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Rates of HIV diagnoses among young Black and Latino sexual minority men (SMM) have continued to increase since 2011; meanwhile, overall rates in the USA have decreased. Despite their importance, academic and medical institutions have often struggled to engage and recruit racial and ethnic minority SMM in HIV prevention services and research. The current study compares the success of two strategies for recruiting racial and ethnic minority SMM. Recruitment occurred in the context of a larger implementation study testing the effectiveness of a substance use and HIV prevention intervention among SMM at high risk for HIV infection. SMM (n = 778) were reached through either (1) field-based outreach conducted by two local community-based organizations (CBOs) delivering the intervention or (2) online recruitment coordinated by the trial's academic research partner. Field-based recruitment reached a significantly larger proportion of Black (42.9% vs. 18.2% reached online) and Latino individuals (40.3% vs. 28.1% reached online). Although online recruitment reached a greater proportion of SMM who met trial eligibility criteria (58.4% vs. 35.3% for field-based outreach; χ

Cisgender men are frequently vectors for HIV transmission among transgender women. Despite this, the correlates of sexual risk among these men remain under-examined. The purpose of the present study was to explore potential differences in relationship characteristics, sexual risk-taking, and risk-reduction strategies among cisgender men partnered with transgender women. The study utilized secondary screening data provided by adult cis men who reported being in a primary relationship with a trans woman (N = 710). Gay men (18%) were comparatively older, and most likely to report both HIV seropositivity and committed pairings. Heterosexual men (14%) were more likely to report exchange sex, briefer relationships, extra-dyadic sex, lesser serostatus awareness or PrEP uptake. Queer men (7%) were youngest, and most likely to access PrEP. Heterosexual cis men with trans women partners may be subject to unique socio-cultural drivers of sexual risk, such as heteronormative pressures and relationship stigma.

Couples HIV Testing and Counseling (CHTC) is now a standard of care for partnered sexual minority men. While adolescent sexual minority men (ASMM; ages 15–19) face disproportionate HIV risk, the emergent nature of relationships and communication skills may present challenges to accessing and engaging in CHTC. This study utilized qualitative data from 28 ASMM recruited in 4 urban centers in the USA during the formative stage of Adolescent Trials Network study ATN-156. Participants were cis-male, HIV-negative, and in a relationship with a similarly-aged cis-male partner. Thematic analysis indicated low and high levels of commitment were barriers to CHTC. Concerns about caregiver attitudes towards HIV testing were salient. Adolescents’ perception of structural barriers highlighted reliance on caregiver resources, which limited access to sexual health services. Prevention programming must address structural barriers to access encountered by adolescents. ASMM in relationships may benefit from programming that includes options for individual and dyadic participation.

The association between “illicit drugs” (e.g., cocaine/crack, methamphetamine, gamma-hydroxybutyrate-GHB, ketamine, and ecstasy) and condomless anal sex (CAS) with casual partners is well established for sexual minority men (SMM). Recent evidence from adult SMM has indicated that marijuana is associated with the occurrence of CAS with casual partners above and beyond illicit drug use. The purpose of the current study was to evaluate associations between CAS and the use of marijuana and illicit drugs in a sample of young SMM (aged 15–24). Participants (n = 578) completed an online survey assessing demographics, current PrEP prescription, age, marijuana use, as well as drug use and sexual behavior in the past 90 days. A hurdle model simultaneously predicted the occurrence of CAS as well as the frequency of CAS among those reporting it. Illicit drug use was associated with both the occurrence (OR = 2.26; p = .01) and frequency of CAS (RR = 1.63; p = .02). In contrast, marijuana use was associated with the occurrence (OR = 1.69; p = .01), but not the frequency of CAS (RR = 1.07; p = .74). Findings mirror recent observations in large samples of adult SMM. While the effect size of marijuana is more modest than illicit drug use, marijuana does have significant and unique associations with the occurrence of CAS. HIV prevention services for young SMM may therefore benefit from assessing and addressing marijuana use in the context of HIV sexual behavior.

Although transgender women (TGW), and especially TGW of color, are disproportionately exposed to discrimination and violence, many of them experience stress-related growth. However, little is known about the experience of stress-related growth and its correlates among TGW. Using data from a racially-diverse sample of 210 TGW, the short version of the Stress-Related Growth Scale was modified to assess growth as a result of coming to terms with one's transgender identity among TGW. The psychometric properties of the modified scale were examined, along with its associations with various cognitive, emotional, and social factors. A confirmatory factor analysis revealed a unidimensional factor, along with excellent reliability. A stepwise regression revealed that positive reappraisal, internal locus of control, social support, and emotional expression were associated with greater stress-related growth. Findings suggest that cognitive, emotional, and social resources are related to stress-related growth in TGW. Interventions to foster stress-related growth among TGW are discussed.

Transgender women are disproportionately affected by HIV and experience high rates of depression and anxiety. The importance of secure attachment in buffering against negative sexual and mental health outcomes is well established. However, few studies have examined attachment among transgender women. We recruited a community-based convenience sample of 213 transgender women in New York City (

Purpose: Transgender women in the United States face elevated rates of HIV and of substance use. Studies measuring overall or aggregate levels of substance use have linked use to increased HIV transmission risk behavior (TRB). Although intensive longitudinal studies in other populations have found day-level links between substance use and TRB, no study has yet explored such links among transgender women. This study aimed to fill this gap in the literature. Methods: Utilizing survey and 60-day timeline follow-back interview data from a sample of 214 transgender women in New York City, we tested whether day-level heavy drinking, marijuana use, and/or nonprescription stimulant use were associated with odds of engaging in any sex (vs. no sexual activity) or engaging in TRB (vs. sex without TRB), adjusting for overall levels of use. Results: Multilevel models showed that each of the three substance types was associated with greater odds of engaging in sex on a given day—and more strongly so for heavy drinking among those with higher rates of heavy drinking, and for stimulant use among those with lower rates of stimulant use. Only marijuana use was associated with greater odds of TRB on a given day, but only among those with higher rates of use. Conclusion: These findings substantiate day-level links between substance use and engaging in sexual activity among transgender women, and importantly, between marijuana use and greater likelihood of TRB on a day when sexual activity occurs. This highlights the importance of addressing substance use for sexual health among transgender women especially focusing on marijuana use.

