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Supporting Treatment Adherence Readiness through Training (START) is an HIV antiretroviral adherence intervention, based on the Information Motivation and Behavioral skills (IMB) model, that significantly improved adherence in our randomized controlled trial. To understand how and for whom START had its effects on adherence, we examined mediators and moderators. Ninety-nine HIV-patients (53 control, 46 intervention) who enrolled in the trial and provided month 6 electronic monitored adherence data. The intervention was associated with increased adherence-related knowledge and lower impulsive/careless problem solving, but had no effects on other IMB-related constructs. Neither of these variables mediated the adherence effects of the intervention (based on linear regression models with bootstraping for unbiased standard errors). Four variables interacted with the intervention to moderate its effects: the intervention group had consistent high adherence across the range of depression and time since HIV diagnosis, compared to lower adherence with higher values in the usual care control; those with unstable housing or frequent drug use had higher adherence if in the intervention group compared to the control group. These findings suggest that START provides support that enables its recipients to cope with and overcome challenges (e.g., depression, unstable housing, drug use) that would typically impede adherence.Trial registration: ClinicalTrials.gov identifier: NCT02329782.

The Middle East and North Africa (MENA) is one of only two global regions where rates of HIV are currently on the rise. In Lebanon, new HIV infections are increasing most rapidly among young men who have sex with men (YMSM). While, the majority of YMSM in Lebanon report having recently engaged in condomless anal intercourse, many report reluctance to seek HIV prevention services for fear of stigma and discrimination. Pre-exposure prophylaxis (PrEP) is an effective alternative HIV prevention strategy but there is a dearth of research looking at willingness to take PrEP among YMSM in MENA. This study is the first to delineate factors associated with willingness to take PrEP among a cohort of 218 YMSM recruited from Beirut, Lebanon. Over half (55.5%) reported willingness to take PrEP. At the bivariate level, knowledge of HIV risk, awareness of PrEP, being in a relationship, greater judgementalism about sex in communication with peers, greater number of types of gay-related discrimination experienced, sense of community among YMSM, having had recent condomless anal sex with positive or unknown status partner, and the use of substances just prior to or during sex were each associated with greater willingness to take PrEP. When entered into a linear regression analysis, use of substances just prior to or during sex and sense of community among YMSM remained significant predictors of PrEP willingness. Intervention efforts focused on increasing PrEP uptake among YMSM in MENA should consider the influence substance use and social factors on willingness to take PrEP.

Young gay men in Beirut are at significantly elevated risk of HIV infection compared with the general Lebanese population. Despite nascent HIV prevention efforts in the region, there is a need for effective community-level HIV prevention interventions tailored for young gay men. This qualitative study examined internal dynamics within Beirut's gay community as a basis for developing community-level interventions. Peer ethnographers were trained to collect field notes on conversations between young gay men in public spaces in Beirut, and conducted follow-up focus groups with young gay men. Analyses revealed three major themes: (1) the need for safe spaces in which to socialise, (2) the importance of being able to locate and connect with other young gay men, and (3) ambivalence regarding a gay community that was supportive in some ways but also fragmented and often judgemental. Study findings also confirm the existence of external threats to community such as stigma, cultural and familial norms regarding heterosexuality and criminalisation of refugee status. Understanding such community dynamics and the environmental context is central to designing effective community-based HIV prevention programmes.

Male sex workers (MSW) are a particularly high-risk subset of men who have sex with men in Lebanon and report higher numbers of sex partners and lower rates of condom use. The purpose was to explore the factors influencing sexual risk behaviors and HIV testing among MSW. Qualitative interviews were conducted with 16 MSW living in Beirut and working in bathhouses (hammam) or as escorts; content analysis identified emergent themes. Escorts reported more consistent condom use with clients and HIV testing than hammam MSW, with influential factors including HIV risk knowledge and perceived risk susceptibility, job security, and internalized stigma and related feelings of self-worth and fatalism regarding health and HIV risk. In contrast, both groups of MSW typically opted not to condoms with nonclient sex partners, in an effort to differentiate sex for work versus pleasure. The uptake of HIV testing was limited by concerns about the confidentiality of the test results and fear of repercussions of a positive test result for their health and employment. The respondents described an insular existence within the sex work culture, in part to limit exposure to stigma, which has implications for access to support as well as the influence of peer norms regarding sexual risk behavior and health seeking behaviors such as HIV testing. Further research is needed to tailor prevention and HIV testing efforts to reflect the distinct sexual health “cultures” that distinguish these two populations of MSW in Lebanon.

HIV-positive Latino men have been found to have poorer medication adherence compared to Whites. This study sought to identify how cultural conceptualisations of masculinity are associated with self-reported medication adherence among Latino men. A total of 208 HIV-positive men reported the number of doses of antiretroviral medication missed in the previous seven days (dichotomised at 100% adherence versus less). Conceptualisations of masculinity consisted of traditional machismo (e.g., power and aggressive attitudes, which are normally associated with negative stereotypes of machismo) and caballerismo (e.g., fairness, respect for elders and the importance of family). Multivariate logistic regression was used to identify factors associated with adherence. The mean adherence was 97% (SD = 6.5%; range = 57-100%). In all, 77% of the participants reported 100% adherence in the previous seven days. Caballerismo was associated with a greater likelihood (OR = 1.77; 95% CI: 1.08-2.92; p = 0.03) and machismo with a lower likelihood (OR = 0.60; 95% CI: 0.38-0.95; p = 0.03) of medication adherence. In addition, higher medication side-effects were found to be associated with a lower likelihood (OR = 0.59; 95% CI: 0.43-0.81; p = 0.001) of medication adherence. These findings reinforce the importance of identifying cultural factors that may affect medication adherence among HIV-positive Latino men resident in the USA.

