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OBJECTIVE: Identify characteristics of hospital-based language services (LS), and describe practices of identifying patients with limited English proficiency (LEP) and interpreter training. Participants Seventy-one hospitals applied to participate in a national initiative. Applicants were non-federal, acute care hospitals with substantial LEP populations, at least 10,000 discharges, and in-person interpreters. METHODS: Descriptive statistics were generated on language, collection of language data, LEP volume and service utilization, staffing and training requirements and organizational structure. The relationship between admissions and encounters was analyzed. RESULTS: Ninety percent of hospitals collect primary language data. Spanish is the most common language (93% of hospitals). We found no statistically significant correlation between admissions and encounters. Eighty-four percent require training. Eighty-nine percent have a designated LS department but no clear organizational home. CONCLUSIONS: Hospital-based LS programs are facing challenges identifying patients with language needs, staffing and training a workforce, and creating an organizational identity. Need is not associated with utilization, suggesting that LS are not reaching patients. [ABSTRACT FROM AUTHOR]

Objective: To assess the attitudes of HIV seropositive current or former drug users towards HIV partner counseling and referral services (PCRS) and to determine if opinion varies by partner type.Methods: We used a cross-sectional survey using structured and semi-structured questions to measure attitudes towards PCRS.Results: The majority of the sample was African-American (97%), male (63%) and had been diagnosed with HIV for a mean of 7.9 years. Most agreed that PCRS would help stop the spread of HIV and AIDS (87%). A range of reactions to scenarios of their drug and sex partners being informed were observed and included positive reactions (e.g. PCRS as a means to facilitate testing of their partners and early treatment) to negative (e.g. feelings about guilt, shame and concern about partner responses).Conclusion: Data from this study indicate that HIV positive drug users view PCRS as a viable practice for preventing the spread of HIV, though barriers exist to engaging clients to identify partners.Practice Implications: The range of reactions noted in this study underscore the importance of providing flexible options for PCRS based on partner type. Additional training for counselors, time for case-management and meetings with sex and drug partners and fieldwork for locating contacts are important considerations for providers. [ABSTRACT FROM AUTHOR]

Background: Research has linked stigma surrounding preexposure prophylaxis (PrEP) to poor HIV prevention outcomes, including PrEP adherence. However, there remains a limited understanding of the mechanisms through which PrEP stigma affects PrEP adherence, specifically among sexual and gender minority (SGM) youth. In this study, we aimed to investigate the indirect effect of PrEP stigma on PrEP adherence through PrEP confidence and the moderating role of anticipated HIV stigma., Methods: Participants included 235 SGM youth, assigned male sex at birth, aged 16-24, and self-reported HIV-negative, with an active PrEP prescription from the Prepared, Protected, emPowered randomized controlled trial. Participants were recruited from 9 clinics in the United States between 2019 and 2021. Using baseline data, we tested cross-sectional indirect and conditional indirect effects using the Statistical Package for the Social Sciences Process with confidence intervals and 2000 resamples., Results: We found significant indirect effects, suggesting that PrEP stigma was negatively associated with PrEP confidence, which in turn resulted in both monthly and weekly optimal PrEP adherence (Indirect effects: B = -0.11, Standard Error [SE] = 0.05, CI: [-0.244 to -0.032]; B = -0.09, SE = 0.04, CI: [-0.191 to -0.014], respectively). Anticipated HIV stigma moderated these indirect effects (B = -0.11, SE = 0.08, CI: [-0.315 to -0.001]; B = -0.09, SE = 0.06, CI: [-0.245 to -0.001], respectively), suggesting that the conditional indirect effects were significant at high but not low levels of anticipated HIV stigma., Conclusion: Results suggest that SGM youth who are on PrEP anticipating HIV stigma experience a compounding effect of PrEP stigma on PrEP confidence, consequently leading to suboptimal adherence. Interventions addressing the intersectionality of PrEP and HIV stigmas and enhancing confidence could improve PrEP adherence, particularly among SGM youth., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Disclosing one's HIV status can involve complex individual and interpersonal processes interacting with discriminatory societal norms and institutionalized biases. To support disclosure decision-making among young men who have sex with men (YMSM) living with HIV, we developed Tough Talks™, an mHealth intervention that uses artificially intelligent-facilitated role-playing disclosure scenarios and informational activities that build disclosure skills and self-efficacy. Qualitative interviews were conducted with 30 YMSM living with HIV (mean age 24 years, 50% Black) who were enrolled in a randomized controlled trial assessing Tough Talks™ to understand their experiences with HIV status disclosure. Interviews were recorded, transcribed, and thematically coded. Barriers to disclosure focused on fear, anxiety, stigma, and trauma. Facilitators to disclosure are described in the context of these barriers including how participants built comfort and confidence in disclosure decisions and ways the Tough Talks™ intervention helped them. Participants' narratives identified meaning-making within disclosure conversations including opportunities for educating others and advocacy. Findings revealed ongoing challenges to HIV status disclosure among YMSM and a need for clinical providers and others to support disclosure decision-making and affirm individuals' autonomy over their decisions to disclose. Considering disclosure as a process rather than discrete events could inform future intervention approaches., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Stigma is a barrier to treatment and harm reduction seeking in people who use drugs. Most stigma reduction interventions offer psychotherapy or psychoeducation in group-based clinical settings, failing to reach people who are not in treatment. SMS text messaging is an effective and acceptable modality for delivering health information to people who use drugs and may be a suitable conduit for providing information and advice to understand and cope with stigma., Objective: This paper presents the protocol for a study that aims to determine the feasibility, acceptability, and preliminary effectiveness of a 4-week automated SMS text message intervention to increase stigma resistance and reduce self-stigma in people who use drugs., Methods: We designed a novel automated SMS text message intervention to address the four personal-level constructs of stigma resistance: (1) not believing stigma and catching and challenging stigmatizing thoughts, (2) empowering oneself through learning about substance use and one's recovery, (3) maintaining one's recovery and proving stigma wrong, and (4) developing a meaningful identity and purpose apart from one's substance use. Theory-based messages were developed and pilot-tested in qualitative elicitation interviews with 22 people who use drugs, resulting in a library of 56 messages. In a single-group, within-subjects, community-based pilot trial, we will enroll 30 participants in the Resisting Stigma and Revaluating Your Thoughts (RESTART) intervention. Participants will receive 2 daily SMS text messages for 4 weeks. Implementation feasibility will be assessed through recruitment, enrollment, retention, and message delivery statistics. User feasibility and acceptability will be assessed at follow-up using 23 survey items informed by the Theoretical Framework of Acceptability. Primary effectiveness outcomes are changes in self-stigma (Substance Abuse Self-Stigma Scale) and stigma resistance (Stigma Resistance Scale) from baseline to follow-up measured via a self-administered survey. Secondary outcomes are changes in hope (Adult Dispositional Hope Scale) and self-esteem (Rosenberg Self-Esteem Scale). Feasibility and acceptability will be assessed with descriptive statistics; effectiveness outcomes will be assessed with paired 2-tailed t tests, and group differences will be explored using ANOVA. Overall, 12 participants will also be selected to complete acceptability interviews., Results: This pilot study was funded by the National Institute on Drug Abuse in April 2023 and received regulatory approval in January 2024 by the University of North Carolina-Chapel Hill Institutional Review Board. Recruitment and enrollment began in March 2024. Follow-up visits are expected to conclude by May 2024. Results will be disseminated in relevant peer-reviewed journals., Conclusions: To the best of our knowledge, this is the first study to address substance use stigma via a self-help SMS text messaging program. Results will add to the nascent literature on stigma reduction in people who use drugs. This protocol may interest researchers who are considering text messaging to address psychosocial needs in hard-to-reach populations., Trial Registration: ClinicalTrials.gov NCT06281548; https://clinicaltrials.gov/ct2/show/NCT06281548., International Registered Report Identifier (irrid): DERR1-10.2196/59224., (©Adams L Sibley, Seth M Noar, Kathryn E Muessig, Nisha G O'Shea, Catherine E Paquette, Abby G Spears, William C Miller, Vivian F Go. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 09.08.2024.)