Persons with HIV (PWH) are a population at risk for adverse sequelae of opioid use. Yet, few studies have examined correlates of chronic high risk opioid use and its impact on HIV outcomes. Trends in prescribing patterns and identification of factors that impact the use of opioid prescriptions among PWH are crucial to determine prevention and treatment interventions. This study examined electronic medical records (EMR) of patients receiving HIV care to characterize prescribing patterns and identify risk factors for chronic high risk prescription opioid use and the impact on HIV outcomes among PWH in primary care from July 1, 2016–December 31, 2017. EMR were analyzed from 8,882 patients who were predominantly male and ethnically and racially diverse with half being 50 years of age or older. The majority of the 8,744 prescriptions (98% oral and 2% transdermal preparations) given to 1,040 (12%) patients were oxycodone (71%), 8% were morphine, 7% tramadol, 4% hydrocodone, 4% codeine, 2% fentanyl, and 4% were other opioids. The number of monthly prescriptions decreased about 14% during the study period. Bivariate analyses indicated that most demographic and clinical variables were associated with receipt of any opioid prescription. After controlling for patient socio-demographic characteristics and clinical factors, the odds of receipt of any prescription were higher among patients with pain diagnoses and opioid use and mental health disorders. In addition, the odds of receipt of high average daily morphine equivalent dose (MED) prescriptions were higher for patients with pain diagnoses. Lastly, patients with substance use disorders (SUD) had an increased likelihood of detectable viral load compared to patients with no SUD, after adjusting for known covariates. Our findings show that despite opioid prescribing guidelines and monitoring systems, additional efforts are needed to prevent chronic high risk prescriptions in patients with comorbid conditions, including pain-related, mental health and substance use disorders. Evidence about the risk for chronic high risk use based on prescribing patterns could better inform pain management and opioid prescribing practices for patients receiving HIV care.

Background Transgender youth demonstrate significantly higher rates of engagement in sexual risk behaviors relative to their cisgender or gender-conforming counterparts, including high rates of condomless anal intercourse and engagement in sex work. In addition, transgender youth experience increased physical or sexual abuse, victimization, substance use, mental health disorders, incarceration, and homelessness. Owing to these syndemic health disparities, transgender youth are at substantially increased risk of HIV infection. Objective This protocol aims to describe a randomized controlled trial (RCT), Adolescent Medicine Trials Network 160 TechStep (N=250), which assesses the differential immediate and sustained effects of each of 3 conditions (text messaging, WebApp, or information-only control) for reducing sexual risk behaviors and increasing pre-exposure prophylaxis (PrEP) uptake among high-risk, HIV-negative transgender youth and young adults (aged 15-24 years). Methods Participants will be recruited through web-based (targeted social media sites and apps) and offline (print ads and flyers) advertisements, peer and clinic referrals, and street- and venue-based outreach, and by contacting potential participants who have requested contact for future studies. Participants will be randomized into 1 of the 3 conditions: (1) text messaging, (2) WebApp, or (3) information-only control for 6 months. Assessments will occur at baseline and at 3, 6, and 9 months. Participants who do not show improvements in sexual risk or PrEP uptake at the 3-month assessment will be rerandomized to receive weekly electronic coaching (eCoaching) sessions in addition to their assigned text messaging or WebApp intervention, or remain in the original text messaging or WebApp intervention using a 2:1 ratio. Participants originally assigned to the information-only condition are not eligible for rerandomization. Results Funding for TechStep was awarded in June 2017. Phase 1 was approved by the Institutional Review Board (IRB) in April 2018. Recruitment began in November 2018 for phase 1, the formative phase. Initial phase 2 IRB approval came in June 2019. The data collection for phase 2, the RCT, is expected to be completed in April 2021. As of March 2020, 54 participants have been enrolled in TechStep. The final results are anticipated in May 2021. Conclusions By providing culturally responsive, technology-based interventions, TechStep aims to improve sexual health outcomes among HIV-negative transgender youth and young adults at high risk of HIV. TechStep will evaluate the efficacy of technology-based interventions for reducing HIV sexual risk behaviors and increasing PrEP initiation, adherence, and persistence. The suite of technology-based interventions developed in TechStep, and assessed for efficacy in a 3-condition RCT, represents an important advancement in intervention science toward developing tailored and scalable interventions for transgender youth and young adults. Trial Registration ClinicalTrials.gov NCT04000724; http://clinicaltrials.gov/ct2/show/NCT04000724 International Registered Report Identifier (IRRID) DERR1-10.2196/18326

Highlights • Marijuana and illegal drug use declined during the COVID-19 pandemic. • Condomless anal sex with casual male partners declined during the COVID-19 pandemic. • Associations between illegal drug use and sex outcomes were stronger during COVID., Background Sexual minority men who use drugs have high sexual HIV transmission risk. Sexual interactions may also increase COVID-19 risk.This study compared marijuana use, other illegal drugs use (i.e. cocaine/crack, methamphetamine, MDMA/ecstasy, GHB, and ketamine) and sexual behavior with casual partners among sexual minority cismen active on social networking and dating applications before and during the COVID-19 epidemic. Methods This cohort-control study compared 455 adult respondents (surveyed May 6th to 17th, 2020) and a matched sample selected from 65,707 respondents surveyed pre-COVID. Participants were recruited on social networking and dating applications and completed surveys online. Results The proportion reporting marijuana use declined significantly in the COVID cohort (34.5 % versus 45.7 % pre-COVID,p < .001) as did their illegal drug use (11.0 % versus 22.9 % pre-COVID, p < .001). While the number of casual partners per month was stable, the proportion reporting condomless anal sex with casual partners declined significantly during COVID (26.4 % versus 71.6 % pre-COVID, p < .001). The effect of illegal drug use (excluding marijuana) on number of casual partners per month (aRR = 1.45 pre-COVID versus 2.84, p < .01) and odds of condomless anal sex (aOR = 2.00 pre-COVID versus 5.22, p = .04) were significantly greater in the COVID cohort. Conclusions While the proportion of participants reporting drug use and condomless anal sex with casual partners declined in the COVID cohort, the association between drug use and sexual behavior was magnified. Sexual minority men who use drugs are significantly more likely to engage in sexual behaviors that place them at risk for HIV and COVID-19 transmission.

Purpose Adolescent sexual minority males (SMMs) are at a high risk of contracting HIV through condomless sex. Many develop serious partnerships, and sex with main partners accounts for many new infections. Previous research with adolescent SMMs largely focused on relationship seriousness and found a positive association with sexual HIV risk. This study tested associations between three relationship functioning indicators and condomless sex. Methods Adolescent SMMs aged 15–19 years (n = 85) completed a brief online survey. Respondents rated commitment, seriousness, and satisfaction on 7-point Likert-type scales. Results Among adolescent SMMs who had sex in their lifetime, those who were more satisfied in their relationship were less likely to have condomless in the past 90 days (odds ratio = .56, p = .04). Conclusions Results support examining multiple domains of relationship functioning in this age group to identify relationship mechanisms that may serve as the target of HIV risk–reduction interventions among adolescent SMM s initiating relationships.

