participants were male (56%) and less than 20 years old (60%). Awareness of oral HIVST was low (19%). However, most participants (75%) were willing to use an oral HIV self-test in the future and ask their sex partner(s) to self-test before having sex (77%). Women (OR = 1.80, 95%CI:1.11, 2.92), older participants (aged 20+) (OR = 2.57, 95% CI:1.48, 4.46), and more educated participants (OR = 2.25, 95%CI:1.36, 3.70) were more willing to use HIVST as compared to men, teen-aged, and less educated participants, respectively. Young adults who reported recent engagement in high-risk sexual behaviors, such as unprotected sex, sex while high or drunk, or sex exchange, were significantly less likely to be willing to use an oral HIV self-test kit (OR = 0.34, 95%CI:0.13,0.86). Those with the highest monthly income (OR = 0.47, 95%CI: 0.25, 0.89) were also less willing to use HIVST. More community- and peer-based efforts are needed to highlight the range of benefits of HIVST (i.e., social, clinical, and structural) to appeal to various youth demographics, in addition to addressing concerns relating to HIVST.

Young Black men who have sex with men (MSM) living with HIV evidence the lowest rates of linkage to care and viral suppression of all US MSM. Kentucky, identified by the US Department of Health and Human Services as a "hot spot" state with elevated HIV incidence compared to the rest of the country, exhibits similar racialized outcomes. Structural, interpersonal, and individual drivers of engagement along the HIV care continuum among people living with HIV have been identified, primarily through quantitative designs. However, the mechanisms by which these factors shape HIV care engagement, and the ways they may combine or reinforce each other, as well as from the lived experience of young Black MSM living with HIV, have been studied to a lesser extent. In this study, a purposive sample of n = 29 HIV-positive young Black MSM (age M = 25 years old; 38% retained in care) residing in Kentucky participated in in-depth interviews. Factors that were most influential on engagement varied along the continuum, with health insurance status and knowledge of HIV being relatively more influential to diagnosis, and housing stability, psychological processes, and interpersonal relationships being more influential on retention. For some participants, barriers to care at multiple levels had a mutually influencing and intensifying impact on care engagement. Additional efforts to center the voices of young Black MSM living with HIV will help illuminate acceptable and sustainable interventions for increasing their care engagement and narrowing persistent racial disparities in HIV morbidity and mortality., (© 2022. W. Montague Cobb-NMA Health Institute.)

Decision-making errors such as present bias (PB) can have important consequences for health behaviors, but have been largely studied in the financial domain. We conducted a mixed-method study on PB in the context of ART adherence among clinic-enrolled adults in Uganda ( n  = 39). Specifically, we quantified PB by asking about preferences between medication available sooner to minimize headaches versus available later to cure headaches. We describe demographic similarities among PB participants and qualitatively explored how participants reflected on their PB (or absence thereof) in the context of health. Participants reporting PB were predominantly male, single/unmarried, older, had higher levels of education and income and more advanced HIV progression. Three common reasons for more present-biased choices provided were: (1) wanting to avoid pain, (2) wanting to return to work, and (3) fear of one's health worsening if s/he did not address their illness immediately. While PB in the financial domain often suggests that poorer individuals are more likely to prefer immediate rewards over their wealthier counterparts, our results suggest poor health is potentially a driving factor of PB. Further research is needed to build on these finding and inform how programs can frame key messages regarding ART adherence to patients displaying PB.Trial registration: ClinicalTrials.gov identifier: NCT03494777.