Purpose: In the United States, youth experience suboptimal HIV pre-exposure prophylaxis (PrEP) adherence. One common idea posits that this is due to their developing decision-making skills. However, quantitative evidence of this assumption is limited. We therefore examined whether individual decision-making factors, such as HIV risk perception and sexual behavior, predicted PrEP adherence in a national trial of young sexual and gender minorities (YSGMs)., Methods: In 2019-2021, the Adolescent Medicine Trials Network for HIV Interventions 142 study enrolled 225 PrEP users (ages 16-24) throughout the country. Regression models estimated the associations between HIV risk perception (using a modified Perceived HIV Risk Scale), sexual behavior (condomless anal sex in ≤ 3 months), and self-reported oral PrEP adherence (≥4 pills in the past week) at the same time point (baseline) and longitudinally (3 months)., Results: Baseline risk perception (risk ratio [RR]: 0.92, 95% confidence interval [CI]: 0.82, 1.04) and condomless anal sex (RR: 1.10, 95% CI: 0.97, 1.25) were not associated with PrEP adherence at the same time point and did not predict 3-month adherence (RR: 0.97, 95% CI: 0.85, 1.11; RR: 1.05, 95% CI: 0.93, 1.19, respectively). Baseline risk perception was not associated with condomless anal sex at either time point (baseline RR: 1.16, 95% CI: 0.94, 1.43; 3-month RR: 1.07, 95% CI: 0.90, 1.28)., Discussion: In this national trial of YSGM, HIV risk perception and condomless anal sex did not predict PrEP adherence. Targeting individual-level perceptions and behaviors will likely insufficiently address youth's suboptimal PrEP use. Future research should identify YSGM-specific adherence drivers and train providers to recognize such motivations., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Loneliness is a frequent experience among family members engaging in caregiving responsibilities and may vary across racial and ethnic groups. This study aimed to examine (a) the difference in loneliness between non-Hispanic Black and non-Hispanic White caregivers, (b) the associations between loneliness and perceptions of choice and purpose in caregiving, and (c) whether those associations with loneliness differ by caregivers' race., Method: Descriptive statistics and ordinal logistic regression were conducted in a population-based sample of 1000 caregivers (Black caregivers, n = 199; White caregivers, n = 801) from the 2020 Caregiving in the U.S., Study: The survey design was properly addressed. Key variables included loneliness (level of feeling alone about being a caregiver), choice (whether or not reporting a choice in taking on the caregiver responsibility), sense of purpose (level of purpose/meaning in life from caregiving), and race (Black/White). Models adjusted for caregiving characteristics (e.g., hour of caregiving) and sociodemographic characteristics (e.g., age and education)., Results: Black caregivers had lower odds of reporting a higher level vs. a lower level of loneliness than White caregivers (aOR = 0.67, 95%CI = 0.47, 0.96). Reporting having no choice was associated with higher odds of a higher level of loneliness (aOR, 0.77, 95%CI = 0.67, 0.88). Higher sense of purpose scores were associated with lower odds of a higher level of loneliness (aOR = 0.81, 95%CI = 0.71, 0.93). No significant moderation effects of race were found., Conclusion: Black caregivers reported lower loneliness scores than White caregivers. Reporting no choice and lower sense of purpose were associated with higher loneliness in both racial groups., (© 2024. International Society of Behavioral Medicine.)

