Search

Female sex workers (FSW) are disproportionately affected by HIV in Lesotho, which highlights the importance of contraception and antiretroviral therapy (ART) given occupational risks of unwanted pregnancies. Seven hundred and forty-four FSW recruited through respondent-driven sampling in Maputsoe and Maseru in Lesotho completed a questionnaire and HIV testing in 2014. RDS-adjusted HIV prevalence was high (66.1; 95% CI: 58.7–72.8); 56% of HIV + participants were not using non-barrier contraception, and 32% were on ART. Among HIV-positive FSW not using non-barrier contraception, negative correlates of ART engagement were older age, lower HIV education, and consuming 5+ alcoholic drinks/day. Tailored HIV information delivery efforts for FSW in Lesotho's high HIV burden environment may reduce horizontal and vertical transmission risks. [ABSTRACT FROM AUTHOR]

Avert.org, the website of the Avert charity, is a global information and education resource on HIV and AIDS which sets the standard for HIV/AIDS consumer health websites. Its general flow sets the stage for an easy to use and accessible resource. The site strives to be inclusive, non-biased, and filled with nothing but the best, evidence-based information about the HIV/AIDS epidemic. Their outreach extends to consumers, educators, and professionals, and is a solid source for any age group, population, or region. [ABSTRACT FROM AUTHOR]

Sex education within the formal bounds of school curricula or clinic consultation is traditionally conceived as age-appropriate and accurate information, delivered by a sanctioned adult such as a nurse or teacher. This article explores another kind of curriculum – taught and learned among young men themselves in the kasi (township) in which they live. Findings are based on primary data gathered during interviews and research workshops with boys and young men (aged 14–22), including focus group discussions and participatory research exercises. In exploring young men's sexual ideas, practices, hopes and fears, it focuses on three themes: (i) consent and coercion; (ii) pleasure and risk; and (iii) advice and authority. We examine diverse perspectives on these themes, and trace the tensions and ambiguities that surface within young men's accounts. We focus in particular on contradictions between what is learned about sex through formal curricula, and what is learned through peers and older men, including within ulwaluko (a rite of passage of traditional initiation and circumcision for Xhosa men). [ABSTRACT FROM AUTHOR]

We conducted a quasi-experiment to investigate whether a peer education intervention could result in positive sexual behavioral change outcomes in selected schools in Northern Malawi. The experimental participants (n = 158) were exposed to an HIV risk reduction intervention. The control participants (n = 147) were exposed to a Health Promotion Package. At 8 months, there were significant improvements in the intervention arm on several outcomes. The experimental group was 96% less likely to have sex than the control (OR = 0.04, CI = 0.01–0.20). Intervention participants were also 3.49 times likely to report condom use when they had sex (OR = 3.49, 95% CI = 0.96 to 12.65) and had lower odds of having multiple sexual partners. There were no significant differences on abstinence and the desire to have medical male circumcision (MMC). We suggest the intervention has potential efficacy to improve HIV risk reduction among adolescents in Malawi and perhaps in other similar settings. [ABSTRACT FROM AUTHOR]

The study explored constructions of sexuality among young people of Venda in Limpopo, South Africa, and cultural practices that can be used to develop context-specific HIV prevention programmes. HIV prevention can be promoted by including some cultural practices in prevention programmes and changing some aspects of culture that may contribute negatively to health. Six focus group discussions were held with school-going young people (Grades 10 to 12) in urban and rural areas to explore their constructions of sexuality and HIV risk. Four focus group discussions were held with community leaders in the same areas to explore their constructions of young people's sexuality and cultural practices relevant to HIV prevention. Through discourse analysis, the following dominant discourses that influence young people's sexual risk behaviour were identified: rite of passage, the male sexual drive discourse (sex is natural and unavoidable); discourse of hegemonic masculinity (sex to prove masculinity); sex as a commodity; non-adherence to cultural practices; and HIV is normalised (AIDS is like flu). Some alternative constructions and shifts in gender norms were noticed, especially among female participants. The constructions of young people were not culture-specific but similar to those identified in other South African cultures. Community leaders identified a few cultural practices that could be considered in HIV prevention, for example, reinstating the rite of passage to provide age-appropriate sex and HIV education (behavioural intervention), and promoting traditional male circumcision (biological intervention). Cultural practices that contribute negatively to health should be challenged such as current constructions of gender roles (masculinity and femininity) and the practice that parents do not talk to young people about sex (both structural interventions). [ABSTRACT FROM AUTHOR]

This study evaluated the association between microfinance participation and HIV literacy within a nationally representative sample of 3,614 married women aged 15–49 years from the Bangladesh Demographic and Health Survey, 2011. Using logistic regression, we assessed the relationship between microfinance participation and HIV literacy. Controlling for demographic factors such as wealth, age, and education, we found that microfinance participants were 30% more likely to be HIV literate, in comparison with women who did not participate in microfinance. These results suggest that microfinance is a cost-effective way to enhance HIV literacy for poor, less educated women in rural areas of Bangladesh. [ABSTRACT FROM AUTHOR]

To assess perceptions of HIV treatment as prevention (TasP), we conducted an online survey of MSM in New York City (n = 732) asking them to rate the effectiveness of different strategies to reduce HIV risk during serodiscordant condomless anal sex between men. Only 6.1% reported not knowing what TasP was, with significantly less awareness among non-gay-identified MSM, men with less education, men who reported fewer anal sex partners in the prior 3 months, and HIV-negative/unaware men who had never used PrEP. The strategy most frequently perceived to offer "a lot" or "complete" protection from HIV was daily PrEP (70.0%), followed by TasP (39.1%), intermittent PrEP (16.6%), strategic positioning (15.8%), and withdrawal before ejaculation (10.8%). Men who were HIV positive, who had ever used PrEP, and who identified as gay/homosexual were significantly more likely to see TasP as effective. Further studies should investigate MSM's apparent skepticism towards TasP. [ABSTRACT FROM AUTHOR]