Background: Behavioral economic (BE) biases have been studied in the context of numerous health conditions, yet are understudied in the field of HIV prevention. This aim of this study was to quantify the prevalence of four common BE biases-present bias, information salience, overoptimism, and loss aversion-relating to condom use and HIV testing in economically-vulnerable young adults who had increased likelihood of acquiring HIV. We also qualitatively examined participants' perceptions of these biases., Methods: 43 participants were enrolled in the study. Data were collected via interviews using a quantitative survey instrument embedded with qualitative questions to characterize responses. Interviews were transcribed and analyzed using descriptive statistics and deductive-inductive content analyses., Results: 56% of participants were present-biased, disproportionately discounting future rewards for smaller immediate rewards. 51% stated they were more likely to spend than save given financial need. Present-bias relating to condom use was lower with 28% reporting they would engage in condomless sex rather than wait one day to access condoms. Most participants (72%) were willing to wait for condom-supported sex given the risk. Only 35% knew someone living with HIV, but 67% knew someone who had taken an HIV test, and 74% said they often think about preventing HIV (e.g., high salience). Yet, 47% reported optimistically planning for condom use, HIV discussions with partners, or testing but failing to stick to their decision. Most (98%) were also averse (b = 9.4, SD  ±.9) to losing their HIV-negative status. Qualitative reasons for sub-optimal condom or testing choices were having already waited to find a sex partner, feeling awkward, having fear, or not remembering one's plan in the moment. Optimal decisions were attributed qualitatively to self-protective thoughts, establishing routine care, standing on one's own, and thinking of someone adversely impacted by HIV. 44% of participants preferred delayed monetary awards (e.g., future-biased), attributed qualitatively to fears of spending immediate money unwisely or needing time to plan., Conclusion: Mixed methods BE assessments may be a valuable tool in understanding factors contributing to optimal and sub-optimal HIV prevention decisions. Future HIV prevention interventions may benefit from integrating savings products, loss framing, commitment contracts, cues, or incentives., (© 2023. The Author(s).)

Background: Women employed by sex work (WESW) have a high risk of human immunodeficiency virus (HIV) infection and experience economic barriers in accessing care. However, few studies have described their financial lives and the relationship between expenditures and HIV-related behaviors., Methods: This exploratory study used financial diaries to collect expenditure and income data from WESW in Uganda over 6 months. Data were collected as part of a larger trial that tested the efficacy of an HIV prevention intervention method. Descriptive statistics were used to quantify women's income, relative expenditures, and negative cash balances. Bivariate and multivariate logistic regressions were used to examine the odds of sexual risk behavior or use of HIV medications for several cash scenarios., Results: A total of 163 WESW were enrolled; the participants mean age was 32 years old. Sex work was the sole source of employment for most WESW (99%); their average monthly income was $62.32. Food accounted for the highest proportion of spending (44%) followed by sex work (20%) and housing expenditures (11%). WESW spent the least on health care (5%). Expenditures accounted for a large but variable proportion of these women's income (56% to 101%). Most WESW (74%) experienced a negative cash balance. Some also reported high sex work (28%), health care (24%), and education (28%) costs. The prevalence of condomless sex (77%) and sex with drugs/alcohol (70%) was high compared to use of ART/PrEP (Antiretroviral therapy/Pre-exposure prophylaxis) medications (45%). Women's cash expenditures were not statistically significantly associated with HIV-related behaviors. However, the exploratory study observed a consistent null trend of lower odds of condomless sex (adjusted odds ratio (AOR) = 0.70, 95% confidence interval (CI): 0.28-1.70), sex with drugs/alcohol (AOR = 0.93, 95% CI: 0.42-2.05), and use of ART/PrEP (AOR = 0.80, 95% CI: 0.39-1.67) among women who experienced a negative cash balance versus those who did not. Similar trends were observed for other cash scenarios., Conclusion: Financial diaries are a feasible tool to assess the economic lives of vulnerable women. Despite having paid work, most WESW encountered a myriad of financial challenges with limited spending on HIV prevention. Financial protections and additional income-generating activities may improve their status. More robust research is needed to understand the potentially complex relationship between income, expenditures, and HIV risk among vulnerable sex workers.