Purpose of Review: Despite highly effective biomedical HIV pre-exposure prophylaxis (PrEP) options, suboptimal PrEP uptake impedes progress towards ending the epidemic in the United States of America (USA). Implementation science bridges what we know works in controlled clinical trial settings to the context and environment in which efficacious tools are intended to be deployed. In this review, we focus on strategies that target PrEP use barriers at the system or structural level, exploring the implications and opportunities in the context of the fragmented USA healthcare system., Recent Findings: Task shifting could increase PrEP prescribers, but effectiveness evidence is scarce in the USA, and generally focused in urban settings. Integration of PrEP within existing healthcare infrastructure concentrates related resources, but demonstration projects rarely present the resource implications of redirecting staff. Changing the site of service via expanded telehealth could improve access to more rural populations, though internet connectivity, technology access, and challenges associated with determining biomedical eligibility remain logistical barriers for some of the highest burden communities in the USA. Finally, a tailored care navigation and coordination approach has emerged as a highly effective component of PrEP service provision, attempting to directly modify the system-level determinants of PrEP use experienced by the individual. We highlight recent advances and evidence surrounding task shifting, integration, service delivery, and tailoring. With the exception of tailored care navigation, evidence is mixed, and the downstream impact and sustainability of task shifting and care integration require further attention. To maximize PrEP outcomes, research will need to continue to examine the interplay between individuals, clinics, and the healthcare system and associated policies within which they operate., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Oral pre-exposure prophylaxis (PrEP) as a safe and effective antiretroviral medicine-based prevention against HIV has not been widely adopted by gay, bisexual, and other men who have sex with men (MSM) in China. A deeper understanding of barriers and facilitators to PrEP uptake is needed to inform the development of effective interventions., Method: During July-August 2020, we conducted one-on-one semi-structured interviews with 31 Chinese MSM with varied PrEP use experiences (PrEP-naïve, former, and current PrEP users). Interviews were digitally recorded and transcribed in Chinese. Informed by the Information-Motivation-Behavioral Skills Model (IMB), we analyzed the data using a thematic analysis approach to identify the barriers and facilitators to PrEP uptake among Chinese MSM., Results: Major barriers to PrEP uptake among MSM in the sample included uncertainty about PrEP efficacy and lack of PrEP education (information), concerns over potential side effects and cost (motivation), and difficulties in identifying authentic PrEP medications and managing PrEP care (behavioral skills). Facilitators include the perceived benefit of PrEP in improving the quality of sex life and control over health. At the contextual level, we also identified barriers to PrEP access from a thriving informal PrEP market and stressors related to being MSM., Conclusion: Our findings identified a need to invest in non-discriminatory public health messaging of PrEP, explore options for MSM-friendly provision of PrEP outside of traditional HIV care settings, and be attentive to the unique context of an established informal PrEP market in future PrEP initiatives., (© 2023. International Society of Behavioral Medicine.)

Purpose of Review: The goal of this review was to examine online engagement using paradata (i.e., intervention usage metrics) as part of the reporting of online behavioral HIV prevention and care interventions' findings. We underscore the importance of these data in examining intervention engagement and effectiveness., Recent Findings: We focused on studies indexed in PubMed and published between April 1, 2017, and June 30, 2023, that reported the development and testing of online behavioral interventions for HIV prevention and/or care. Of the 689 extracted citations, 19 met the study criteria and provided engagement data - only six studies tested the association between engagement and intervention outcomes. Of these, four studies found a positive association between participants' engagement and improvements in HIV-related outcomes. Increasing attention is being paid to the collection and reporting of paradata within HIV online behavioral interventions. While the current evidence suggests a dose-response relationship due to user engagement on HIV outcomes, greater efforts to systematically collect, report, and analyze paradata are warranted., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Mobile health (mHealth) is a promising intervention mode for HIV prevention, but little is known about its feasibility and effects in promoting pre-exposure prophylaxis (PrEP) uptake among Chinese gay, bisexual and other men who have sex with men (GBMSM)., Methods: We evaluated an instant messaging application using a WeChat-based mini-app to promote PrEP uptake among GBMSM via a mixed-methods design that includes a 12-week, two-arm randomized controlled pilot trial and in-depth progress interviews in Guangzhou, China. Primary outcomes include the number of PrEP initiations, individual-level psychosocial variables related to PrEP initiation, and usability of the PrEP mini-app., Results: Between November 2020 and April 2021, 70 GBMSM were successfully enrolled and randomized into two arms at 2:1 ratio (46 to the intervention arm, 24 to the control arm). By the end of 12-week follow-up, 22 (31.4%) participants completed the initial consultation and lab tests for PrEP, and 13 (18.6%) filled their initial PrEP prescription. We observed modest but non-significant improvements in participants' intention to use PrEP, actual PrEP initiation, PrEP-related self-efficacy, stigma, and attitudes over 12 weeks when comparing the mini-app and the control arms. Qualitative interviews revealed the key barriers to PrEP uptake include anticipated stigma and discrimination in clinical settings, burden of PrEP care, and limited operating hours of the PrEP clinic. In-person clinic navigation support was highly valued., Conclusions: This pilot trial of a mobile phone-based PrEP mini-app demonstrated feasibility and identified limitations in facilitating PrEP uptake among Chinese GBMSM. Future improvements may include diversifying the content presentation in engaging media formats, adding user engagement features, and providing off-line in-clinic navigation support during initial PrEP visit. More efforts are needed to understand optimal strategies to identify and implement alternative PrEP provision models especially in highly stigmatized settings with diverse needs., Trial Registration: Trial registration: The study was prospectively registered on clinicaltrials.gov (NCT04426656) on 11 June, 2020., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Rationale: Known as the "Black-White mental health paradox," Black Americans typically report better mental health than White Americans, despite chronic exposure to the psychologically harmful effects of racism and discrimination. Yet, researchers rarely examine how mental health is experienced across racial groups in economically distressed rural regions where all residents have disproportionately less access to mental healthcare resources., Objective: The purpose of this study was to explore how the racialized social system potentially contributes to the mental health beliefs and attitudes of racially majoritized and minoritized rural residents., Methods: We conducted a secondary analysis of 29 health-focused oral history interviews from Black American (n = 16) and White American (n = 13) adults in rural North Carolina. Through critical discourse analysis, we found nuanced discourses linked to three mental-health-related topics: mental illness, stressors, and coping., Results: White rural residents' condemning discourses illustrated how their beliefs about mental illnesses were rooted in meritocratic notions of individual choice and personal responsibility. Conversely, Black rural residents offered compassionate discourses toward those who experience mental illness, and they described how macro-level mechanisms can affect individual well-being. Stressors also differed along racial lines, such that White residents were primarily concerned about perceived social changes, and Black residents referenced experiences of interpersonal and structural racism. Related to coping, Black and White rural residents characterized the mental health benefits of social support from involvement in their respective religious organizations. Only Black residents signified that a personal relationship with a higher power was an essential positive coping mechanism., Conclusions: Our findings suggest that belief (or disbelief) in meritocratic ideology and specific religious components could be important factors to probe with Black-White patterning in mental health outcomes. This research also suggests that sociocultural factors can disparately contribute to mental health beliefs and attitudes among diverse rural populations., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