Copyright of African Journal of Reproductive Health is the property of Women's Health & Action Research Centre and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Over the past two decades, southern Africa has experienced both exceptionally high AIDS prevalence and recurrent food shortages. International institutions have responded to these challenges by framing them as security concerns that demand urgent intervention. Young people are implicated in both crises and drawn into the securitisation discourse as agents (of risk and protection) and as (potential) victims. However, the concepts of security deployed by global institutions and translated into national policy do not reflect the ways in/security is experienced 'on the ground' as a subjective and embodied orientation to the future. This paper brings work on youth temporalities to bear on social and cultural geographies of in/security and securitisation. It reports on research that explored insecurities among young people in Lesotho and Malawi. It concludes that, by focusing on 'threats' in isolation, and seeking to protect 'society' as an abstract aggregate of people, global securitisation discourses fail either to engage with the complex contextualised ways in which marginalised people experience insecurity or to proffer the political responses that are needed if those felt insecurities are to be addressed. However, while securitisation is problematic, in/security is nonetheless an important element in young people's orientation to the future. [ABSTRACT FROM AUTHOR]

Faith-based organisations (FBOs) have long been part of the fight against HIV and AIDS. International bodies continue to collaborate with FBOs to implement HIV-prevention programmes with mixed success. Zambia has been a target of such programmes in part due to its high HIV prevalence. The Trusted Messenger approach to provide religious leader networks with biomedical, science-focused education about HIV and AIDS was piloted in 2006, but participant experiences of the intervention have not been explored qualitatively. In 2016, in-depth interviews were conducted of 34 randomly chosen individuals who attended Trusted Messenger workshops between 2006 and 2016 in Livingstone, Lusaka, and the Copperbelt region. Findings indicate that the religious leader attendees gained scientific insights about HIV which motivated their action in personal, social, and religious contexts. Participants found the science comprehensible and empowering and identified workshop frequency and language as challenging. Utilising science-focused education within contextual settings of religious leader networks can combat the spread of HIV and the mistreatment of people living with HIV and AIDS. [ABSTRACT FROM AUTHOR]

As stakeholders embrace the efficiency of early disease detection and linkage to care services, corresponding demand for linkage specialists necessitates a clearer understanding of what defines and differentiates this role from the similar work of social workers and epidemiologists. The purpose of the present literature review was to identify the most frequently cited duties, knowledge, skills and abilities required of linkage specialists in employment advertisements and described in peer-reviewed literature. We conducted searches using Google, MEDLINE with Full Text, Academic Search Complete, Health Source: Nursing/Academic Edition, SocINDEX with Full Text, Social Sciences Full Text, and PubMed with MEDLINE. Two reviewers applied exclusion criteria and assessed search returns. Employment ads for linkage specialists and disease intervention specialists most often described linkage to care, client education, and maintenance of client data. The linkage specialist role can be cultivated through its roots in disease detection and programmatic development. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to identify and prioritize the information that persons living with HIV (PLWH) in a limited‐resource setting need to effectively manage their health. Design and Methods: A data sources triangulation method was used to compare data from three separate sources: (a) 107 interviews with Spanish‐speaking PLWH being seen at a healthcare clinic in the Dominican Republic (DR); (b) 40 interviews with Spanish‐speaking healthcare providers from the same clinic in the DR; and (c) an integrative literature review of English‐ and Spanish‐language articles that assessed the health information needs of PLWH in Latin America and the Caribbean. We compared information needs across sources and developed a prioritized list of the topics important to provide PLWH in a clinical setting. Findings: Triangulation identified the most important topics for HIV‐related health education for PLWH as medication and adherence, followed by transmission, including risks and prevention strategies, mental health management, and knowledge of HIV in general. Conclusions: The identification of evidence‐based health education priorities establishes a guide that healthcare providers may use to help PLWH effectively manage their health and creates a foundation from which further studies on improving clinical interactions may be generated. Clinical Relevance: Using the priorities identified, nurses and other health educators can improve patient education, and consequently self‐management, by making evidence‐based choices about what information to provide to their patients. [ABSTRACT FROM AUTHOR]

This study assessed the practical value of HIV/AIDS education among at-risk adolescents in the United States. Data were drawn from the 2013 Youth Risk Behavior Surveillance System spanning students in grades 9-12 who have engaged in sexual intercourse. A multivariate hierarchical logistic regression analysis was employed to test: (1) the individual effects of school-based HIV/AIDS education and risky sexual behaviors on the probability of HIV testing and (2) the interaction effects to estimate the degree to which the education effect varied by specific risky sexual behavior. The results indicated that students who engaged in risky sexual activities and received HIV/AIDS education were more likely to test for HIV compared to those who did not receive HIV/AIDS education. The relationship between education and HIV testing also varied according to the number of recent sexual partners. The findings have policy and practice implications. Specifically, HIV/AIDS education that promotes HIV testing should be encouraged particularly with the high-risk student population. [ABSTRACT FROM AUTHOR]

Sexual health education, including HIV prevention information, can help prevent unintended pregnancy and sexually transmitted infections. National Youth Risk Behavior Survey data from 2011 and 2013 were used to determine HIV education prevalence among 9,825 currently sexually active students in grades 9-12. Associations between HIV education and contraceptive methods used at last sexual intercourse were examined for: (1) condom use; (2) any contraceptive method; (3) dual use of a condom and either birth control pills; IUD or implant; or shot, patch, or birth control ring; and (4) primary contraceptive method. Primary contraceptive method options were (1) no method; (2) birth control pills; (3) condoms; (4) IUD or implant; (5) shot, patch, or birth control ring; (6) withdrawal or some other method; and (7) not sure. Logistic regression (prevalence ratios [PRs] and 95% confidence intervals [CIs]) and Chi-squares were used for testing. Students who received HIV education were more likely than students who did not to use a condom (PR:1.09;CI:1.01,1.18) and any contraceptive method (PR:1.08;CI:1.04,1.12); there was no significant association with dual use. Primary contraceptive method varied significantly by receipt of HIV education (p < .001). School-based HIV education may be important for promotion of adolescent condom and contraceptive use. [ABSTRACT FROM AUTHOR]