Fish landing sites have high levels of harmful use of alcohol. This paper examines the role of religion and religiosity on alcohol consumption at two fish landing sites on Lake Victoria in Uganda. Questionnaires were administered to randomly selected people at the sites. Dependent variables included alcohol consumption during the previous 30 days, whereas the key independent variables were religion and religiosity. Bivariate and multivariate analysis techniques were applied. People reporting low religiosity were five times more likely to have consumed alcohol (95% confidence interval: 2.45-10.04) compared with those reporting low/average religiosity. Religion and religiosity are potential channels for controlling alcohol use.

The association between substance use and relationship quality was explored in a sample of 117 serodiscordant male couples. Several measures of relationship quality were used including dyadic satisfaction, affection, commitment, sexual satisfaction, and domestic violence. Although frequency of use was assessed for several substances, only alcohol, marijuana, and cocaine were used frequently enough for statistical analyses. The highest frequency of use within the couple in the past 2 months as well as the discrepancy in the frequency of use between the 2 members of the couple were considered. Although daily substance use was relatively rare in this sample, alcohol use was reported by 79%, marijuana use by 35%, and cocaine use by 15% of the men. Domestic violence was not associated with any substance use variable. Marijuana use was generally not associated with relationship quality. Alcohol and cocaine use were moderately associated with several indicators of poorer relationship quality.

Few studies have analyzed the impact of HIV infection on dyadic functioning and on the distress levels of each partner, independently, in HIV-serodiscordant relationships, particularly in same-sex dyads. The main purpose of this study was to assess levels of psychological distress in the HIV-positive and HIV-negative members of HIV-discordant male couples and to explore possible couple-related factors associated with distress. This was done within a systems theory framework. Levels of distress among the men were in the mild to moderate range, according to general population norms. Factors associated with distress in the men included dyadic satisfaction, sexual satisfaction, avoidance and self-blame coping style, and support from one's partner. Results suggest the need for 'couple-focused' clinical interventions for HIV-discordant couples.

Antiretroviral therapy is being increasingly delayed until later stages of illness. Therefore, prior to prescribing HAART, providers are emphasizing the need for patients to be ready to adhere well to the treatment regimen. Unfortunately, providers are no better than chance at predicting a patient's adherence, and there are no established methods for accurately assessing a patient's adherence readiness. This pilot study assessed the utility of a series of up to five 1-week placebo practice trials accompanied by adherence counseling as a clinical tool to both assess and improve adherence readiness.Participants were not prescribed treatment until they demonstrated readiness, which was defined as 90+% adherence during a single practice trial. Once HAART was initiated, adherence to one selected antiretroviral was monitored for 4 weeks. Electronic monitoring caps were used to measure adherence.Twenty men enrolled in the study at two HIV outpatient clinics in Southern California. Mean age was 33, 50% were non-White, 35% were employed, 30% had not completed high school, 15% were Spanish monolingual, and 30% had unstable housing. Nine participants achieved 90+% adherence in the first practice trial, with an additional 8 participants demonstrating readiness after two to four practice trials; two participants withdrew from the study because of intolerance of the restrictions related to the use of the caps; and one participant was removed from the study after no effort was given during two practice trials. Of the 17 participants who completed the program and demonstrated adherence readiness, 15 started on an antiretroviral regimen and 2 decided to defer treatment indefinitely. Of the 15 who started therapy, 13 (87%) achieved 90+% adherence during the first month of antiretroviral therapy. The sample's mean adherence during the first 4 weeks of treatment was 93% (SD = 13).These results suggest that once a patient is able to adhere well to a 1-week practice trial they are likely to adhere equally well to HAART. A larger controlled study is needed to further assess the effectiveness of practice trials as a clinical tool for both assessing and improving adherence readiness.

Self-reports overestimate adherence compared to more objective measures such as electronic monitoring. However, self-report is the most feasible method for clinical settings; therefore, it is important to identify the context in which this method can provide an accurate assessment. To address whether self-reports are more accurate when missed doses are reported, we conducted a secondary analysis of data from a methodological study comparing multiple measures of adherence (including self-report and electronic monitoring) to a two-week placebo regimen mimicking HAART among 30 HIV-positive patients not on HAART. Results indicated a mean adherence of 85% and 62%, as measured by self-report and electronic monitoring, respectively. Self-report and electronic monitoring were not significantly correlated in the measurement of proportion of prescribed doses taken among the sub-group of 17 patients who reported missed doses (r = 0.22), nor among those who reported no missed doses, or the group as a whole. Using electronic monitoring as the validity criterion, these findings indicate that self-reports overestimate adherence even among patients who report missed doses.

This report documents findings from the first 80 patients to enter our ongoing clinical trial of testosterone replacement therapy, designed for HIV+ men with low CD4 cell counts and low levels of serum testosterone, who complain of diminished sexual interest and/or sexual dysfunction. Patients were treated with testosterone for 8 weeks with biweekly intramuscular injections, starting at 200 mg. and increasing at Week 2 to 400 mg. biweekly. Week 8 responders were treated with testosterone for at least four more weeks and were then randomized to testosterone or placebo for six weeks or until relapse. Seventy‐three men completed the initial eight‐week phase of treatment; of the seven dropouts (9%), two men discontinued treatment because of side effects (irritability and hair loss). Of the 73 completers, 67 (92%) were rated as clearcut responders by the study doctor. Self‐ratings of sexual interest, erectile functioning, and satisfaction with one's sex life revealed significant improvement in all areas. Altho...