We aimed to examine the mediating role of alcohol use in the pathway from the interventions to depression and anxiety symptoms using data from a randomized controlled trial among people living with HIV (PWH) with hazardous alcohol use ( n  = 440) in Thai Nguyen, Vietnam. Participants were randomized into either a combined intervention (CoI), a brief intervention (BI) and a standard of care arm. Both interventions were based on cognitive behavioral therapy and motivational enhancement therapy. Alcohol use was measured as the percentage of days abstinent from alcohol in the last 30 days. Symptoms of depression and anxiety were measured with the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 scales. Alcohol use was a significant mediator of the effects of two alcohol interventions on depression symptoms, but not anxiety symptoms. There were significant indirect effects via alcohol use of both interventions on depression symptoms at 12 months (CoI: mean difference (MD) = -0.134; 95%CI: -0.251, -0.035); (BI: MD = -0.141; 95%CI: -0.261, -0.038). There were no significant direct or total effects of the interventions on either symptoms at 12 months. Interventions with a dual focus on mental health and alcohol disorders are needed to determine optimal ways to tackle these common comorbidities among PWH.

Background: Adolescents and young adults with HIV repeatedly demonstrate low rates of antiretroviral therapy (ART) adherence as well as low rates of viral suppression. Digital health interventions are a promising way to engage adolescents and young adults with HIV to support ART adherence. However, few digital health interventions have been developed and tested with adolescents and young adults in countries like South Africa, where the HIV burden among adolescents and young adults is greatest. Masakhane Siphucule Impilo Yethu (MASI; Xhosa for "Let's empower each other and improve our health") is a comprehensive ART adherence-supporting app for South African adolescents and young adults with HIV. It was culturally adapted using the HealthMpowerment platform., Objective: The aim of this paper is to describe the protocol for a pilot randomized controlled trial examining the feasibility, acceptability, and preliminary efficacy of MASI on self-reported ART adherence and social support., Methods: We will enroll 50 adolescents and young adults with HIV ages 15-21 years. Participants will be recruited from public ART clinics linked to a large government-funded teaching hospital in Cape Town, South Africa. Participants will be randomized 1:1 into either the intervention arm receiving a full version of MASI or the control arm receiving an information-only version of the app (n=25 per arm). Participants will be asked to engage with MASI daily for 6 months. All participants will complete baseline and follow-up assessments at 3 and 6 months., Results: Study screening began in May 2022 and the first participant was enrolled on June 21, 2022. As of June 12, 2023, 81 participants have completed screeners, and 36 eligible participants have been enrolled in the pilot randomized controlled trial. Recruitment is anticipated to last through August 31, 2023, with study activities anticipated through February 29, 2024., Conclusions: There is an urgent need for innovative interventions to improve ART adherence among adolescents and young adults in settings like South Africa. If found to be feasible and acceptable, MASI could be implemented with adolescents and young adults with HIV in other parts of the country., Trial Registration: ClinicalTrials.gov NCT04661878; https://clinicaltrials.gov/ct2/show/study/NCT04661878., International Registered Report Identifier (irrid): DERR1-10.2196/47137., (©Marta I Mulawa, Jacqueline Hoare, Elizabeth T Knippler, Bulelwa Mtukushe, Mluleki Matiwane, Kathryn E Muessig, Maryam Al-Mujtaba, T Harper Wilkinson, Alyssa Platt, Joseph R Egger, Lisa B Hightow-Weidman. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 19.09.2023.)