BACKGROUND Transgender youth demonstrate significantly higher rates of engagement in sexual risk behaviors relative to their cisgender or gender-conforming counterparts, including high rates of condomless anal intercourse and engagement in sex work. In addition, transgender youth experience increased physical or sexual abuse, victimization, substance use, mental health disorders, incarceration, and homelessness. Owing to these syndemic health disparities, transgender youth are at substantially increased risk of HIV infection. OBJECTIVE This protocol aims to describe a randomized controlled trial (RCT), Adolescent Medicine Trials Network 160 TechStep (N=250), which assesses the differential immediate and sustained effects of each of 3 conditions (text messaging, WebApp, or information-only control) for reducing sexual risk behaviors and increasing pre-exposure prophylaxis (PrEP) uptake among high-risk, HIV-negative transgender youth and young adults (aged 15-24 years). METHODS Participants will be recruited through web-based (targeted social media sites and apps) and offline (print ads and flyers) advertisements, peer and clinic referrals, and street- and venue-based outreach, and by contacting potential participants who have requested contact for future studies. Participants will be randomized into 1 of the 3 conditions: (1) text messaging, (2) WebApp, or (3) information-only control for 6 months. Assessments will occur at baseline and at 3, 6, and 9 months. Participants who do not show improvements in sexual risk or PrEP uptake at the 3-month assessment will be rerandomized to receive weekly electronic coaching (eCoaching) sessions in addition to their assigned text messaging or WebApp intervention, or remain in the original text messaging or WebApp intervention using a 2:1 ratio. Participants originally assigned to the information-only condition are not eligible for rerandomization. RESULTS Funding for TechStep was awarded in June 2017. Phase 1 was approved by the Institutional Review Board (IRB) in April 2018. Recruitment began in November 2018 for phase 1, the formative phase. Initial phase 2 IRB approval came in June 2019. The data collection for phase 2, the RCT, is expected to be completed in April 2021. As of March 2020, 54 participants have been enrolled in TechStep. The final results are anticipated in May 2021. CONCLUSIONS By providing culturally responsive, technology-based interventions, TechStep aims to improve sexual health outcomes among HIV-negative transgender youth and young adults at high risk of HIV. TechStep will evaluate the efficacy of technology-based interventions for reducing HIV sexual risk behaviors and increasing PrEP initiation, adherence, and persistence. The suite of technology-based interventions developed in TechStep, and assessed for efficacy in a 3-condition RCT, represents an important advancement in intervention science toward developing tailored and scalable interventions for transgender youth and young adults. CLINICALTRIAL ClinicalTrials.gov NCT04000724; http://clinicaltrials.gov/ct2/show/NCT04000724 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/18326

Depression negatively impacts the health and well-being of gay and bisexual men (GBM). However, little is known about the contexts in which rural GBM live relative to those living in urban areas and their overall mental health. The aim of this study was to examine associations between population density and depressive symptoms and the role of internalized homonegativity and social support as potential mediators.A nationally representative sample of 1071 GBM (mean age = 40.24) was enrolled. Participants provided their zip codes, which were categorized according to population density and rank-normalized.In a path analysis model adjusted for race/ethnicity, college education, age, and relationship status, higher population density was significantly associated with increased social support (B = 0.11, P = 0.002) and decreased internalized homonegativity (B = -0.06, P 0.001). In turn, lower social support (B = -2.93, P 0.001) and greater internalized homonegativity (B = 4.93, P 0.001) were significantly associated with greater depressive symptoms. The indirect effects of population density on depression through social support (B = -0.33, P 0.001) and internalized homonegativity (B = -0.31, P 0.001) were statistically significant, suggesting evidence for mediation of the effects.These results indicate that living in less inhabited areas acts on depressive symptoms through mechanisms of lower social support and higher internalized homonegativity. These findings suggest that social contexts in which GBM live can affect mental health outcomes and indicate the need for further support and inclusion of GBM, especially in less inhabited areas.

Transgender and gender-expansive (TGE) youth endure stark disparities in health and wellbeing compared to their cisgender peers. A key social determinant of health for TGE adolescents and emerging adults is gender affirmation, which encompasses multidimensional validations of an individual’s lived gender. Lacking available resources for one’s gender affirmation, TGE young people may engage in high-risk maladaptive coping behaviors, linked to their disproportionately high HIV-acquisition risk. A range of innovative mobile technologies are guided by the Gender-Affirmative Framework to promote the health of TGE communities, including through HIV prevention and care continuum outcomes. The aim of this review was to examine key features of existing mobile technologies that can be leveraged to advance the field of TGE-responsive mHealth. We systematically searched scientific records, gray literature, and the iOS and Android app distribution services. To be eligible, platforms and interventions needed to be tailored exclusively to a TGE user base, incorporate gender-affirming features, and be optimized for or adaptive to mobile technologies. Eligible interventions (N=24) were compared on evidence of utility, core functionalities, and dimensions of gender affirmation. Smartphone applications (apps) and webapps (n=16) were the most common delivery modality. Many interventions (n=9) aimed to address HIV-related outcomes and integrated gender-affirmative features. The most common gender-affirmative features originated in fields of human-computer interactions and informatics, or were crowdfunded by TGE developers. HIV-focused interventions incorporated evidence-based health behavior change strategies and utilized rigorous evaluation methods. Across modalities and disciplines, behavioral self-monitoring and access to HIV prevention services were the most frequent features. Over two-thirds of the interventions reviewed aimed to provide medical gender affirmation (e.g, provided guidance on obtaining medically sanctioned hormone therapies, or safely practicing non-medical options such as chest-binding) or psychological gender affirmation (e.g, provided linkage to mental health counseling). Our results show that mHealth and other technology-mediated interventions offer a diverse range of both evidence-based and innovative features; however, many have not been rigorously evaluated in a randomized controlled trial to support TGE users. A continuing commitment to evidence-based health behavior change strategies, exemplified by the HIV-focused interventions included in this review, is essential to advancing gender-affirmative mHealth. The unique and highly innovative features of platforms originating outside the fields of HIV prevention and care suggest new directions for TGE-responsive mHealth, and the need for more conscientious models of knowledge exchange with investigators across scientific disciplines, private-sector developers, and potential users.

Background The association between drug use and condomless anal sex (CAS) is well documented among sexual minority men (SMM). Less is known about whether this association generalizes to marijuana and across relationship status and sexual agreements groups (single, partnered monogamous, partnered open –outside partners permitted, and partnered monogamish –outside partners permitted when main partners are together). Methods A nationwide sample of SMM (N = 65,707) were recruited through a geosocial networking app between November 2017 and November 2019. Participants reported on drug use and instances of CAS with casual partners in the previous 30 days. Results Both marijuana and club drug use were associated with the occurrence of CAS with casual partners among single men. Only club drug use was associated with CAS frequency in this group. The association between marijuana and the occurrence of CAS did not differ significantly among monogamous men, while the associations between club drug use and the occurrence as well as frequency of CAS were significantly weaker. Meanwhile, the associations between club drug use and the occurrence as well as frequency of CAS did not differ significantly between single and non-monogamous (open and monogamish) subgroups; however, the association between marijuana and the occurrence of CAS was significantly weaker. Conclusions Findings largely replicated the robust association between club drug use and CAS with casual partners. They support the assertion that marijuana use predicts sexual risk for some SMM subgroups. Finally, they illustrate the potential for relationship status – and sexual agreements – to contextualize associations between drug use and CAS.

BACKGROUND The Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) research program aims to defeat the rising HIV epidemic among adolescents and young adults in the United States. OBJECTIVE This study aims to optimize cross-study analyses and comparisons of standardized measures (variables) collected in the ATN. METHODS Guidelines were developed for harmonizing measures to be collected across ATN studies. RESULTS Eight domains were identified for harmonization—Demographics and Socioeconomic Characteristics, Sexual Behavior and Risk, Substance Use and Abuse, HIV-Positive Cascade, HIV-Negative Cascade, Mental Health, Social Support and Isolation, and Pre-exposure Prophylaxis Cascade. CONCLUSIONS The collection of selected key measures in a uniform manner across studies facilitates the characterization of participant populations, comparisons between studies, and pooled analysis of data from multiple studies.