Background: Racial or ethnic and socioeconomic disparities in adverse birth outcomes are well known, but few studies have examined disparities in the receipt of prenatal health education. The objectives of this study were to examine racial or ethnic and socioeconomic variations in receiving (1) comprehensive prenatal health education and (2) education about human immunodeficiency virus (HIV) testing, breastfeeding, alcohol, and smoking cessation from health care practitioners. Methods: Data were drawn from the 2012 to 2014 Pregnancy Risk Assessment Monitoring System (PRAMS). Twenty‐seven states were included with an analysis sample size of 68 025 participants. Receiving counseling on all listed health topics during prenatal care visits was denoted as comprehensive prenatal health education. Logistic regression was used to examine the association of racial or ethnic and socioeconomic variables with receiving comprehensive prenatal health education, and HIV testing, breastfeeding, alcohol, and smoking cessation advice separately. Results: Multivariable results showed that racial or ethnic minorities and women with a high school degree or less; receiving Women, Infant, and Children (WIC) assistance; and on Medicaid during pregnancy have higher odds of receiving comprehensive prenatal health education (all P  ≤0 .001). Results were similar for receiving HIV testing, breastfeeding, alcohol, and smoking counseling. Low household income was associated with receiving counseling on HIV testing, alcohol, and smoking (all P ≤ 0.001). Conclusion: Despite reporting higher levels of prenatal health education on a variety of health‐related topics, disadvantaged women continue to experience disparities in adverse birth outcomes suggesting that education is insufficient in promoting positive behaviors and birth outcomes. [ABSTRACT FROM AUTHOR]

Purpose: The United Nations Convention on the Rights of Persons with Disabilities aims to protect the human rights and dignity of all people with disabilities. In low-and middle-income countries (LMICs), one way this goal is pursued is through Community-Based Rehabilitation (CBR), a strategy to support the full and equal participation of people with disabilities. In spite of policy and community-based interventions, people with disabilities continue to experience inequities in many areas of life - one of these being their sexual and reproductive health (SRH) rights. This scoping review explored the literature to understand how CBR programming has supported sex(uality), sexual abuse prevention, and SRH for people with disabilities. Methods: Arksey and O'Malley's (2007) framework was used to identify relevant studies in academic and grey literature. This included six databases, the WHO website, and five Regional CBR Network websites. Relevant studies were selected using criteria and data was charted to examine the quantity, variation, and nature of CBR interventions. Results: Fifteen studies were identified. The majority were implemented in Africa; targeted all people with disabilities, regardless of gender, age, or type of disability; and frequently focussed on the topic of HIV/AIDS. The interventions were most commonly designed to educate people with disabilities on issues of sex(uality), sexual abuse prevention, or SRH. Conclusion: A number of studies discussed CBR programmes that aim to support sex(uality), sexual abuse prevention and SRH for people with disabilities, yet gaps were identified that indicate that certain populations and topics are being overlooked by CBR interventions. Implications: CBR practitioners can focus on filling the gaps identified in this review through future programming. Further action must concentrate on implementing a variety of CBR Matrix strategies to address comprehensive issues related to sex(uality), sexual abuse prevention, or SRH. [ABSTRACT FROM AUTHOR]

Pre-exposure prophylaxis (PrEP) has the potential to be an empowering HIV prevention tool among female sex workers (FSW), yet little is known about PrEP awareness and interest in this population. Sex workers and Police Promoting Health in Risky Environments (SAPPHIRE) is a prospective cohort study of street-based FSW in Baltimore, MD. A cross-sectional analysis explored awareness and interest in PrEP among HIV-negative FSW. Multivariable Poisson regressions modeled associations between individual, interpersonal, and structural variables and PrEP awareness and interest. Of n = 232 FSW, 66% were white, half were less than 35 years old, 59% injected drugs daily, and 66% sold sex daily. Only 21% of FSW were aware of PrEP, though 74% were interested. PrEP awareness was associated with experiencing client condom coercion [adjusted incidence rate ratio (aIRR) = 0.50, 95% CI: 0.28–0.90] and condomless sex with an intimate partner (aIRR = 0.54, 95% CI: 0.30–0.98). PrEP interest was associated with perceiving PrEP as "very easy" to take (aIRR = 1.91, 95% CI: 1.49–2.45) and moving to an unfamiliar geographic area to sell sex (aIRR = 1.20, 95% CI: 1.04–1.39). Women who had a current gonorrhea or chlamydia infection were less likely to be interested in PrEP (aIRR = 0.75, 95% CI: 0.59–0.95). Though PrEP awareness among FSW is low, there are FSW who are significantly more likely to express interest in PrEP and outreach efforts should target these women. Results suggest that women-controlled HIV prevention methods may be important for reducing incidence among FSW. [ABSTRACT FROM AUTHOR]

BACKGROUND: Health educators in public high schools can provide educational interventions to reduce teen unintended pregnancy and sexually transmitted infections (STIs). Characteristics of teachers and schools influence their decision to provide condom education. Studies to determine characteristics must be conducted so HIV/sex education can be improved. If schools do not participate in these studies, barriers must be identified so researchers can collect sufficient data to produce information for curriculum reform. METHODS: A study was conducted to identify teacher characteristics that influence their decision and intention to provide appropriate condom education. Follow‐up e‐mails were sent to administrators who opted out of the study to request more information about their decision to not participate. All responses were submitted via e‐mail correspondence. RESULTS: Six superintendents and 6 principals provided a reason for their decision to opt out. Superintendents cited being busy with district initiatives, time constraints, and lack of interest in participating in the study as reasons they did not wish to participate. Principals cited competing requests for participation in research, participation in other surveys, and time constraints. CONCLUSIONS: Securing administrative approval for human sexuality research is challenging. Administrators contend with many priorities, do not wish to overburden teachers, consider participation in voluntary research as a low priority, and may be more likely to respond to telephone requests. Administrators may not want to disclose that human sexuality or HIV education courses may not be taught by certified or qualified health educators. [ABSTRACT FROM AUTHOR]