Introduction: Little is known about the effects of universal test and treat (UTT) policies on HIV care outcomes among youth living with HIV (YLHIV). Moreover, there is a paucity of information regarding when YLHIV are most susceptible to disengagement from care under the newest treatment guidelines. The longitudinal HIV care continuum is an underutilized tool that can provide a holistic understanding of population-level HIV care trajectories and be used to compare treatment outcomes across groups. We aimed to explore effects of the UTT policy on longitudinal outcomes among South African YLHIV and identify temporally precise opportunities for re-engaging this priority population in the UTT era., Methods: Using medical record data, we conducted a retrospective cohort study among youth aged 18-24 diagnosed with HIV from August 2015-December 2018 in nine health care facilities in South Africa. We used Fine and Gray sub-distribution proportional hazards models to characterize longitudinal care continuum outcomes in the population overall and stratified by treatment era of diagnosis. We estimated the proportion of individuals in each stage of the continuum over time and the restricted mean time spent in each stage in the first year following diagnosis. Sub-group estimates were compared using differences., Results: A total of 420 YLHIV were included. By day 365 following diagnosis, just 23% of individuals had no 90-or-more-day lapse in care and were virally suppressed. Those diagnosed in the UTT era spent less time as ART-naïve (mean difference=-19.3 days; 95% CI: -27.7, -10.9) and more time virally suppressed (mean difference = 17.7; 95% CI: 1.0, 34.4) compared to those diagnosed pre-UTT. Most individuals who were diagnosed in the UTT era and experienced a 90-or-more-day lapse in care disengaged between diagnosis and linkage to care or ART initiation and viral suppression., Conclusions: Implementation of UTT yielded modest improvements in time spent on ART and virally suppressed among South African YLHIV- however, meeting UNAIDS' 95-95-95 targets remains a challenge. Retention in care and re-engagement interventions that can be implemented between diagnosis and linkage to care and between ART initiation and viral suppression (e.g., longitudinal counseling) may be particularly important to improving care outcomes among South African YLHIV in the UTT era., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Mental health problems, including anxiety and depression, are a common comorbidity among gay, bisexual and other men who have sex with men (GBMSM) living with HIV. Informed by social support theory, health navigation is a strengths-based intervention that has been demonstrated to improve HIV care outcomes. The purpose of this study was to explore how health navigation influences the mental health of GBMSM living with HIV. We analyzed longitudinal qualitative in-depth interviews conducted with GBMSM (n = 29) in a 12-month multi-component intervention to improve HIV care outcomes, including health navigation. We used narrative and thematic analytic approaches to identify salient themes, including if and how themes changed over time. Participants described that navigator support helped them maintain good mental health, prevent crises and respond to crises. Navigator support included providing motivational messaging, facilitating participants' control over their health and improving access to care, which aided with supporting mental health. Navigators also responded to acute crises by providing guidance for those newly diagnosed with HIV and support for those experiencing critical life events. Participants emphasized the importance of feeling heard and valued by their navigators and gaining hope for the future as key to their wellbeing. In conclusion, health navigation may be an effective intervention for promoting mental health among GBMSM living with HIV. Additional research is needed to examine mediating pathways between navigation and mental health, including informational support, or if navigator support moderates the relationship between stressors and mental health outcomes for GBMSM., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Novel smartphone app-delivered interventions have the potential to improve HIV treatment adherence among adolescents with HIV, although such interventions are limited. Our team has developed Masakhane Siphucule Impilo Yethu (MASI; Xhosa for "Let's empower each other and improve our health"), a smartphone app-delivered intervention to improve treatment adherence among adolescents with HIV in South Africa. MASI was adapted to the South African cultural context using the HealthMpowerment platform, an evidence-based digital health intervention developed for and with youth in the United States., Objective: We conducted this beta-testing study to (1) explore the initial usability of MASI, (2) examine engagement and experiences using MASI features, and (3) inform refinements to the app and intervention implementation plan prior to a subsequent pilot randomized controlled trial (RCT)., Methods: This study was conducted from August 2021 to December 2021 in Cape Town, South Africa. Beta-testing participants received access to MASI for 3 weeks. A mixed methods approach was used, with brief questionnaires and semistructured in-depth interviews conducted prior to app installation and after 1 week to 2 weeks of app testing. Engagement with MASI was measured through analysis of back-end app paradata, and follow-up in-depth interview guides were tailored to each participant based on their app use., Results: Participants in the beta-testing study (6 male participants, 6 female participants; ages 16-19 years) collectively spent 4.3 hours in MASI, averaging 21.4 minutes per participant over the 3-week period (range 1-51.8 minutes). Participants logged into MASI an average of 24.1 (range 10-75) times during the study period. The mean System Usability Scale score was 69.5 (SD 18), which is considered slightly above average for digital health apps. Thematic analysis of qualitative results revealed generally positive experiences across MASI features, although opportunities to refine the app and intervention delivery were identified., Conclusions: Initial usability of MASI was high, and participants described having a generally positive experience across MASI features. Systematically analyzing paradata and using the interview findings to explore participant experiences allowed us to gain richer insights into patterns of participant engagement, enabling our team to further enhance MASI. The results from this study led to a few technological refinements to improve the user experience. Enhancements were also made to the intervention implementation plan in preparation for a pilot RCT. Lessons learned from the conduct of this beta-testing study may inform the development, implementation, and evaluation of similar app-delivered interventions in the future., (©Marta I Mulawa, Bulelwa Mtukushe, Elizabeth T Knippler, Mluleki Matiwane, Maryam Al-Mujtaba, Kathryn E Muessig, Jacqueline Hoare, Lisa B Hightow-Weidman. Originally published in JMIR Formative Research (https://formative.jmir.org), 01.06.2023.)

Multiple aspects of Black young men who have sex with men's (YMSM) identities cause them to be differentially targeted for arrest and incarceration. However, limited research has explored structural drivers of Black YMSM' criminal justice involvement, particularly co-occurring forms of discrimination. This article examines the temporal relationship between perceived racial discrimination, perceived sexual orientation discrimination, and community-level HIV discrimination and criminal justice involvement among Black YMSM in North Carolina. The study followed 465 Black YMSM from November 2013 to October 2016 who were recruited for a randomized controlled trial to test an internet-based intervention for Black YMSM living with, and at risk for HIV; participants completed online surveys at baseline, 3, 6, and 12 months. Logistic regression was used to explore the relationship between the three predictors at baseline (i.e., perceived racism and sexual orientation discrimination and community-level HIV discrimination) and criminal justice involvement at follow-up. All three predictor variables were significantly associated with subsequent criminal justice involvement in separate regression models that adjusted for other covariates: HIV discrimination (aOR = 1.06 [1.01-1.11]), perceived sexual orientation discrimination (aOR = 1.12 [1.00-1.27]), and perceived racism (aOR = 1.26 [1.12-1.42]). Perceived racism remained significant in the model with all three predictors (aOR = 1.29 [1.07-1.55]). Racism did not modify the relationship between HIV discrimination and perceived sexual orientation discrimination and criminal justice involvement. This study expands existing research by exploring racism as a structural driver of criminal justice involvement; we subsequently examined whether racism modified the effect of the two other predictors. It also contributes to research on co-occurring discrimination by examining their impact on an underrepresented population.