BACKGROUND The Exploration, Preparation, Implementation, and Sustainment (EPIS) model is an implementation framework for studying the integration of evidence-based practices (EBPs) into real-world settings. The EPIS model conceptualizes implementation as a process starting with the earliest stages of problem recognition (Exploration) through the continued use of an EBP in a given clinical context (Sustainment). This is the first implementation science (IS) study of the integration of EBPs into adolescent HIV prevention and care settings. OBJECTIVE This protocol (ATN 153 EPIS) is part of the Scale It Up program, a research program administered by the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), described in this issue by Naar et al. The EPIS study is a descriptive study of the uptake of 4 EBPs within the Scale It Up program. The goal of EPIS is to understand the barriers and facilitators associated with the Preparation, Implementation, and Sustainment of EBPs into HIV prevention and clinical care settings. METHODS The EPIS study is a convergent parallel mixed-methods IS study. Key implementation stakeholders, that is, clinical care providers and leaders, located within 13 ATN sites across the United States will complete a qualitative interview conducted by telephone and Web-based surveys at 3 key implementation stages. The Preparation assessment occurs before EBP implementation, Implementation occurs immediately after sites finish implementation activities and prepare for sustainment, and Sustainment occurs 1 year postimplementation. Assessments will examine stakeholders’ perceptions of the barriers and facilitators to EBP implementation within their clinical site as outlined by the EPIS framework. RESULTS The EPIS baseline period began in June 2017 and concluded in May 2018; analysis of the baseline data is underway. To date, 153 stakeholders have completed qualitative interviews, and 91.5% (140/153) completed the quantitative survey. CONCLUSIONS The knowledge gained from the EPIS study will strengthen the implementation and sustainment of EBPs in adolescent prevention and clinical care contexts by offering insights into the barriers and facilitators of successful EBP implementation and sustainment in real-world clinical contexts. INTERNATIONAL REGISTERED REPOR DERR1-10.2196/11202

BACKGROUND Young men who have sex with men (YMSM), particularly those who are partnered, are at unique risk for HIV. YMSM are among those at highest risk for HIV. Meanwhile, despite the fact that primary partners account for many—possibly most—new HIV infections, partnered men who have sex with men perceive themselves to be at much lower risk for HIV infection and therefore test less often than single men. In response to the risk of primary partner HIV transmission, couples HIV testing and counseling (CHTC) procedures have been developed for use in adult populations. Although promising, YMSM couples may require additional support to complete CHTC given their developmental context in which sexual and romantic relationships are relatively new, and communication skills are emergent. OBJECTIVE The aim of this study was to test the additive benefit of adjunct treatment components tailored for YMSM, which enhance communication skills before the completion of CHTC. The intervention tests a continuum of prevention packages including assertive communication training videos and motivational interviewing focused on assisting with identification and development (MI-AID) before entering into the dyadic intervention components. This protocol is part of the Adolescent Medicine Trials Network (ATN) Scale It Up program described in this issue. METHODS This is a comparative effectiveness trial that will be executed in 3 phases. Phase 1 will gather qualitative data related to intervention development and implementation from partnered YMSM at 4 subject recruitment venues (SRVs). Phase 2 will compare a continuum of these interventions in a pilot randomized controlled trial (RCT) at 2 SRVs. Phase 3 will compare the most successful adapted intervention package from phase 2 to CHTC as usual in a larger RCT at 4 SRVs. This phase is focused on implementation and sustainment phases of the Exploration, Preparation, Implementation, and Sustainment framework. RESULTS Phase 1 data will be drawn from qualitative interviews with partnered YMSM (n=24) and staff from ATN sites (n=20). Baseline enrollment for phase 2 is expected to begin across 2 SRVs in June 2018 (ncouples=36). In phase 2, survey data collection along with HIV and sexually transmitted infection (STI) testing will occur at baseline, and 1- and 3-month (postintervention) follow-ups. Phase 3 will begin enrollment across 4 SRVs in September 2019 (ncouples=144) and follow-ups will occur at 1, 3, 6, and 9 months postintervention. CONCLUSIONS Although MI-AID, video-based assertive communication training, and CHTC have established efficacy when administered on their own, this study will be the first to evaluate the strongest adjunctive version of these interventions to address the specific developmental needs of partnered YMSM. CLINICALTRIAL ClinicalTrials.gov NCT03386110; http://clinicaltrials.gov/ct2/show/NCT03386110 (Archived by WebCite at http://www.webcitation.org/75mlO7GCx) INTERNATIONAL REGISTERED REPOR DERR1-10.2196/11186

BACKGROUND Youth living with HIV (YLH) aged 13 to 24 years made up over a fifth (21%) of new HIV diagnoses in 2016, yet only 27% of YLH are virally suppressed. YLH have been shown to be poorly adherent to antiretroviral therapy (ART); however, there has been limited research investigating how to increase adherence in YLH. Mobile health (mHealth) interventions may be one promising way to do this. OBJECTIVE This study (ATN [Adolescent Trials Network] 144 SMART) aimed to compare adaptive interventions that could increase ART adherence in YLH aged 15 to 24 years. This includes mHealth initiatives, the tapering of interventions, and the use of incentives. Cost-effectiveness of sequencing the interventions without incentives before providing incentives and the savings on societal costs due to suppressed viral loads will be determined. This protocol is part of the ATN Scale It Up program described in this issue by Naar et al. METHODS This study uses a Sequential Multiple Assignment Randomized Trial design. Approximately 190 participants are being recruited, enrolled, and randomized to either cell phone support or text message support. Both intervention groups receive 3 months of intervention, followed by a second randomization based on response to the intervention. Responders test tapering their intervention, and nonresponders test receiving incentives. RESULTS Data collection for this study is projected to begin in August 2018 and last until June 2020. CONCLUSIONS This is an innovative study, particularly in terms of population, intervention types, focus on cost-effectiveness, and recruitment. This study could be particularly effective in improving adherence in YLH while reducing long-term individual and societal costs. CLINICALTRIAL ClinicalTrials.gov NCT03535337; https://clinicaltrials.gov/ct2/show/NCT03535337 (Archived by WebCite at http://www.webcitation.org/74alXb92z) INTERNATIONAL REGISTERED REPOR PRR1-10.2196/11183