We examined factors associated with HIV self-testing (HIVST) willingness among male ever-testers and never-testers who participated in a midpoint survey of a cluster randomized controlled HIV prevention trial in Dar es Salaam. Linear mixed binary logistic regression models were constructed to examine factors (demographic, HIV risk behavior, and sexual/social network) associated with willingness to self-test. Sixtyseven percent of 301 never-testers were willing to self-test for HIV compared to 72% 577 of ever-testers. Among never-testers, having discussed testing for HIV with a sexual partner was the only factor associated with HIVST willingness (2.36, 95% CI: 1.35-4.15). For evertesters, younger men were less willing to self-test than older men while men with higher education were more willing to self-test than less educated men. Having a moderate/great HIV risk perception decreased the odds of HIVST willingness relative to no risk perception (0.40, 95% CI 0.23-0.70) for ever-testers. Discussing HIV testing with a sexual partner and having been encouraged to test for HIV by a friend were associated with higher odds of being willing to self-test (2.22, 2.23; 95% CI 1.34-3.67, 1.14-4.39, respectively) among ever-testers. These findings suggest that HIVST willingness is highly acceptable among both male ever-testers and never-testers. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to assess the level of HIV/AIDS knowledge and sexual activity among secondary school students, and to offer specific intervention strategies. Materials and Methods: Random sampling technique was used and cross-sectional study was conducted among 6347 students using self-administered questionnaire. Results: The ages of participants range from 9 to 21 years with a mean of 14.83±1.63 years. Of 6347 students, 3214 (50.6%) were female. Results showed that 65% of male and 71% of female had been pornography reader Overall, the prevalence of knowledge on HIV caused by virus was high for male and female. On intimate contact, 25.7% of the male and 17.7% of the female students reported that they had a history of hugging; 11.3% of male and 5.6% of female students reported that they had an experience of kissing; 11.3% of male and 4.0% of female students reported that they had an experience of caressing, 27% of male and 18% of female students reported that they had an experience of sexual intercourse; and 49.5% of male and 58.4% of female students reported to have been forced to have sex. Accordingly, 75.1% of male and 90% of female students heard of HIV. Conclusion: Education of the students on HIV /AIDS seems poorer at the secondary school in certain areas of China; more attention should be paid to those of senior grade students and students from divorced families. [ABSTRACT FROM AUTHOR]

Physical and sexual assault are potential risk factors for HIV/AIDS. Little is known about whether assault victims get tested for HIV/AIDS. The purpose of this study was to examine whether victims of sexual assault are more likely to get tested for HIV if they had education about the virus prior to attack. A secondary data analysis of the 2015 Youth Risk Behavior Survey (YRBS) was used to explore the relationship among female victims of date or sexual assault, HIV testing, and education. HIV education, testing, and date and sexual assault were statistically related. A small percentage of students reported being forced to have sex (n=717; 10.8%) and experienced date assault (n=706; 10.6%). Of all female high school students who took the survey, 85% (n=5,512) had been educated about HIV at some point in their lives. However, only 992 (16.2%) of the young women who participated in the survey had reported getting tested for HIV. Victims were more likely to get tested for HIV. This study provides information for changes in HIV education to adolescents. [ABSTRACT FROM AUTHOR]

For persons living with HIV and AIDS (PLWHA), care by an HIV-specialist improves outcomes and satisfaction with one's HIV primary care provider (PCP) promotes engagement with care. In the United States, we are facing a workforce shortage of HIV providers. As we aim to train a new generation of HIV providers, it is unclear how PLWHA perceive their experience when cared for by trainees compared to experienced providers. Therefore we assessed patient satisfaction with HIV providers, both trainees in an HIV Primary Care residency program and HIV-specialists. A secondary objective was to evaluate providers' performance in adhering to standard management guidelines for HIV-associated and non-HIV-associated conditions. We surveyed 75 PLWHA, including 51 (68%) assigned to an HIV-specialist PCP and 24 (32%) to a trainee PCP. Overall patient satisfaction on a 10-point scale was similar (mean 9.6 HIV-specialist vs 9.7 trainee, p = 0.71) and remained similar in multivariate logistic regression analysis when controlling for patient age, gender, race, and recently establishing care (Odds Ratio 1.1, 95% Confidence Interval 0.3-5.0). Participants in the trainee group were more likely to feel their provider "always" spent enough time with them (100% vs 81%, p = 0.03). Adherence to HIV guidelines was similar, though trainees were more likely to document counseling on risk reduction (83% vs 47%, p = 0.005) and adherence to antiretroviral therapy (100% vs 66%, p = 0.001). In conclusion, in a structured HIVtraining program, residents can provide subspecialty level care in an HIV continuity clinic with levels of performance and patient satisfaction equivalent to those of experienced specialists. [ABSTRACT FROM AUTHOR]

Botswana is the world's second HIV heavily affected country, with an average HIV prevalence of 17.6% in 2013. The data used for this study are from Botswana AIDS Impact Surveys, I-IV, which are nationally representative sample surveys conducted in 2001, 2004, 2008 and 2013 respectively by the Central Statistics Office and the National AIDS Coordinating Agency. The purpose of this study was to investigate the levels, trends and factors associated with misconceptions about HIV transmission among adolescents. Both descriptive statistics and binary logistic regression analysis were used to address the study objectives. Overall the levels of HIVrelated misconceptions among adolescents showed a declining trend over time, even though this trend is not consistent across the various misconception variables. The statistically significant factors influencing misconceptions were primary or lower education and being male in three surveys out of the four surveys. The study results show that despite major intervention aimed at behaviour change, myths and misconceptions about HIV transmission remain. Therefore, the intensification of the information, education and communication campaigns aimed at dispelling misconceptions are required, particularly aimed at the less educated and male adolescents. [ABSTRACT FROM AUTHOR]

Increases in HIV prevalence indicate ongoing need for HIV interventions. A brief manualized intervention called the Texas Christian University (TCU) WaySafe, which addresses multiple HIV risks, was further evaluated to determine how it addressed individual's knowledge deficiencies in the assessed risks. The sample of 1,256 offenders in eight correctional substance abuse treatment programs participated either in treatment as usual (TAU) or TCU WaySafe. From multivariate multilevel analysis, WaySafe was more effective in improving the greatest need area, whether knowledge, motivation, or confidence regarding HIV risky behaviors. Findings underscored the importance of addressing HIV risk areas with the greatest need for change and strengthens previous findings of the intervention's potential for individuals with varying HIV risks. [ABSTRACT FROM AUTHOR]

The Health Resources and Services Administration Special Projects of National Significance launched the Systems Linkage and Access to Care for Populations at High Risk of HIV Infection Initiative in 2011. Six state departments of health were funded to utilize a modified Learning Collaborative model to develop and/or adapt HIV testing, linkage to care and retention in care system-level interventions. More than 60 Learning Sessions were held over the course of the Learning Collaborative. A total of 22 unique interventions were tested with 18 interventions selected and scaled up. All interventions were created to impact services at a systems level, with standardized protocols developed to ensure fidelity. Our findings provide key lessons and present considerations for replication for use of a modified Learning Collaborative to achieve state-level systems change. [ABSTRACT FROM AUTHOR]