Purpose: This study aims to describe the cohort of Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) research program participants and evaluate whether the ATN's recently completed 5-year cycle recruited study participants who parallel the populations most impacted by HIV in the United States., Methods: Harmonized measures across ATN studies collected at baseline were aggregated for participants aged 13-24 years. Pooled means and proportions stratified by HIV status (at risk for or living with HIV) were calculated using unweighted averages of study-specific aggregate data. Medians were estimated using a weighted median of medians method. Public use 2019 Centers for Disease Control and Prevention surveillance data for state-level new HIV diagnoses and HIV prevalence among US youth aged 13-24 years were obtained for use as reference populations for ATN at-risk youth and youth living with HIV (YLWH), respectively., Results: Data from 3,185 youth at-risk for HIV and 542 YLWH were pooled from 21 ATN study phases conducted across the United States. Among ATN studies tailored to at-risk youth, a higher proportion of participants were White and a lower proportion were Black/African American and Hispanic/Latinx compared to youth newly diagnosed with HIV in the United States in 2019. Participants in ATN studies tailored to YLWH were demographically similar to YLWH in the United States., Discussion: The development of data harmonization guidelines for ATN research activities facilitated this cross-network pooled analysis. These findings suggest the ATN's YLWH are representative, but that future studies of at-risk youth should prioritize recruitment strategies to enroll more participants from African American and Hispanic/Latinx populations., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

To date, there are no established scales to assess PrEP stigma among youth. We validated the Youth PrEP Stigma Scale within the Adolescent Trials Network P3 study (2019-2021). Data from sexual and gender minority youth (16-24 years) who were prescribed PrEP across nine domestic sites were evaluated (N = 235). Descriptive statistics, exploratory factor analysis, and correlation coefficients are reported. Results yielded a three-factor solution (PrEP Disapproval by Others, Enacted PrEP Stigma, and PrEP User Stereotypes) with strong factor loadings and Cronbach's alphas ranging from 0.83 to 0.90, suggesting excellent internal consistency. Correlations between this Scale, anticipated HIV stigma, perceived HIV risk, and disclosure of sexual identity were significant, indicating potential for robust application. Given the persistence of HIV infections among youth, stigma as a barrier to prevention, and expansion of PrEP modalities, the Youth PrEP Stigma Scale could enhance intervention and mechanistic research among youth at elevated risk for HIV acquisition., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Interventions for increasing the uptake of COVID-19 vaccination among Black young adults are central to ending the pandemic. Black young adults experience harms from structural forces, such as racism and stigma, that reduce receptivity to traditional public health messaging due to skepticism and distrust. As such, Black young adults continue to represent a priority population on which to focus efforts for promoting COVID-19 vaccine uptake., Objective: In aims 1 and 2, the Tough Talks digital health intervention for HIV disclosure will be adapted to address COVID-19 vaccine hesitancy and tailored to the experiences of Black young adults in the southern United States (Tough Talks for COVID-19). In aim 3, the newly adapted Tough Talks for COVID-19 digital health intervention will be tested across the following three southern states: Alabama, Georgia, and North Carolina., Methods: Our innovative digital health intervention study will include qualitative and quantitative assessments. A unique combination of methodological techniques, including web-based surveys, choose-your-own-adventures, digital storytelling, user acceptability testing, and community-based participatory approaches, will culminate in a 2-arm hybrid type 1 effectiveness implementation randomized controlled trial, wherein participants will be randomized to the Tough Talks for COVID-19 intervention arm or a standard-of-care control condition (N=360). Logistic regression will be used to determine the effect of the treatment arm on the probability of vaccination uptake (primary COVID-19 vaccine series or recommended boosters). Concurrently, the inner and outer contexts of implementation will be ascertained and catalogued to inform future scale-up. Florida State University's institutional review board approved the study (STUDY00003617)., Results: Our study was funded at the end of April 2021. Aim 1 data collection concluded in early 2022. The entire study is expected to conclude in January 2025., Conclusions: If effective, our digital health intervention will be poised for broad, rapid dissemination to reduce COVID-19 mortality among unvaccinated Black young adults in the southern United States. Our findings will have the potential to inform efforts that seek to address medical mistrust through participatory approaches. The lessons learned from the conduct of our study could be instrumental in improving health care engagement among Black young adults for several critical areas that disproportionately harm this community, such as tobacco control and diabetes prevention., Trial Registration: ClinicalTrials.gov NCT05490329; https://clinicaltrials.gov/ct2/show/NCT05490329., International Registered Report Identifier (irrid): DERR1-10.2196/41240., (©Henna Budhwani, Allysha C Maragh-Bass, Elizabeth E Tolley, Maria Leonora G Comello, Marie C D Stoner, Margo Adams Larsen, Donald Brambilla, Kathryn E Muessig, Audrey Pettifor, Christyenne L Bond, Christina Toval, Lisa B Hightow-Weidman. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 13.02.2023.)