BACKGROUND Young men who have sex with men (YMSM) are disproportionately at risk for HIV and sexually transmitted infections. Adapting and testing the effectiveness of the Young Men’s Health Project (YMHP), an efficacious intervention designed to reduce substance use and condomless anal sex (CAS) among YMSM, at clinics in Miami, Detroit, and Philadelphia has the potential to reduce HIV and STI disparities among urban YMSM. OBJECTIVE This study (Adolescent Medicine Trials Network for HIV/AIDS Interventions [ATN] 145 YMHP) aims to adapt YMHP for clinic and remote delivery by existing clinic staff and compare their effectiveness in real-world adolescent HIV clinics. This protocol is part of the ATN Scale It Up program described in a recently published article by Naar et al. METHODS This is a comparative effectiveness hybrid type-2 trial of the YMHP intervention with 2 delivery formats—clinic-based versus remote delivery—offered following HIV counseling and testing. Phase 1 includes conducting focus groups with youth to obtain implementation feedback about the delivery of the YMHP intervention and intervention components to ensure culturally competent, feasible, and scalable implementation. Phase 2 includes recruitment and enrollment of 270 YMSM, aged 15 to 24 years, 90 at each of the 3 sites. Enrollment will be limited to HIV-negative YMSM who report recent substance use and either CAS or a positive STI test result. Participants will be randomized to receive the YMHP intervention either in person or by remote delivery. Both conditions involve completion of the 4 YMHP sessions and the delivery of pre-exposure prophylaxis information and navigation services. A minimum of 2 community health workers (CHWs) will be trained to deliver the intervention sessions at each site. Sessions will be audio-recorded for Motivational Interviewing Treatment Integrity (MITI) fidelity coding, and CHWs and supervisors will be given implementation support throughout the study period. RESULTS Phase 1 focus groups were completed in July 2017 (n=25). Feedback from these focus groups at the 3 sites informed adaptations to the YMHP intervention manual, implementation of the intervention, and recruitment plans for phase 2. Baseline enrollment for phase 2 began in November 2018, and assessments will be at immediate posttest (IP)-, 3-, 6-, 9-, and 12-months after the intervention. Upon collection of both baseline and follow-up data, we will compare the effectiveness and cost-effectiveness of clinic-based versus remote delivery of YMHP in the context of health care access. CONCLUSIONS We are conducting YMHP in 3 cities with high rates of YMSM at risk for HIV and STIs. When adapted for real-world clinics, this study will help substance-using YMSM at risk for HIV and STIs and allow us to examine differences in effectiveness and cost by the method of delivery. CLINICALTRIAL ClinicalTrials.gov NCT03488914; https://clinicaltrials.gov/ct2/show/NCT03488914 (Archived by WebCite at http://www.webcitation.org/770WaWWfi) INTERNATIONAL REGISTERED REPOR DERR1-10.2196/11184

Background Young men who have sex with men (YMSM) are disproportionately at risk for HIV and sexually transmitted infections. Adapting and testing the effectiveness of the Young Men's Health Project (YMHP), an efficacious intervention designed to reduce substance use and condomless anal sex (CAS) among YMSM, at clinics in Miami, Detroit, and Philadelphia has the potential to reduce HIV and STI disparities among urban YMSM. Objective This study (Adolescent Medicine Trials Network for HIV/AIDS Interventions [ATN] 145 YMHP) aims to adapt YMHP for clinic and remote delivery by existing clinic staff and compare their effectiveness in real-world adolescent HIV clinics. This protocol is part of the ATN Scale It Up program described in a recently published article by Naar et al. Methods This is a comparative effectiveness hybrid type-2 trial of the YMHP intervention with 2 delivery formats-clinic-based versus remote delivery-offered following HIV counseling and testing. Phase 1 includes conducting focus groups with youth to obtain implementation feedback about the delivery of the YMHP intervention and intervention components to ensure culturally competent, feasible, and scalable implementation. Phase 2 includes recruitment and enrollment of 270 YMSM, aged 15 to 24 years, 90 at each of the 3 sites. Enrollment will be limited to HIV-negative YMSM who report recent substance use and either CAS or a positive STI test result. Participants will be randomized to receive the YMHP intervention either in person or by remote delivery. Both conditions involve completion of the 4 YMHP sessions and the delivery of pre-exposure prophylaxis information and navigation services. A minimum of 2 community health workers (CHWs) will be trained to deliver the intervention sessions at each site. Sessions will be audio-recorded for Motivational Interviewing Treatment Integrity (MITI) fidelity coding, and CHWs and supervisors will be given implementation support throughout the study period. Results Phase 1 focus groups were completed in July 2017 (n=25). Feedback from these focus groups at the 3 sites informed adaptations to the YMHP intervention manual, implementation of the intervention, and recruitment plans for phase 2. Baseline enrollment for phase 2 began in November 2018, and assessments will be at immediate posttest (IP)-, 3-, 6-, 9-, and 12-months after the intervention. Upon collection of both baseline and follow-up data, we will compare the effectiveness and cost-effectiveness of clinic-based versus remote delivery of YMHP in the context of health care access. Conclusions We are conducting YMHP in 3 cities with high rates of YMSM at risk for HIV and STIs. When adapted for real-world clinics, this study will help substance-using YMSM at risk for HIV and STIs and allow us to examine differences in effectiveness and cost by the method of delivery. Trial registration ClinicalTrials.gov NCT03488914; https://clinicaltrials.gov/ct2/show/NCT03488914 (Archived by WebCite at http://www.webcitation.org/770WaWWfi). International registered report identifier (irrid) DERR1-10.2196/11184.

BACKGROUND Past research shows that youth living with HIV (YLH) are not as engaged in the HIV treatment cascade as other HIV-positive populations. To achieve the health benefits of rapid and widespread testing and advanced pharmacologic treatment, YLH must be fully engaged in every stage of the treatment cascade. Cascade monitoring provides an opportunity to assess the youth care cascade, including engagement in care and when youth commonly drop out of care, across 10 clinical sites in the United States. Collecting electronic health record (EHR) data for prevention and care across participant recruitment venues within the Adolescent Medicine Trials Network (ATN) allows for monitoring of the prevention and care cascades within the ATN, for comparing the ATN population to large-scale surveillance, for future integration of technology-based interventions into EHRs, and for informing ATN strategic planning. OBJECTIVE The aim of this protocol study is to examine the trends in treatment cascade, including whether patients are receiving antiretroviral therapy, adhering to regimens, attending care appointments, and maintaining suppressed viral loads, to guide new protocol development and to facilitate community engagement. This protocol is part of the ATN Scale It Up (SIU) program described in this issue. METHODS Deidentified EHR data of YLH, aged 15 to 24 years, will be collected annually (2017 to 2022) from 10 ATN clinical sites, resulting in patient data from 2016 to 2021. These data will be transferred and stored using Dropbox Business, a Health Insurance Portability and Accountability Act–compliant site and then analyzed by the SIU analytic core. RESULTS This study was launched in December 2017 in 10 clinical sites, with 2016’s EHR data due on January 31, 2017. All 10 sites electronically uploaded their EHR data. The mandatory variables requested to monitor cascade of care include date of visit, age, gender, height, weight, race, ethnicity, viral load, and International Classification of Diseases codes for other diagnosis. In total, 70% of the sites provided data for all mandatory variables. The remaining mandatory variables were manually extracted. CONCLUSIONS This study will provide a platform to determine how YLH across the nation progress through or drop out of the HIV treatment cascade. It will also provide a foundation for assessing impact of SIU projects on treatment cascade outcomes.