The updated National HIV/AIDS Strategy recommends widespread HIV education and testing and calls the faith community to assist in these efforts. Yet, limited information exist on church-based HIV testing interventions. This study examined feasibility and assessed HIV testing outcomes of Taking It to the Pews (TIPS), a multilevel HIV education and testing intervention. Four African American churches were matched and randomized to TIPS or a standard-information control arm. Intervention churches delivered the religiously-tailored TIPS Tool Kit, which included educational materials to individuals and ministry groups; pastoral activities (e.g., sermons preached, receipt of HIV testing role-modeled), responsive readings, and church bulletin inserts in church services; and HIV testing during church services and church outreach events. All churches delivered 2-3 tools/month and coordinated 3 HIV testing events. At 12 months, significant increases in receipt of HIV testing (59% vs. 42%, p = 0.008), and particularly church-based testing (54% vs. 15%, p < 0.001), relative to controls were found. TIPS has great potential to increase reach, feasibility, and impact of HIV testing in African American churches. [ABSTRACT FROM AUTHOR]

The article discusses the strategies to address HIV infection in marginalized communities in Vancouver with targeted outreach, education, and point-of-care testing. Topics include HIV-infected People who use drugs (PWUD) face additional challenges associated with suboptimal therapeutic outcomes with delayed antiretroviral treatment (ART) initiation that may lead to disease progression and death; and education-based interventions have shown promise in reducing stigma as well as risk behaviors.

Persistent Human Immunodeficiency Virus (HIV) prevalence rates remain a challenge, particularly because health care providers (HCP) are not fully prepared to engage in HIV care. This hesitancy to engage creates access to care barriers for people living with HIV (PLWH). We conducted a systematic review to identify educational interventions focused on developing HIV competencies in higher education across health science disciplines. We searched databases for primary studies focused on interventions. Using PRISMA guidelines, we identified 20 articles from 19 distinct studies. While there was an overwhelming body of literature that assessed knowledge, skills, and attitudes in health sciences students on HIV and AIDS, the low number of intervention studies was notable. With the exception of two studies, PLWH were not included in the interventions. This finding stands in sharp contrast to the well-established Greater Involvement of People Living with HIV and/or AIDS (GIPA) and Meaningful Engagement of People Living with HIV and/or AIDS (MEPA) principles. The primary means of the educational intervention was focused on delivering lectures to address HIV and AIDS knowledge for HCP. There was a significant lack of focus on historical, cultural, policy and legal contexts of HIV and AIDS care; theoretical justifications for the interventions were absent. No study focused on the impact of an intervention on the care provided to PLWH by HCP after graduation. There is an urgent need to develop long-term sustainable and scalable interventions that address the consistently identified lack of knowledge and skills, and stigmatizing attitudes of HCP and students. [ABSTRACT FROM AUTHOR]

Sub-Saharan Africa carries a high burden of the HIV epidemic, with young adults being particularly affected. Well-designed school-based HIV prevention interventions can contribute to establishing protective behaviour. The aim of this study was to explore the needs of primary school students and teachers in the region of Kagera, Tanzania, regarding an HIV prevention intervention in the primary school setting. The needs assessment was structured according to the PRECEDE component of the PRECEDE–PROCEED model. Qualitative data was collected in six focus group discussions with primary school students and teachers. Key informant interviews with seven experts were conducted. We employed qualitative content analysis to analyse data in MAXQDA. The findings suggest that teachers need to be adequately trained to provide HIV and sex education and to support HIV-positive students. Enabling structural factors, such as an appropriate syllabus, are required. Stigmatization has been reported a major barrier to HIV prevention in schools. Teachers and students identified a more trustful relationship between each other as well as to legal guardians of children as a basis for HIV prevention. These findings will inform the development of a tailored HIV prevention intervention. [ABSTRACT FROM AUTHOR]

The Health Resources and Services Administration's Ryan White HIV/AIDS Program (RWHAP) supports direct health care treatment and support services to more than 50% of all people living with diagnosed HIV in the United States. A critical goal of the RWHAP is to reduce HIV-related health disparities to help end the HIV epidemic. From 2010 through 2016, the RWHAP made significant progress reducing viral suppression disparities among client populations, particularly among women, transgender persons, youths, Blacks or African Americans, and unstably housed clients. To assist with the reduction of the remaining disparities in HIV-related health outcomes among clients, the RWHAP continues to support planning and resource allocation for RWHAP Parts A through D and AIDS Drug Assistance Program, as well as through implementing policy and program initiatives, Special Projects of National Significance, evaluation studies, and collaborations to disseminate effective interventions. [ABSTRACT FROM AUTHOR]

Gay, bisexual, and other men who have sex with men (gbMSM) are at the highest risk for HIV infection in British Columbia (BC). Pre-exposure prophylaxis (PrEP) has been recently licensed but is currently not publicly funded in BC. Using respondent-driven sampling, we recruited a cohort of gbMSM to complete a computer-assisted self-interview with follow-up every 6 months. Stratified by HIV status, we examined trends in awareness of PrEP from 11/2012 to 02/2016 and factors associated with PrEP awareness. 732 participants responded to the PrEP awareness question. Awareness of PrEP among HIV-negative men increased from 18 to 80% (p < 0.0001 for trend); among HIV-positive men, awareness increased from 36 to 77% (p < 0.0001). PrEP awareness was associated with factors related to HIV risk including sero-adaptive strategies and sexual sensation seeking. Eight HIV-negative men reported using PrEP. Low PrEP uptake highlights that PrEP access should be expanded for at-risk gbMSM in BC. [ABSTRACT FROM AUTHOR]

A 33-minute dramatic production, Do You Know?, was written and produced using episodic framing to create a storyline around several college students and the potential spread of HIV/AIDS. This edutainment project was also constructed using exemplars to present key health messages that show the importance of getting tested, knowing your status and protecting yourself in personal relationships. Study participants over 18 years old watched Do You Know? on the Internet (Facebook or YouTube) and completed a survey. Study participants under 18 years old watched the video as part of a focus group, completed the survey, and then participated in a 30-min discussion. The findings of this study suggest that edutainment and the Internet can be effective in reaching African Americans with important health information. [ABSTRACT FROM AUTHOR]