Black men who have sex with men (BMSM) face disproportionately higher risks for adverse sexual health outcomes compared to their non-Hispanic White counterparts. This disparity can be attributable to overlapping and intersecting risk factors at the individual and structural levels and can be understood through syndemic theory. Using longitudinal data from the HealthMPowerment trial (n = 363), six conditions related to stigma syndemics were indexed as a cumulative risk score: high alcohol use, polydrug use, depression and anxiety symptomology, and experiences of racism and sexual minority stigma. Using Poisson regression, we found a positive association between baseline risk scores and sexual risk behavior (b: 0.32, SE: 0.03, p < 0.001). Using a Generalized Estimating Equation, we also found a 0.23 decrease in the within-participant risk scores at 3-month follow-up (SE: 0.10, p < 0.020). Future work examining how care and prevention trials improve health outcomes in this population is needed., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Young Black gay and bisexual men who have sex with men experience stigma related to race, gender expression, sexuality and HIV status. Stigma impacts access to HIV care and prevention as well as interactions with healthcare providers. The amplification of stigma through popular media is under-researched in the health sciences. HealthMpowerment is a mobile phone optimised intervention to reduce sexual risk and support community-building for young Black gay and bisexual men (age 18-30). We analysed Forum conversations from 48 participants, 45.8% living with HIV. Of 322 stigma-relevant conversations, 18.9% referenced the media (e.g. television, news, social media) as a source of stigma. Forum conversations covered media representations of Black gay and bisexual men, media's influence on identity, and the creation of stigma by association with media representations. Cultural messages embedded in the media may accentuate stereotypes that influence perceptions of Black gay and bisexual men and disregard intersectional identities. HealthMpowerment provided a space to challenge stigmatising representations. Participants used HealthMpowerment to garner social support and celebrate positive media representations. Interventions for young Black gay and bisexual men should consider the influential role of media and include spaces for participants to process and address stigma.

Interactive stories are a relatively newer form of storytelling with great potential to correct misinformation while increasing self-efficacy, which is crucial to vaccine acceptance. To address COVID-19 vaccine hesitancy and medical mistrust in young Black adults (BYA), we sought to adapt a pre-existing application ("app"; Tough Talks) designed to address HIV disclosure decision-making through choose-your-own adventure (CYOA) narratives and other activities. The adapted app (Tough Talks - COVID) uses a similar approach to situate COVID-19 vaccination decision-making within social contexts and to encourage greater deliberation about decisions. To inform content for the CYOA narratives, we conducted an online survey that was used to elicit the behavioral, cognitive, and environmental determinants influencing COVID-19 vaccine hesitancy among 150 BYA (ages 18-29) in Georgia, Alabama, and North Carolina. The survey included scenario questions that were developed with input from a youth advisory board to understand responses to peer and family influences. In two scenarios that involved discussions with family and friends about vaccination status, most respondents chose to be honest about their vaccination status. However, vaccinated individuals perceived more social pressure and stigma about not being vaccinated than unvaccinated respondents who were not as motivated by social pressure. Personal choice/agency in the face of perceived vaccine risks was a more common theme for unvaccinated respondents. Results suggest that relying on changing social norms alone may not impact barriers to vaccination in unvaccinated young adults without also addressing other barriers to vaccination such as concerns about autonomy and vaccine safety. Based on these findings, CYOA narratives in the app were adapted to include discussions with family and friends but also to touch on themes of personal choice as well as other topics that influence behaviors besides norms such as safety, side effects, and risk of COVID-19 in an evolving pandemic., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Scaling up use of Pre-Exposure Prophylaxis (PrEP) among young men who have sex with men and transgender women (YMSM/TGW) is a critical part of the Ending the HIV Epidemic plan. This qualitative study contextualized the social determinants of health (SDOH) that can impede HIV prevention in rural North and South Carolina with 14 key informant interviews with stakeholders and 3 focus groups with YMSM/TGW ( N  = 23). A deductive-inductive approach with multiple coders was employed to identify themes related to SDOH in rural areas, including economic challenges (e.g., housing and food insecurity), neighborhood characteristics (e.g., lack of transportation), healthcare-related issues (e.g., provider shortages) and educational barriers (e.g., lack of comprehensive and inclusive sexual education). The socio-environmental context of the rural South and prioritization of local, community-based partnerships are necessary to reduce the burden of HIV.

Pre-exposure prophylaxis (PrEP) is a lifesaving medical intervention that protects against human immunodeficiency virus (HIV), but to date, PrEP uptake has been limited. PrEP utilization and adherence among youth, including stigmatized and highly vulnerable young sexual and gender minorities, have been exceptionally low across all regions, leading to preventable HIV transmission. Considering the scientific value of measuring and understanding predictors or associations of PrEP adherence, our study team validated two scales: a PrEP Difficulties Scale and a PrEP Confidence Scale tested within the Adolescent Trials Network P3 study (2019-2021). Data from sexual and gender minorities who were prescribed PrEP across nine domestic sites were evaluated ( N  = 235). Descriptive statistics, exploratory factor analysis, and correlation coefficients are reported herein. Results for the PrEP Difficulties Scale yielded a four-factor solution (Disclosure, Health Effects, Logistics, and Cost), and results for the PrEP Confidence Scale produced a three-factor solution (Scheduling, Distraction, and Planning). Factor loadings and Cronbach's alphas suggested good internal consistency for both scales. PrEP Confidence Scale subscales were correlated with PrEP adherence, and subscales of both scales were associated with dimensions of social support and PrEP-related stigma. Given the persistence of preventable HIV infections among key populations, multi-level barriers and facilitators to medication adherence, and expansion of PrEP modalities, the PrEP Difficulties Scale and PrEP Confidence Scale have the potential to enhance intervention, exploratory, and mechanistic HIV prevention research. ClinicalTrials.gov Identifier: NCT03320512.