This study examined the effect of four syndemic conditions—namely, polydrug use, depression, childhood sexual abuse, and intimate partner violence—on rates of HIV transmission risk behavior (TRB) and separately, transactional sex among transgender women. TRB was defined as the number of condomless penetrative sex events with a casual or main partner of discordant or unknown HIV status. Using data from 212 transgender women in New York City, multivariable analyses revealed that, compared to those with no syndemic conditions, dramatically higher rates of recent HIV TRB events (ARR = 8.84, p

Substance use among HIV-positive persons exacerbates health problems. This study sought to estimate the prevalence of alcohol and drug-use diagnoses and examined hypothesized predictors associated with alcohol and drug-use diagnoses among HIV-positive patients in New York City (NYC).This cohort study reviewed electronic medical records (EMRs) of 4965 HIV-positive patients based on diagnostic codes. These patients attended a comprehensive care clinic in NYC in 2012. Multinomial logistic regression was used to predict the odds of classification into substance use diagnosis grouping.Of the full sample, only 12.7% of patients had an alcohol use diagnosis documented in their EMR compared with more than one-quarter (26.4%) of patients having a recorded drug use diagnosis (p0.001). Compared with the No Alcohol or Drugs group, the regression model showed that older age and having a recent inpatient hospital stay independently predicted being in the Alcohol Only group; years living with HIV, having an unsuppressed viral load, and having a recent inpatient hospital stay were associated with higher odds of being in the Drugs Only and Alcohol and Drugs groups; and being women and men who have sex with men (MSM) were associated with decreased odds of being in the Drugs Only and Alcohol and Drugs groups.Substance use diagnosis was associated with viremia and low CD4 counts and hospital stays. This implies that providers should screen for substance use in HIV-positive patients with poor health. Further examination of the extent of such comorbidity is instrumental for intervention efforts.

We describe enrollment for the One Thousand Strong panel, present characteristics of the panel relative to other large U.S. national studies of gay and bisexual men (GBM), and examine demographic and behavioral characteristics that were associated with passing enrollment milestones. A U.S. national sample of HIV-negative men were enrolled via an established online panel of over 22,000 GBM. Participants (n = 1071) passed three milestones to join our panel. Milestone 1 was screening eligible and providing informed consent. Milestone 2 involved completing an hour-long at-home computer-assisted self-interview (CASI) survey. Milestone 3 involved completing at-home self-administered rapid HIV testing and collecting/returning urine and rectal samples for gonorrhea and chlamydia testing. Compared to those who completed milestones: those not passing milestone 1 were more likely to be non-White and older; those not passing milestone 2 were less likely to have insurance or a primary care physician; and those not passing milestone 3 were less educated, more likely to be bisexual as opposed to gay, more likely to live in the Midwest, had fewer male partners in the past year, and less likely to have tested for HIV in the past year. Effect sizes for significant findings were small. We successfully enrolled a national sample of HIV-negative GBM who completed at-home CASI assessments and at-home self-administered HIV and urine and rectal STI testing. This indicates high feasibility and acceptability of incorporating self-administered biological assays into otherwise fully online studies. Differences in completion of study milestones indicate a need for further investigation into the reasons for lower engagement by certain groups.

Theory-based sexual risk reduction interventions are often demonstrated effective, but few studies have examined the mechanisms that mediate their behavior changes. In addition, critical contextual factors, such as alcohol use, are often not accounted for by social cognitive theories and may add to the explanatory value of intervention effects. The purpose of this study is to examine the underlying mechanisms driving condom use following a brief sexual risk reduction intervention grounded in the information, motivation, behavioral skills (IMB) model of behavior change. We examined IMB theoretical constructs and alcohol-related contextual factors as potential mediators in separate models. Patients (n = 617) from an STI clinic in Cape Town, South Africa were randomly assigned to either a brief risk reduction intervention or an education-only control condition. We assessed IMB, and alcohol-related variables at baseline, 3, 6, 9, and 12 months and modeled IMB constructs and alcohol-related factors as mediators of behavior change. Results of growth-curve mediational modeling showed that 1 year after counseling, the intervention indirectly affected sexual risk behavior through alcohol-related constructs, but not IMB constructs. Alcohol use and related factors play critical roles in explaining HIV and STI risk reduction intervention effects. Interventions that directly address alcohol use as a factor in sexual risk behavior and behavior change should be the focus of future research.

Background: Young men who have sex with men (YMSM), particularly those who are partnered, are at unique risk for HIV. YMSM are among those at highest risk for HIV. Meanwhile, despite the fact that primary partners account for many—possibly most—new HIV infections, partnered men who have sex with men perceive themselves to be at much lower risk for HIV infection and therefore test less often than single men. In response to the risk of primary partner HIV transmission, couples HIV testing and counseling (CHTC) procedures have been developed for use in adult populations. Although promising, YMSM couples may require additional support to complete CHTC given their developmental context in which sexual and romantic relationships are relatively new, and communication skills are emergent. Objective: The aim of this study was to test the additive benefit of adjunct treatment components tailored for YMSM, which enhance communication skills before the completion of CHTC. The intervention tests a continuum of prevention packages including assertive communication training videos and motivational interviewing focused on assisting with identification and development (MI-AID) before entering into the dyadic intervention components. This protocol is part of the Adolescent Medicine Trials Network (ATN) Scale It Up program described in this issue. Methods: This is a comparative effectiveness trial that will be executed in 3 phases. Phase 1 will gather qualitative data related to intervention development and implementation from partnered YMSM at 4 subject recruitment venues (SRVs). Phase 2 will compare a continuum of these interventions in a pilot randomized controlled trial (RCT) at 2 SRVs. Phase 3 will compare the most successful adapted intervention package from phase 2 to CHTC as usual in a larger RCT at 4 SRVs. This phase is focused on implementation and sustainment phases of the Exploration, Preparation, Implementation, and Sustainment framework. Results: Phase 1 data will be drawn from qualitative interviews with partnered YMSM (n=24) and staff from ATN sites (n=20). Baseline enrollment for phase 2 is expected to begin across 2 SRVs in June 2018 (ncouples=36). In phase 2, survey data collection along with HIV and sexually transmitted infection (STI) testing will occur at baseline, and 1- and 3-month (postintervention) follow-ups. Phase 3 will begin enrollment across 4 SRVs in September 2019 (ncouples=144) and follow-ups will occur at 1, 3, 6, and 9 months postintervention. Conclusions: Although MI-AID, video-based assertive communication training, and CHTC have established efficacy when administered on their own, this study will be the first to evaluate the strongest adjunctive version of these interventions to address the specific developmental needs of partnered YMSM. Trial Registration: ClinicalTrials.gov NCT03386110; http://clinicaltrials.gov/ct2/show/NCT03386110 (Archived by WebCite at http://www.webcitation.org/75mlO7GCx) International Registered Report Identifier (IRRID): DERR1-10.2196/11186

Background: South African alcohol-serving establishments (i.e., shebeens) offer unique opportunities to reduce HIV risks among men who drink. Purpose: To test an individual- and a social structural-level HIV prevention intervention for men who drink in shebeens. Methods: Twelve matched pairs of township neighbourhoods were randomized to receive either (i) an HIV prevention intervention (guided by Social Action Theory) to reduce sexual risk and increase risk reduction communication in social networks, or (ii) an attention-matched control intervention that focused on the prevention of relationship violence. At the individual level, the interventions delivered skills building workshops focused on sexual risk reduction. At the social structural level, the intervention aimed to increase conversations about safer sex among men in the shebeens, distributed small media and implemented community educational events. Individual-level outcomes were assessed by following the workshop cohorts for 1 year (N = 984), and community-level outcomes were examined through cross-sectional community surveys conducted for 1 year in the shebeens (N = 9,678). Results: Men in the HIV prevention workshops demonstrated greater condom use, more HIV prevention-oriented conversations and greater perceptions of safer sex norms than men in the comparison workshops. Changes at the community level demonstrated significant differences in condom use, although the pattern was not consistent over time. Conclusions: Multi-level interventions that target men who drink in South African shebeens may help reduce risks for HIV and other sexually transmitted infections.