HIV/AIDS continues to impact communities of color at disproportionate rates. The Black church remains the most influential institution in the African-American community. This single institution has the power to influence stigma and beliefs needed to change perceptions about persons and families directly impacted by this disease. This research brief utilizes the Theory of Innovation as a framework to describe a training designed to prepare clergy to be the catalyst to influence their congregation and surrounding community about the importance of developing a response to HIV/AIDS. The training described prepared congregational faith leaders with suggestions for developing sermons as well as practical suggestions to help contextualize the reasons that the church is critical in the development of a response to the elimination of HIV in the African-American community. [ABSTRACT FROM AUTHOR]

Religious congregations play an important role in HIV prevention and care. However, most research on congregation-based HIV activities has focused on prevention. Using data from a nationally representative survey of U.S. congregations, this study found that 18.6% of congregations were engaged in some type of HIV activity; 8.7% engaged in prevention; 7.6% offered support to people with HIV; 7.4% raised awareness; and 7.6% provided donations for other organizations' HIV activities. Among congregations that participate in some type of HIV activities, having more educated clergy is associated with higher odds of engaging in support, raising awareness, and giving donations relative to prevention activities. Being a predominantly African-American congregation is associated with lower odds of these other three types of HIV activities compared to prevention activities. Understanding the factors associated with specific types of HIV activities helps inform policy and practice related to congregation-based HIV programming. [ABSTRACT FROM AUTHOR]

AIDS has become a major health care problem in India with an estimated 34 million people suffering from the condition, representing the largest number of any country in the world. Hence it is necessary to assess the knowledge on aids among the adult population to establish preventive strategies'. Objectives: To assess the knowledge on AIDS/HIV among the adult out patients at SRM General Hospital, Kattankulathur. To associate the knowledge on AIDS/HIV among the adult out patients with their demographic variables. Method: A Cross-sectional study was conducted at SRM General Hospital, Kattankulathur, during the month of December 2017. Data was collected from the patients who attended the out patients department. Above 20 years-40 years of aged patients were included in this study. Self structured interview questionnaire was used to collect the data. Using The participants were educated with video programme and posters SPSS version -16 the data was analyzed, frequencies were calculated and values were determined to find the victim between the variables. Result: The result of the study concludes that (26% ) outpatients were having poor knowledge (60% ) of outpatients with moderate knowledge and (14% ) outpatients with high level knowledge regarding AIDS. There was no significant association found between the knowledge on AIDS and with the demographic variables conclusion: The present study on knowledge on AIDS/HIV among adult population concludes AIDS is prevalent among adult population in all regions. There is an urgent need to educate the patient with handout and posters to create awareness about transmission and management of AIDS. [ABSTRACT FROM AUTHOR]

We aim to understand the difference in stigma and discrimination, in particular sexual rejection, experienced between gay and heterosexual men living with HIV in the UK. The People Living with HIV StigmaSurvey UK 2015 recruited a convenience sample of persons with HIV through over 120 cross sector community organisations and 46 HIV clinics to complete an online survey. 1162 men completed the survey, 969 (83%) gay men and 193 (17%) heterosexual men, 92% were on antiretroviral therapy. Compared to heterosexual men, gay men were significantly more likely to report worrying about workplace treatment in relation to their HIV (21% vs. 11%), worrying about HIV-related sexual rejection (42% vs 21%), avoiding sex because of their HIV status (37% vs. 23%), and experiencing HIV-related sexual rejection (27% vs. 9%) in the past 12 months. In a multivariate logistic regression controlling for other sociodemographic factors, being gay was a predictor of reporting HIV-related sexual rejection in the past 12 months (aOR 2.17, CI 1.16, 4.02). Both gay and heterosexual men living with HIV experienced stigma and discrimination in the past 12 months, and this was higher for gay men in terms of HIV-related sexual rejection. Due to the high proportion of men reporting sexual rejection, greater awareness and education of the low risk of transmission of HIV among people on effective treatment is needed to reduce stigma and sexual prejudice towards people living with HIV. [ABSTRACT FROM AUTHOR]

Integrated Access to Care and Treatment (I ACT) for adolescents is an educational support group initiative conducted monthly by trained healthcare providers (counsellors/health promoters). It follows a defined educational curriculum of six topics including, HIV/AIDS, disclosure, sexual and reproductive and mental health. Qualitative assessments, conducted midway of I ACT implementation at four primary healthcare facilities in North West province, South Africa, aimed to explore the perceptions of healthcare providers and the experiences of adolescents living with HIV (ALHIV). Face-to-face interviews were conducted with healthcare providers (n = 4), Facility Managers (n = 4) and ALHIV 15-19 years (n = 15). Interviews were recorded, transcribed, translated, verified and a content analysis performed. ALHIV reported the benefit and educational value of I ACT support groups. Healthcare providers shared their experience with initiating the groups and Facility Managers highlighted implementation challenges. In this study I ACT for adolescents supported ALHIV needs and promoted engagement with healthcare providers and peers. Sustaining I ACT for adolescents will require additional health system strengthening like provision of human and material resources. [ABSTRACT FROM AUTHOR]

Aims and Objectives: To review the literature regarding PrEP and sexual behaviour change in MSM. Background: Pre‐exposure prophylaxis for HIV has been available since 2012. Even so, pre‐exposure prophylaxis has not been widely accepted among healthcare providers and men who have sex with men some of whom are convinced that pre‐exposure prophylaxis decreases condom use and increases sexually transmitted infections. Design: A systematic review of the state of the evidence regarding the association of pre‐exposure prophylaxis with condom use, sexually transmitted infection incidence and change in sexual risk behaviours in men who have sex with men. A structured search of databases resulted in 142 potential citations, but only 10 publications met inclusion criteria and underwent data abstraction and critical appraisal. Methods: An adapted Cochrane Collaboration domain‐based assessment tool was used to critically appraise the methodological components of each quantitative study, and the Mixed Methods Appraisal Tool was used to critically appraise qualitative and mixed‐methods studies. Results: Condom use in men who have sex with men using pre‐exposure prophylaxis is influenced by multiple factors. Studies indicate rates of sexually transmitted infections in treatment and placebo groups were high. Pre‐exposure prophylaxis did not significantly change sexually transmitted infection rates between baseline and follow‐up. Reporting of sexual risk improved when questionnaires were completed in private by clients. Our review found that pre‐exposure prophylaxis may provide an opportunity for men who have sex with men to access sexual health care, testing, treatment and counselling services. We did not find any conclusive evidence that pre‐exposure prophylaxis users increase sexual risk behaviours. Conclusion: The perception among healthcare providers that pre‐exposure prophylaxis leads to increased sexual risk behaviours has yet to be confirmed. In order to provide effective sexual health services, clinicians need to be knowledgeable about pre‐exposure prophylaxis as an HIV prevention tool. Relevance to clinical practice: In an era where HIV prevention methods are rapidly improving, strategies for sexually transmitted infection testing, treatment, counselling and prevention remain vital to improve health. All healthcare providers are uniquely positioned to promote sexual health through the dissemination of accurate information. [ABSTRACT FROM AUTHOR]