Purpose: Intersectional stigma fuels inequities among transgender women of color, which have been exacerbated by coronavirus disease 2019 (COVID-19). This study evaluated a community-led emergency assistance program for transgender women of color., Methods: We conducted a pilot program evaluation ( n =8)., Results: Retention was 87.5% over the follow-up. Funds were primarily used for bills, food, and housing. Requesting and receiving funds was described as "somewhat to extremely easy." Participants identified the need for economic empowerment components in future programming, specifically gender affirmation, skill-building for education and employment, and entrepreneurial opportunities., Conclusion: Findings highlight the need to invest in community-led strategies to address inequities experienced by transgender women of color., Competing Interests: No competing financial interests exist., (Copyright 2023, Mary Ann Liebert, Inc., publishers.)

We examined the correlates of self-reported adherence to antiretroviral therapy (ART) among women engaged in commercial sex work (WESW) in Uganda. We used baseline data from a longitudinal study, which recruited 542 WESW in Southern Uganda. We used nested regression models to determine the individual and family, and economic level correlates of self-reported adherence. Study findings show that older age (OR = 1.07, 95% CI = 1.013, 1.139), secondary education (OR = 2.01, 95% CI = 1.306, 3.084), large household size (OR = 1.08, 95% CI = 1.020, 1.136), high family cohesion (OR = 1.06, 95% CI = 1.052, 1.065), and high financial self-efficacy (OR = 1.07, 95% CI = 1.006, 1.130) were associated with good self-reported adherence to ART. Married women (OR=-0.39, 95% CI = 0.197, 0.774), depression (OR = 0.85, 95% CI = 0.744, 0.969), alcohol use (OR = 0.72, 95% CI = 0.548, 0.954), ever been arrested (OR = 0.58, 95% CI = 0.341, 0.997), and high household assets ownership (OR = 0.48, 95% CI = 0.313, 0.724) were associated with poor self-reported adherence to ART. Findings suggest a need to adopt a multi-level approach to address gaps in ART adherence among WESW., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Economic hardship is a driver of entry into sex work, which is associated with high HIV risk. Yet, little is known about economic abuse in women employed by sex work (WESW) and its relationship to uptake of HIV prevention and financial support services. This study used cross-sectional baseline data from a multisite, longitudinal clinical trial that tests the efficacy of adding economic empowerment to traditional HIV risk reduction education on HIV incidence in 542 WESW. Mixed effects logistic and linear regressions were used to examine associations in reported economic abuse by demographic characteristics, sexual behaviors, HIV care-seeking, and financial care-seeking. Mean age was 31.4 years. Most WESW were unmarried (74%) and had less than primary school education (64%). 48% had savings, and 72% had debt. 93% reported at least one economic abuse incident. Common incidents included being forced to ask for money (80%), having financial information kept from them (61%), and being forced to disclose how money was spent (56%). WESW also reported partners/relatives spending money needed for bills (45%), not paying bills (38%), threatening them to quit their job(s) (38%), and using physical violence when earning income (24%). Married/partnered WESW (OR = 2.68, 95% CI:1.60-4.48), those with debt (OR = 1.70, 95% CI:1.04-2.77), and those with sex-work bosses (OR = 1.90, 95% CI:1.07-3.38) had higher economic abuse. Condomless sex ( β = +4.43, p < .05) was higher among WESW experiencing economic abuse, who also had lower odds of initiating PrEP (OR = .39, 95% CI:.17-.89). WESW experiencing economic abuse were also more likely to ask for cash among relatives (OR = 2.36, 95% CI:1.13-4.94) or banks (OR = 2.12, 95% CI:1.11-4.03). The high prevalence of HIV and economic abuse in WESW underscores the importance of integrating financial empowerment in HIV risk reduction interventions for WESW, including education about economic abuse and strategies to address it. Programs focusing on violence against women should also consider economic barriers to accessing HIV prevention services.

Clinical Trial Registration: ClinicalTrials.gov identifier: NCT03583541.