Background: The Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) research program aims to defeat the rising HIV epidemic among adolescents and young adults in the United States. Objective: This study aims to optimize cross-study analyses and comparisons of standardized measures (variables) collected in the ATN. Methods: Guidelines were developed for harmonizing measures to be collected across ATN studies. Results: Eight domains were identified for harmonization—Demographics and Socioeconomic Characteristics, Sexual Behavior and Risk, Substance Use and Abuse, HIV-Positive Cascade, HIV-Negative Cascade, Mental Health, Social Support and Isolation, and Pre-exposure Prophylaxis Cascade. Conclusions: The collection of selected key measures in a uniform manner across studies facilitates the characterization of participant populations, comparisons between studies, and pooled analysis of data from multiple studies.

Background Youth living with HIV (YLH) aged 13 to 24 years made up over a fifth (21%) of new HIV diagnoses in 2016, yet only 27% of YLH are virally suppressed. YLH have been shown to be poorly adherent to antiretroviral therapy (ART); however, there has been limited research investigating how to increase adherence in YLH. Mobile health (mHealth) interventions may be one promising way to do this. Objective This study (ATN [Adolescent Trials Network] 144 SMART) aimed to compare adaptive interventions that could increase ART adherence in YLH aged 15 to 24 years. This includes mHealth initiatives, the tapering of interventions, and the use of incentives. Cost-effectiveness of sequencing the interventions without incentives before providing incentives and the savings on societal costs due to suppressed viral loads will be determined. This protocol is part of the ATN Scale It Up program described in this issue by Naar et al. Methods This study uses a Sequential Multiple Assignment Randomized Trial design. Approximately 190 participants are being recruited, enrolled, and randomized to either cell phone support or text message support. Both intervention groups receive 3 months of intervention, followed by a second randomization based on response to the intervention. Responders test tapering their intervention, and nonresponders test receiving incentives. Results Data collection for this study is projected to begin in August 2018 and last until June 2020. Conclusions This is an innovative study, particularly in terms of population, intervention types, focus on cost-effectiveness, and recruitment. This study could be particularly effective in improving adherence in YLH while reducing long-term individual and societal costs. Trial registration ClinicalTrials.gov NCT03535337; https://clinicaltrials.gov/ct2/show/NCT03535337 (Archived by WebCite at http://www.webcitation.org/74alXb92z). International registered report identifier (irrid) PRR1-10.2196/11183.

South African townships have high HIV prevalence and a strong need for collective action to change normative sexual risk behaviors. This study investigated the relationship between perceptions of individuals about collective efficacy in the community's ability to prevent HIV and their personal HIV risk behaviors. Men (n = 1,581) and women (n = 718) completed anonymous surveys within four Black African Townships in Cape Town, South Africa from June 2008 to December 2010. Measures included demographics, alcohol use, attitudinal and behavioral norms, sexual health communications, and sexual risk behaviors. In multivariate logistic regressions, men were more likely to endorse collective efficacy if they were married, drank less often in alcohol serving establishments, believed that fewer men approve of HIV risk behaviors, talk more with others about HIV/AIDS, and had more sex partners in the past month. Women were more likely to endorse collective efficacy if they drank alcohol less often, talked more with others about HIV/AIDS, had more sex partners in the past month, but reported fewer unprotected sex acts in the past month. Community level interventions that strengthen collective efficacy beliefs will have to consider both protective and risk behaviors associated with believing that the community is ready and capable of preventing HIV.

South Africa has the highest rate of fetal alcohol syndrome (FAS) in the world. While efforts have been made to curb the high rate of FAS, little is known about situational factors that may contribute to alcohol use during pregnancy. In the current paper, we focus on the role of food insecurity and its relationship to alcohol use among pregnant women. Women completed computer-assisted interviews. Generalized linear modeling was used in all analyses. Women attending alcohol-serving establishments in a township in Cape Town, South Africa were recruited for the study. Five hundred sixty women were sampled and 95 women reported being pregnant. High levels of alcohol use were reported among pregnant women: 65 % of women consumed alcohol at least every month and 29 % consumed alcohol as often as two to three times per week. Thirty-four percent of the women reported having six or more drinks per occasion on at least a weekly basis. The majority (87 %) of pregnant women reported experiencing some form of food insecurity (e.g., food unavailable, eating less) in the past month. Alcohol use was significantly associated with food insecurity, even when controlling for relevant demographic variables. Intervention with pregnant women who consume alcohol is urgently needed. Future research should focus on understanding the intersection of food insecurity and alcohol, and how the experience of food insecurity may contribute to greater rates of alcohol use and abuse among pregnant women.

The relationship between transactional sex, HIV risk, and partner violence has been well documented in South Africa, but research has focused primarily on women and has not been conducted in high-risk social contexts. The aim of this study was to examine associations between transactional sex and HIV risk among women and men in alcohol-serving venues in Cape Town, South Africa. We surveyed 1,989 women and 2,468 men attending alcohol-serving venues in Cape Town, South Africa to assess transactional sex behavior (i.e., receiving money or goods in exchange for sex), alcohol and drug use, history of childhood abuse, current relationship violence, and sexual risk behaviors. Among both women and men, trading sex was related to higher alcohol use, greater likelihood of drug use, substance use in sexual contexts, and a greater likelihood of experiencing physical and sexual violence. Compared to other women, women who traded sex reported a greater proportion of condom-unprotected sex; this relationship was not found for men. Analyses showed that men were almost twice as more likely to report trading sex for items, including money or alcohol, than women (9.7 vs. 5.8 %). Overall, men who traded sex were similar to their female counterparts. Similar associations between trading sex and different risk behaviors were found among women and men with limited economic means and substance use problems. Future research should more closely study transactional sex in high-risk venues as it relates to violence and should examine men who trade sex as a potential bridge population between heterosexual women and men who have sex with men.