This article describes the influence of a peer education programme on skills development among 22 women participating in HIV prevention trials. Interviews were used to collect data on peer educator experiences and their opinions of the trainings. The training enhanced their agency and confidence to engage their family and community on health promotion, including HIV prevention research procedures, thus improving their self-esteem and communication skills. Training and partnering with clinical trial participants as peer educators is an effective and sustainable community-based approach for HIV prevention. [ABSTRACT FROM AUTHOR]

We conducted a systematic review of safer conception strategies (SCS) for HIV-affected couples in sub-Saharan Africa to inform evidence-based safer conception interventions. Following PRISMA guidelines, we searched fifteen electronic databases using the following inclusion criteria: SCS research in HIV-affected couples; published after 2007; in sub-Saharan Africa; primary research; peer-reviewed; and addressed a primary topic of interest (SCS availability, feasibility, and acceptability, and/or education and promotion). Researchers independently reviewed each study for eligibility using a standardized tool. We categorize studies by their topic area. We identified 41 studies (26 qualitative and 15 quantitative) that met inclusion criteria. Reviewed SCSs included: antiretroviral therapy (ART), pre-exposure prophylaxis, timed unprotected intercourse, manual/self-insemination, sperm washing, and voluntary male medical circumcision (VMMC). SCS were largely unavailable outside of research settings, except for general availability (i.e., not specifically for safer conception) of ART and VMMC. SCS acceptability was impacted by low client and provider knowledge about safer conception services, stigma around HIV-affected couples wanting children, and difficulty with HIV disclosure in HIV-affected couples. Couples expressed desire to learn more about SCS; however, provider training, patient education, SCS promotions, and integration of reproductive health and HIV services remain limited. Studies of provider training and couple-based education showed improvements in communication around fertility intentions and SCS knowledge. SCS are not yet widely available to HIV-affected African couples. Successful implementation of SCS requires that providers receive training on effective SCS and provide couple-based safer conception counseling to improve disclosure and communication around fertility intentions and reproductive health. [ABSTRACT FROM AUTHOR]

The effectiveness of peer leaders in promoting health may depend on the position they occupy within their social networks. Using sociocentric (whole network) and behavioral data from the intervention arm of a cluster-randomized HIV prevention trial in Dar es Salaam, Tanzania, we used generalized linear models with standardized predictors to examine the association between heath leaders’ baseline structural network position (i.e., in-degree and betweenness centrality) and their 12-month self-reported (1) confidence in educating network members about HIV and gender-based violence (GBV) and (2) number of past-week conversations about HIV and GBV. As in-degree centrality increased, leaders reported fewer HIV-related conversations. As betweenness centrality increased, leaders reported greater number of conversations about GBV. Network position was not significantly associated with confidence in discussing either topic. Our results suggest that peer leaders who occupy spaces between sub-groups of network members may be more effective in engaging their peers in sensitive or controversial topics like GBV than more popular peer leaders. [ABSTRACT FROM AUTHOR]

This study developed a computer-based program to teach HIV prevention behaviors and raise awareness of pre-exposure prophylaxis (PrEP) among individuals at risk for HIV. The program was divided into modules containing educational material and multiple-choice questions. Participants received immediate feedback for responses and incentives for correct responses to multiple-choice questions. Participants trained on each module until they met speed and accuracy criteria. The modules were divided into: Course 1 (HIV), Course 2 (PrEP), and Course 3 (HIV risk behaviors). Tests of content from all three courses were delivered before and after participants completed each course. Test scores on the content delivered in the courses improved only after participants completed training on each course. HIV and PrEP knowledge was initially low and increased following completion of each part of the program. Computer-based training offers a convenient and effective approach to promoting HIV prevention knowledge, including use of PrEP. [ABSTRACT FROM AUTHOR]

Clinician-delivered HIV prevention interventions are common and often effective but have small reach, particularly in remote, rural, or sparsely populated areas. Electronic health (eHealth) interventions may be an efficient alternative to providing HIV prevention to geographically dispersed or traditionally hard-to-reach populations, though eHealth interventions tend to have high start-up costs. We present cost data from a video-based eHealth intervention, Sex Positive!, among 1,208 U.S. gay, bisexual, and other men who have sex with men living with HIV. Specifically, we provide estimates for the cost of the intervention, overall, and per participant based on funding amounts. The total average cost per participant was $1,021. Sensitivity analyses demonstrated that reaching more participants would greatly reduce the average cost per participant. Findings indicate that the cost per person engaged in an eHealth HIV intervention is consistent with previous studies, and that further scaling up would greatly reduce the cost while increasing reach. [ABSTRACT FROM AUTHOR]

Background Using data from a large internet-based survey of European men having sex with men (MSM), we assessed factors associated with HIV testing and reasons for dissatisfaction with HIV testing and counselling among Hungarian MSM. Methods A total of 2052 Hungarian MSM provided evaluable data for the European MSM Internet Survey (EMIS) in 2010. χ2 tests and Poisson regression with a robust variance estimator were used to assess factors associated with HIV testing and dissatisfaction with HIV testing and counselling. Results A total of 42.1% of MSM reported never being testing for HIV. Over one-half of men (54.1%) who reported condomless anal intercourse (CAI) in the prior 12 months with a person of unknown or sero-discordant HIV status reported no lifetime HIV testing. The factor most strongly associated with dissatisfaction with HIV testing and counselling was test site with increased dissatisfaction with inpatient hospital settings vs. community-based organizations. Both lack of HIV testing and dissatisfaction with testing were independently associated with MSM who reported that no one, or only a few people, knew they were attracted to men. Conclusions Lack of HIV testing was strongly associated with CAI. MSM reported that community-based organizations better supported confidentiality and were more respectful during HIV testing. [ABSTRACT FROM AUTHOR]