Background: Mobile phone-based health (mHealth) interventions have the potential to improve HIV outcomes for high-risk young adults living in informal urban settlements in Kenya. However, less is known regarding young adults' differential access to mobile phones and their willingness and use of mobile phone technologies to access HIV prevention, care, and treatment services. This is important as young adults make up the largest demographic segment of impoverished, informal urban settlements and are disproportionately impacted by HIV., Methods: This study used observational survey data from 350 young adults, aged 18-22, who were living informal urban settlements in Nairobi, Kenya. Respondent driven sampling methods were used to recruit and enroll eligible youth. Using descriptive statistics and logistical regressions, we examined the prevalence of mobile phone access, willingness, and use for HIV services. We also assessed associated demographic characteristics in the odds of access, willingness, and use., Results: The mean age of participants was 19 years (±1.3). 56% were male. Mobile phone coverage, including text messaging and mobile internet, was high (>80%), but only 15% of young adults had ever used mobile phones to access HIV services. Willingness was high (65%), especially among those who had individual phone access (77%) compared to lower willingness (18%) among those who shared a phone. More educated (OR = 1.84, 95 %CI:1.14-2.97) and employed (OR = 1.70, 95 %CI:1.02 = 2.83) young adults were also more willing to use phones for HIV services. In contrast, participants living in large households (OR = 0.47, 95 %CI:0.24-0.921), were religious minorities (OR = 0.56, 95 %CI:0.32-0.99), partnered/married (OR = 0.30, 95 %CI:0.10-0.91), or female (OR = 0.29, 95 %CI:0.16-0.55) were significantly less likely to have mobile phone access or usage, limiting their potential participation in HIV-related mHealth interventions. Given the low usage of mobile phones currently for HIV services, no differences in demographic characteristics were observed., Conclusion: Mobile health technologies may be under-utilized in HIV services for at-risk youth. Our findings highlight the importance of preliminary, formative research regarding population differences in access, willingness, and use of mobile phones for HIV services. More efforts are needed to ensure that mHealth interventions account for potential differences in preferences for mobile phone-based HIV interventions by gender, age, religion, education, and/or employment status., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

To slow the spread of COVID-19, most countries implemented stay-at-home orders, social distancing, and other nonpharmaceutical mitigation strategies. To understand individual preferences for mitigation strategies, we piloted a web-based Respondent Driven Sampling (RDS) approach to recruit participants from four universities in three countries to complete a computer-based Discrete Choice Experiment (DCE). Use of these methods, in combination, can serve to increase the external validity of a study by enabling recruitment of populations underrepresented in sampling frames, thus allowing preference results to be more generalizable to targeted subpopulations. A total of 99 students or staff members were invited to complete the survey, of which 72% started the survey (n = 71). Sixty-three participants (89% of starters) completed all tasks in the DCE. A rank-ordered mixed logit model was used to estimate preferences for COVID-19 nonpharmaceutical mitigation strategies. The model estimates indicated that participants preferred mitigation strategies that resulted in lower COVID-19 risk (i.e. sheltering-in-place more days a week), financial compensation from the government, fewer health (mental and physical) problems, and fewer financial problems. The high response rate and survey engagement provide proof of concept that RDS and DCE can be implemented as web-based applications, with the potential for scale up to produce nationally-representative preference estimates., Competing Interests: Conflict of interestThe authors declare no conflicts of interest., (© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021.)