Background Concurrent sexual relationships facilitate the spread of HIV infection, and sex with non-primary partners may pose particularly high risks for HIV transmission to primary partners. Objective We examined the sexual and alcohol-related risks associated with sex partners outside of primary relationships among South African men and women in informal drinking establishments. Methods Men (n=4959) and women (n=2367) with primary sex partners residing in a Xhosa-speaking South African township completed anonymous surveys. Logistic regressions tested associations between having outside partners and risks for sexually transmitted infections (STI)/HIV. Results Forty-four percent of men and 26% women with primary sex partners reported also having outside sex partners in the previous month. Condom use with outside partners was inconsistent for men and women; only 19% of men and 12% of women used condoms consistently with outside sex partners. Multivariable regressions for men and women showed that having outside partners was significantly associated with having been diagnosed with an STI, consuming alcohol in greater frequency and quantity, alcohol use during sex, meeting sex partners in alcohol-serving venues, and higher rates of unprotected sex. Conclusions Having outside sex partners was associated with multiple risk factors for HIV infection among South African shebeen patrons. Social and structural interventions that encourage condom use are needed for men and women with outside partners who patronise alcohol-serving venues.

In South Africa, women comprise the majority of HIV infections. Syndemics, or co-occurring epidemics and risk factors, have been applied in understanding HIV risk among marginalized groups.The purposes of this study are to apply the syndemic framework to examine psychosocial problems that co-occur among women attending drinking venues in South Africa and to test how the co-occurrence of these problems may exacerbate risk for HIV infection.Five hundred sixty women from a Cape Town township provided data on multiple psychosocial problems, including food insufficiency, depression, abuse experiences, problem drinking, and sexual behaviors.Bivariate associations among the syndemic factors showed a high degree of co-occurrence and regression analyses showed an additive effect of psychosocial problems on HIV risk behaviors.These results demonstrate the utility of a syndemic framework to understand co-occurring psychosocial problems among women in South Africa. HIV prevention interventions should consider the compounding effects of psychosocial problems among women.

This study examined the association between alcohol use and sexual behaviors among South African adults who reported current drinking.Street-intercept surveys were administered to adults residing in neighborhoods in a South African township.Analyses were restricted to participants reporting current drinking (N=1285; mean age=32; 27% women; 98% Black). Most participants (60%) reported heavy episodic drinking (i.e., 5 or more drinks on a single occasion) at least once per week in the past 30 days. Compared to non-heavy episodic drinkers, participants who reported heavy episodic drinking were more likely to drink before sex (79% vs. 66%) and have sex with a partner who had been drinking (59% vs. 44%). Overall, drinking before sex (self or partner) and heavy episodic drinking was associated with multiple sexual partners, discussing condom use with sexual partner(s), and proportion of protected sex. The frequency of condom use varied among participants with steady, casual, or both steady and casual sexual partners.Alcohol use among South African adults is associated with sexual risk behaviors, but this association differs by partner type. Findings suggest the need to strengthen alcohol use components in sexual risk reduction interventions especially for participants with both steady and casual sex partners.

Objectives. As a result of the impact of HIV among men who have sex with men (MSM), multiple strategies for reducing HIV risks have emerged from within the gay community. One common HIV risk reduction strategy limits unprotected sex partners to those who are of the same HIV status (serosorting). We tested a novel, brief, one-on-one intervention, based on informed decision-making and delivered by peer counselors, designed to address the limitations of serosorting (e.g., risk for HIV transmission). Methods. In 2009, we recruited a group of 149 at-risk men living in Atlanta, Georgia, and randomly assigned them to an intervention condition addressing serosorting or a standard-of-care control condition. Results. Men in the serosorting intervention reported fewer sexual partners (Wald χ2 = 8.79, P < .01) at the study follow-ups. Behavioral results were also consistent with changes in psychosocial variables, including condom use self-efficacy and perceptions of risk for HIV transmission. Conclusions. With the current intervention, service providers can offer risk reduction for men arguably at the highest risk for HIV infection in the United States. Addressing risks associated with serosorting in a feasible, low-cost intervention has the potential to significantly affect the HIV epidemic.

Objectives The South African government recently launched a national campaign to test 15 million South Africans for HIV by 2011. Little is known about how receipt of HIV testing might influence interpersonal communication. To explore these questions, the authors examined the effects of prior HIV testing on sexual health communication among South Africans. Methods Adults (N=1284; 98% black, 36% women, mean age 31) residing in a South African township completed street-intercept surveys. Results Of the 1284 participants, 811 (63%) had been tested for HIV. Among those who had been tested, 77% tested negative, 12% tested positive, and 11% did not know their test result or refused to answer. Compared with those who had not been tested, participants who had been tested for HIV were more likely to communicate with community members about ( a ) HIV/AIDS, ( b ) getting tested for HIV, and ( c ) using condoms. Testing positive for HIV was associated with communication with sexual partners about condom use. Among participants who had been tested for HIV, exploratory analyses revealed that those who had engaged in sexual health communication with community members or sexual partners reported more condom-protected sex than those who had not engaged in sexual health communication. Conclusions HIV testing is associated with sexual health communication among South African community members and sexual partners. Offering HIV testing to all South Africans may increase communication and lead to reductions in sexual risk.

We investigated alcohol-related sexual risk behavior from the perspective of social norms theory. Adults (N = 895, 62% men) residing in a South African township completed street-intercept surveys that assessed risk and protective behaviors (e.g., multiple partners, drinking before sex, meeting sex partners in shebeens, condom use) and corresponding norms. Men consistently overestimated the actual frequency of risky behaviors, as reported by the sample, and underestimated the frequency of condom use. Relative to actual attitudes, men believed that other men were more approving of risk behavior and less approving of condom use. Both behavioral and attitudinal norms predicted the respondents' self-reported risk behavior. These findings indicate that correcting inaccurate norms in HIV-risk reduction efforts is worthwhile.

Sexual risk behavior is higher when people vacation as compared to when they are at home. The current study uses survey data to compare sexual risk behavior of gay men who vacation at gay resorts to those who do not. Independent predictors of vacationing at gay resorts included income level, relationship status, ever having attended a circuit party, and HIV serostatus. For men who visit resorts to meet sex partners, independent predictors included relationship status, ever having attended a circuit party, HIV serostatus, number of male sex partners in the past six months, and number of anal insertive male partners using a condom. These results show a need for the development of structural interventions in the gay resort and hotel setting.

Background: South Africa has one of the fastest growing HIV epidemics in the world and new infections may often result from people who have tested HIV positive. This study examined the sexual practices and risk behaviours of men and women living with HIV/AIDS being treated for a co-occurring sexually transmitted infection (STI). Methods: A sample of men and women receiving services at three South African STI clinics completed a computer administered behavioural assessment. Results: Among the 218 HIV positive STI clinic patients, 34 (16%) had engaged in unprotected vaginal or anal intercourse with uninfected or unknown HIV status sex partners in the previous month. A multivariate logistic regression indicated that unprotected sex with uninfected or unknown HIV status partners was independently associated with older age, female gender, alcohol use, and other drug use, and drug use in sexual contexts. Conclusions: People living with HIV/AIDS who contract co-occurring STI are at significant risk for transmitting HIV to uninfected partners. Positive prevention interventions are urgently needed for South Africa.