Adherence to antiretroviral medication among people living with HIV (PL-HIV) is critical to individual and public health. By some estimates only a quarter of PL-HIV are sufficiently adherent, underscoring a continued need for adherence-promoting strategies. In this analysis we explore the effect of adherence education posters developed via Photovoice. A group of PL-HIV generated images and captions to describe their adherence experiences and used their photo-stories to design 10 posters. We assessed viewers’ (N = 111) adherence knowledge, self-efficacy, and communication changes quantitatively and qualitatively before and 3 months after poster placement in the clinic. We analyzed quantitative data with an independent groups t test or a Mann–Whitney test, and qualitative interviews via theme analysis. Quantitative findings indicated no significant differences. Qualitative interviewees said that posters enhanced knowledge with nonthreatening, relatable information; self-efficacy by motivating patients to take medicine and disclose HIV to others; and communication by facilitating adherence conversations and creating a visually supportive clinic. Divergent quantitative and qualitative findings can be partially explained by inquiry methods. The posters may be more effective as part of discussions about their content, like those facilitated by qualitative interviews. Additional research regarding the application of Photovoice to health promotion is warranted. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: The UNAIDS 90‐90‐90 targets to diagnose 90% of people living with HIV, put 90% of them on treatment, and for 90% of them to have suppressed viral load have focused the international HIV response on the goal of eliminating HIV by 2030. They are also a constructive tool for measuring progress toward reaching this goal but their utility is dependent upon data availability. Though more than 25% of new infections are among key populations (KP)‐ sex workers, men who have sex with men, transgender people, people who inject drugs, and prisoners‐ and their sex partners, there is a dearth of treatment cascade data for KP. We assess the availability of cascade data and review the opportunities offered by biobehavioral and programme data to inform the HIV response. Discussion: The emphasis on the collection of treatment cascade data among the general population in higher prevalence countries has not led to a similar increase in the availability of cascade data for KP. The limited data available for KP highlight large gaps in service uptake across the cascade, particularly in the first 90, awareness of HIV status. Biobehavioral surveys (BBS), with linked population size estimation, provide population‐based data on the treatment cascade and should be conducted every two to three years in locations with services for KP. With the inclusion of viral load testing, these surveys are able to monitor the entire treatment cascade among KP regardless of whether these populations access HIV services targeting the general population or KP. BBS also reach people accessing services and those who do not, thereby providing a unique opportunity to learn about barriers to service uptake including stigma and discrimination. At the same time high‐quality programme data can play a complementary role in identifying missed opportunities that can be addressed in real‐time. Conclusions: Data are more important than ever for guiding the HIV response toward reaching 90‐90‐90 targets and eliminating HIV, particularly in the face of decreased funding for HIV and specifically for KP. Timely high‐quality BBS data can be triangulated with high‐quality programme data to provide a comprehensive picture of the epidemic response for KP. [ABSTRACT FROM AUTHOR]

Objectives High adherence is needed to maintain antiretroviral therapy efficacy. Few attempts at therapeutic patient education (TPE) have been made in sub-Saharan Africa. We describe patients’ achievements before intervention and identified needs, TPE programme implementation and evaluation, and patients’ satisfaction. Methods The TPE programme was proposed to patients in the ANRS-12286/MOBIDIP trial. Beforehand, a directory of competences to manage HIV infection was designed. Patients’ HIV-related knowledge and skills assessment was realised, leading to an educational contract. Evaluation was performed using a standardised collection form and a satisfaction survey. Results Of 154 patients, 146 underwent TPE. During a median of 1.8 years, 47% of patients had ≥3 consultations. Educational assessment revealed limited knowledge about HIV disease. Conversely, patients had frequently managed issues of adherence or disclosure. A median of 12 objectives were considered per patient, and 75% were attained. Objectives from the cognitive domain were less frequently attained. Patients appeared satisfied with the intervention: more emphasis was placed on psycho-affective aspects or experience-sharing than on the acquisition of knowledge. Conclusion Active listening, know-how and a space for discussion appear more important for patients than knowledge on disease or treatments. Practice implications In HIV care, the directory of learning objectives should be revised to include more objectives concerning practical skills for disease management. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis (TB), common among the poor in developing countries, can be difficult to cure due to poor treatment adherence. This study aims to develop and evaluate the effectiveness of photovoice in improving TB knowledge, attitude, practice, self-efficacy, and treatment outcome among TB patients in Specialist Hospital Sokoto, Nigeria. Materials and Methods: A double-blinded randomized trial to determine the effectiveness of photovoice among newly diagnosed TB patients in Specialist Hospital Sokoto, Nigeria. Participants of the photovoice are to be compared with a control group who will receive an HIV health education. Both the participants and assessors will be blinded to the participation status of the patients (photovoice or control group). The study is to last for 6 months. Two hundred newly diagnosed TB patients will be recruited for the study. Structured and closed- ended questionnaires will be used to obtain data for the study. The primary end-points are TB knowledge, attitude, practice, and treatment outcome, while self-efficacy is the secondary endpoint. Results: The participants of photovoice are expected to have more mean scores in knowledge, attitude, practice, self-efficacy and successful treatment compared with the control group. Conclusion: The photovoice intervention will be more effective in improving TB knowledge, attitude, practice, self-efficacy, and treatment outcome among the patients to be studied. [ABSTRACT FROM AUTHOR]

Youths are disproportionately affected by HIV infection. This article presents the achievements and implications of HIV Programme Development Project among Out-of-School Youths (OSY) in Osun State, Nigeria. A total of 5934 peer educators from randomly selected areas of the State were trained. The Minimum Prevention Package for Intervention (MPPI) strategy including structural, behavioural and biomedical interventions was used. Data from DHIS2 platform was analysed with Microsoft Excel and qualitative interviews with the stakeholders was reported. Two hundred and sixty-three community dialogues were held within the period of the project with 2406 participants and 27,449 peers recruited by the peer educators. A total of 15,984 OSY were counselled, tested and received results for HIV and 167 (1.05%) of them tested positive to HIV infection. There is a need to scale-up this programme in Osun State and efforts at reaching the OSY based on MPPI should be intensified. [ABSTRACT FROM AUTHOR]