This study examined the factors associated with depressive symptoms and post traumatic depressive disorder (PTSD) among economically vulnerable women engaged in commercial sex work (WESW) in southern Uganda. Baseline data from a longitudinal cluster randomized study involving 542 self-identified WESW (18-55 years), recruited from 19 HIV hotspots were analyzed. Hierarchical linear regression modelling was utilized to estimate individual, family-level and economic-level predictors of depressive symptoms and PTSD. Family cohesion, sex work stigma, HIV status, financial distress, household assets, number of children and number of household income earners, were associated with PTSD. Similarly, family cohesion, number of people in the household, HIV status, sex work stigma, financial distress, and household assets, were associated with depressive symptoms. Women engaged in commercial sex work are at a higher risk of HIV and poor mental health outcomes. Sex work stigma and financial distress elevate levels of depressive symptoms and PTSD, over and above an individual's HIV status. Family and economic-level factors have the potential to mitigate the risk of poor mental health outcomes. As such, integrating stigma reduction and economic strengthening components in the programming targeting WESW-a key population, may be critical to address their mental health outcomes., (Copyright © 2021. Published by Elsevier B.V.)

Aims: To synthesise the current, global evidence-informed guidance that supports nurses and midwives to recognise and respond to intimate partner violence (IPV), and how these practices can be translated from face-to-face encounters to care that is delivered through telehealth., Background: COVID-19-related social and physical distancing measures increase the risk for individuals who are socially isolated with partners who perpetuate violence. Providing support through telehealth is one strategy that can mitigate the pandemic of IPV, while helping patients and providers stay safe from COVID-19., Design and Methods: In this discursive paper, we describe how practical guidance for safely recognising and responding to IPV in telehealth encounters was developed. The ADAPT-ITT (Assessment, Decisions, Administration, Production, Topical Experts, Integration, Testing, Training) framework was used to guide the novel identification and adaptation of evidence-informed guidance. We focused on the first six stages of the ADAPT-ITT framework., Conclusions: This paper fills a gap in available guidance, specifically for IPV recognition and response via telehealth. We present strategies for prioritising safety and promoting privacy while initiating, managing or terminating a telehealth encounter with patients who may be at risk for or experiencing IPV. Strategies for assessment, planning and intervention are also summarised. System-level responses, such as increasing equitable access to telecommunication technology, are also discussed., Relevance to Clinical Practice: Integrating innovative IPV-focused practices into telehealth care is an important opportunity for nurses and midwives during the current global COVID-19 pandemic. There are also implications for future secondary outbreaks, natural disasters or other physically isolating events, for improving healthcare efficiency, and for addressing the needs of vulnerable populations with limited access to health care., (© 2020 John Wiley & Sons Ltd.)

COVID-19 measures that restrict movement may negatively impact access to HIV care and treatment. To contribute to the currently limited evidence, we used telephone interviews with quantitative and qualitative questions to examine how clients perceived COVID-19 and its effect on their HIV care and ART adherence. One hundred (n = 100) Ugandan adults on ART from an existing study were randomly selected and enrolled. Interviews were recorded, transcribed, and analyzed using descriptive statistics and rapid content analyses. 76% of clients indicated that COVID-19 negatively impacted travel to HIV clinics; 54% perceived that coming to the clinic increased their risk of acquiring COVID-19; and 14% said that COVID-19 had negatively impacted their ART adherence. Qualitative feedback suggests that fear of COVID-19 infection discouraged clinic attendance while stay-at-home orders helped routinize ART adherence and employ new community-based approaches for HIV care. Addressing negative unintended consequences of COVID-19 lockdowns on HIV care is urgently needed.

Background: Acceptability is a critical requisite in establishing feasibility when planning a larger effectiveness trial. This study assessed the acceptability of conducting a feasibility randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults, aged 18 to 24, in Baltimore, Maryland. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors., Methods: Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19). The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Qualitative and quantitative post-intervention, in-person interviews were used in addition to process documentation of study methods., Results: Our results found that the study design and interventions showed promise for being acceptable to economically-vulnerable African-American young adults. The largely positive endorsement suggested that factors contributing to acceptability included perceived economic potential, sexual health education, convenience, incentives, and encouraging, personalized feedback to participants. Barriers to acceptability for some participants included low cell phone connectivity, perceived payment delays, small cohort size, and disappointment with one's randomization assignment to comparison group. Use of peer referral, network, or wait-list designs, in addition to online options may enhance acceptability in a future definitive trial. Expanding administrative and mentoring support may improve overall experience., Conclusion: Microenterprise interventions are acceptable ways of providing young adults with important financial and sexual health content to address HIV risks associated with economic vulnerability., Trial Registration: ClinicalTrials.gov. NCT03766165 . Registered 04 December 2018.

Economic vulnerability, such as homelessness and unemployment, contributes to HIV risk among U.S. racial minorities. Yet, few economic-strengthening interventions have been adapted for HIV prevention in this population. This study assessed the feasibility of conducting a randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors. The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Primary feasibility objectives assessed recruitment, randomization, participation, and retention. Secondary objectives examined employment, sexual risk behaviors, and HIV preventive behaviors. Outcome assessments used an in-person pre- and post-intervention interview and a weekly text message survey. Several progression criteria for a definitive trial were met. Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19) of which 95% were retained. The comparison intervention enhanced willingness to be randomized and reduced non-participation. Mean age of participants was 21.0 years; 35% were male; 81% were unemployed. Fifty-eight percent (58%) of experimental participants completed ≥ 70% of intervention activities, and 74% completed ≥ 50% of intervention activities. Participation in intervention activities and outcome assessments was highest in the first half (~ 10 weeks) of the study. Seventy-one percent (71%) of weekly text message surveys received a response through week 14, but responsiveness declined to 37% of participants responding to ≥ 70% of weekly text message surveys at the end of the study. The experimental group reported higher employment (from 32% at baseline to 83% at week 26) and lower unprotected sex (79% to 58%) over time compared to reported changes in employment (37% to 47%) and unprotected sex (63% to 53%) over time in the comparison group. Conducting this feasibility trial was a critical step in the process of designing and testing a behavioral intervention. Development of a fully-powered effectiveness trial should take into account lessons learned regarding intervention duration, screening, and measurement.Trial Registration ClinicalTrials.gov. NCT03766165. Registered 04 December 2018. https://clinicaltrials.gov/ct2/show/NCT03766165.

Condom use remains a mainstay of HIV prevention programs around the world. However, data characterizing economic determinants of condom use among female sex workers (FSW) are limited, including in Senegal. We recruited 718 FSWs via respondent-driven sampling. Bivariate and multivariable regressions were conducted to assess the associations between economic variables and condom use at last sex. Paying rent (aRR: 1.07, 95%CI 1.01-1.13) was positively associated with condom use at last sex with new clients. No statistically significant associations were found between condom use and financial responsibility for dependent children, having additional source of income, sharing sex work earnings, or the ability to borrow from other FSWs, regardless of sexual partner types. The relationship between economic marginalization and consistent condom use among sex workers is complex reinforcing the need for behavioral economic research and prevention to be integrated into HIV prevention and treatment research and programs.

Background: Text messages offer the potential to better evaluate HIV behavioral interventions using repeated longitudinal measures at a lower cost and research burden. However, they have been underused in US minority settings., Objective: This study aims to examine the feasibility of assessing economic and sexual risk behaviors using text message surveys., Methods: We conducted a single-group study with 17 African-American young adults, aged 18-24 years, who were economically disadvantaged and reported prior unprotected sex. Participants received a text message survey once each week for 5 weeks. The survey contained 14 questions with yes-no and numeric responses on sexual risk behaviors (ie, condomless sex, sex while high or drunk, and sex exchange) and economic behaviors (ie, income, employment, and money spent on HIV services or products). Feasibility measures were the number of participants who responded to the survey in a given week, the number of questions to which a participant responded in each survey, and the number of hours spent from sending a survey to participants to receiving their response in a given week. One discussion group was used to obtain feedback., Results: Overall, 65% (n=11/17) of the participants responded to at least one text message survey compared with 35% (n=6/17) of the participants who did not respond. The majority (n=7/11, 64%) of the responders were women. The majority (n=4/6, 67%) of nonresponders were men. An average of 7.6 participants (69%) responded in a given week. Response rates among ever responders ranged from 64% to 82% across the study period. The mean number of questions answered each week was 12.6 (SD 2.7; 90% of all questions), ranging from 72% to 100%. An average of 6.4 participants (84%) answered all 14 text message questions in a given week, ranging from 57% to 100%. Participants responded approximately 8.7 hours (SD 10.3) after receiving the survey. Participants were more likely to answer questions related to employment, condomless sex, and discussions with sex partners. Nonresponse or skip was more often used for questions at the end of the survey relating to sex exchange and money spent on HIV prevention services or products. Strengths of the text message survey were convenience, readability, short completion time, having repeated measures over time, and having incentives., Conclusions: Longitudinal text message surveys may be a valuable tool for assessing HIV-related economic and sexual risk behaviors., Trial Registration: ClinicalTrials.gov NCT03237871; https://clinicaltrials.gov/ct2/show/NCT03237871., (©Larissa Jennings Mayo-Wilson, Nancy E Glass, Alain Labrique, Melissa Davoust, Fred M Ssewamala, Sebastian Linnemayr, Matthew W Johnson. Originally published in JMIR Formative Research (http://formative.jmir.org), 17.07.2020.)

Men in sub-Saharan Africa continue to experience health disparities that are exacerbated by low employment. This study qualitatively assessed men's perceptions of the economic and health-care-seeking effects of participation in an integrated microfinance and peer health leadership intervention on violence and HIV risk reduction in Tanzania. Three focus group discussions with 27 men, aged 20 to 44 years, examined the perceived effects on income generation, employability, mental health, and uptake of HIV and related health services. All discussions were recorded, transcribed, and analyzed using deductive and inductive coding methods. Men reported that the benefits of the intervention included increased employability and income-earning activities due to greater access to entrepreneurial training, low-interest microfinancing, and male-oriented group supports to start or strengthen their businesses. Increased wages through business or other forms of employment were also attributed to men's lower anxiety and distress as financial providers for their families. However, men indicated that apart from the uptake of free HIV testing services, there was limited change in overall health-care-seeking behavior given the high clinic fees and lost time to earn income when attending routine health visits. Men recommended that future microfinance and health promotion interventions provide larger loan amounts, less frequent repayment intervals, and access to health and social insurance. Microfinance and peer health leadership interventions may help to address economic and health disparities in poor, urban men. Efforts are needed to assist lower income men in accessing financial tools as well as fee-based preventive and health-care services.

Background: Despite initial high motivation, individuals receiving antiretroviral therapy (ART) for several years may experience incomplete adherence over time, increasing their risk of HIV-related morbidity and mortality. Habits, defined as automatic and regular practices, do not rely on conscious effort, and may therefore support high long-term ART adherence., Methods: This qualitative study contributes to the evidence on how clients with adherence problems remember and form habits to take ART medications. Free-listing and unstructured interviewing were used among 42 clinic-enrolled adults in Kampala, Uganda who were receiving ART and participating in a randomized clinical trial for treatment adherence (clinicaltrials.gov: NCT03494777). Data were coded and analyzed using inductive content analysis., Results: Findings indicated that clients' most routine habits (eating, bathing, sleeping) did not always occur at the same time or place, making it difficult to reliably link to pill-taking times. Efforts to improve ART habits included having a relative to ask about pill-taking, re-packaging medications, leaving medications in view, using alarms, carrying water, or linking pill-taking to radio/prayer schedules. Reported challenges were adhering to ART schedules during changing employment hours, social activities, and travel., Conclusion: While habit-forming interventions have the potential to improve ART adherence, targeting treatment-mature clients' existing routines may be crucial in this population.

Background: Transgender women ("trans women"), particularly African-American and Latina trans women, have disproportionately high prevalence of HIV in the United States (U.S.). In order to decrease gender dysphoria and overcome discrimination, trans women affirm their gender through social and medical transition, often in contexts of economic hardship and sexual risk. This study qualitatively examined how gender-affirming behaviors enhance or diminish vulnerability to HIV in light of structural and economic barriers to gender transition., Methods: We conducted individual interviews with 19 adult trans women in two U.S. cities (Richmond, VA and St. Louis, MO) who reported one or more sexual risk behaviors and recent economic hardship related to employment/income, housing, or food security. Interviews were recorded, transcribed, and analyzed using thematic content analysis., Results: The majority (74%) of trans women were racial/ethnic minorities with mean age of 26.3 years. Gender-affirming behaviors varied with 58% of trans women having legally changed their name and gender marker; 79% having initiated hormone therapy; and 11% having not initiated any medical or legal changes. None had undertaken surgical changes. Findings suggested that the process of gender transitioning resulted in both increasing and decreasing HIV risk. The high need for gender affirmation by male sex partners contributed to trans women's exposure to sexual objectification, sexual risk behaviors, and conflicting interests in HIV prevention messaging. Loss of housing and employment due to transition along with the high costs of transition products and medical visits increased reliance on sex work and created new obstacles in accessing HIV services. Trans women experienced lower HIV risk as they acquired legal and medical transition services, reshaped interactions with sex partners, and received gender-affirming support by others, including health providers, employers, peers, and housing professionals. Sexual abstinence was viewed as a negative consequence of incomplete transition, although characterized as a period of low HIV risk., Conclusions: Structural and policy initiatives that promote safe gender transition and economic stability in trans women may play a critical role in reducing HIV in this population. Addressing the harmful pressures for U.S. trans women to conform to perceived feminine stereotypes may also serve an important role.

Background: Respondent-driven sampling (RDS) is a peer-referral sampling methodology used to estimate characteristics of underserved groups that cannot be randomly sampled. RDS has been implemented in several settings to identify hidden populations at risk for HIV, but few studies have reported the methodological lessons learned on RDS design and implementation for assessing sexual risk behaviors in marginalized youth., Methods: We used RDS to recruit N = 350 young adults, aged 18 to 22, who were living in urban slum settlements in Nairobi, Kenya. A structured survey was used to assess sexual risk behaviors. Twenty seeds were selected and asked to recruit up to three eligible peers. We used small monetary incentives and a three-day recruitment coupon with sequential numbers linking recruiters to their recruits., Results: Data collection was completed in 8 days with a maximum chain length of 6 waves. Each seed yielded 16 to 21 eligible recruits. Three (15%) seeds were unproductive and were replaced. RDS benefits were high identification rates (90% coupons returned per coupons given), high eligibility rates (100% eligible recruits per coupons returned), and high efficiency (~39 eligible recruits per day). 44% of the sample was female. Most recruits (74%) reported being "friends" for 7+ years with their recruiter. RDS overcame feasibility concerns of household-, clinic-, and school-based sampling methodologies in that underserved youth who were unemployed (68%), out of school (48%), ethnic minorities (26%), and having prior residential instability (≥2 moves in the past year) (20%) were successfully recruited, based on weighted analyses. Youth reporting HIV risk behaviors, including unprotected sex (38%), sex while high/drunk (35%), and sex exchange for pay (14%), were also enrolled. However, 28% were not sexually active within the last 6 months. Challenges included managing wait times during peaks and participant referral expectations. Community engagement, use of study-stamped coupons, broad inclusion criteria, incentives, and study sites within walking distances all contributed to the successful implementation of the sampling methodology., Conclusion: RDS is an important tool in reaching a diverse sample of underserved and at-risk young adults for study participation. Implications for optimizing RDS for behavioral studies in this population are discussed., Competing Interests: The authors have declared that no competing interests exist.