Background: Few studies have focused on attitudes toward COVID-19 vaccination among Black or African American young adults (BYA) in the Southern United States, despite high levels of infection in this population., Objective: To understand this gap, we conducted an online survey to explore beliefs and experiences related to COVID-19 vaccination among BYA (aged 18-29 years) in 3 southern states., Methods: We recruited 150 BYA to participate in an online survey as formative research for an intervention to address vaccine hesitancy in Alabama, Georgia, and North Carolina from September 22, 2021, to November 18, 2021. Participants were recruited through social media ads on Facebook, Twitter, Instagram, and YouTube. Additionally, we distributed information about the survey through organizations working with BYA in Alabama, Georgia, and North Carolina; our community partners; and network collaborations. We used measures that had been used and were previously validated in prior surveys, adapting them to the context of this study., Results: Roughly 28 (19%) of the participants had not received any doses of the COVID-19 vaccine. Half of the unvaccinated respondents (n=14, 50%) reported they wanted to wait longer before getting vaccinated. Motivators to get vaccinated were similar between unvaccinated and vaccinated respondents (eg, if required, to protect the health of others), but the main motivator for those vaccinated was to protect one's own health. Among unvaccinated individuals, reasons for not receiving the COVID-19 vaccine included concern about vaccine side effects (n=15, 54%) and mistrust of vaccine safety (n=13, 46%), of effectiveness (n=12, 43%), and of the government's involvement with vaccines (n=12, 43%). Experiences of discrimination (n=60, 40%) and mistrust of vaccines (n=54, 36%) were common overall. Among all respondents, those who said they would be motivated to get vaccinated if it was required for school, work, or travel were more likely to endorse negative beliefs about vaccines compared to those motivated for other reasons., Conclusions: Mistrust in COVID-19 vaccine safety and efficacy is common among BYA in the Southern United States, irrespective of vaccination status. Other motivators, such as safety of family and community and vaccination requirements, may be able to tip the scales toward a decision to be vaccinated among those who are initially hesitant. However, it is unclear how vaccine requirements among BYA in the South affect trust in the government or health care in the long term. Interventions that include BYA in vaccination messaging and programs may more proactively build feelings of trust and combat misinformation., (©Marie CD Stoner, Erica N Browne, David Tweedy, Audrey E Pettifor, Allysha C Maragh-Bass, Christina Toval, Elizabeth E Tolley, Maria Leonora G Comello, Kathryn E Muessig, Henna Budhwani, Lisa B Hightow-Weidman. Originally published in JMIR Formative Research (https://formative.jmir.org), 02.09.2022.)

Little is known about the potential mental health impacts of cognitive behavioral therapy and motivational interviewing interventions that focus on alcohol reduction among people with HIV (PWH). Our study aimed to assess the impact of two evidence-based alcohol reduction interventions on depression and anxiety symptoms of antiretroviral therapy (ART) clients with hazardous alcohol use. We conducted a secondary data analysis of data from a three-arm randomized controlled trial among ART clients in Thai Nguyen, Vietnam that evaluated the impacts of two alcohol reduction interventions in Vietnam. ART clients 18 years old or more with hazardous alcohol use (based on the Alcohol Use Disorders Identification Test-Consumption) were enrolled and randomized into one of three arms: Combined intervention, Brief intervention, and Standard of care (SOC). Symptoms of depression, measured with the Patient Health Questionnaire-9, and anxiety, measured with the Generalized Anxiety Disorder-7 scale, were assessed at baseline and 3, 6, and 12 months post-intervention. Generalized estimating equations were used to evaluate the effects of the interventions on depression and anxiety symptoms. The prevalence of depression and anxiety symptoms at baseline was 25.1% and 16.1%, respectively. Decreases in depression and anxiety symptoms were observed in all three arms from baseline to 12-month follow-up. There were no significant differences in depression and anxiety symptoms among participants receiving either intervention, relative to the SOC. Interventions with a dual focus on alcohol and mental health are needed to achieve more pronounced and sustainable improvements in depression and anxiety symptoms for PWH with hazardous alcohol use., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: The large number of key populations in China who would benefit from HIV pre-exposure prophylaxis (PrEP) in the context of limited health system capacity and public awareness will pose challenges for timely PrEP scale-up, suggesting an urgent need for innovative and accessible interventions. This study aims to develop and pilot test a theory-informed, tailored mobile phone intervention that was codeveloped by young gay men, HIV clinicians and public health researchers to increase engagement in PrEP education and initiation among Chinese gay, bisexual and other men who have sex with men (GBMSM), who bear a disproportionate burden of HIV infections and remain underserved in the healthcare system., Methods and Analysis: This two-phase study includes a formative assessment using in-depth interviews (N=30) and a 12-week experimental pilot study using a two-arm randomised controlled trial design (N=70). The primary intervention is delivered through a WeChat-based mini-app (a program built into a Chinese multipurpose social media application) developed by young GBMSM from a 2019 crowdsourcing hackathon. Using mixed methods, we will further investigate the specific needs and concerns among GBMSM in terms of using PrEP as an HIV prevention strategy, how their concerns and PrEP use behaviours may change with exposure to the mini-app intervention during the study period and how we can further refine this intervention tool to better meet GBMSM's needs for broader implementation., Ethics and Dissemination: This study and its protocols have been reviewed and approved by the Institutional Review Boards of the University of North Carolina at Chapel Hill, USA (19-3481), the Guangdong Provincial Dermatology Hospital, China (2020031) and the Guangzhou Eighth People's Hospital, China (202022155). Study staff will work with local GBMSM community-based organisations to disseminate the study results to participants and the community via social media, workshops and journal publications., Trial Registration Number: The study was prospectively registered on clinicaltrials.gov (NCT04426656) on 11 June 2020., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Rationale: Historic and present-day racism and inequity in the United States (U.S.) have resulted in diminished trust in health care among many populations. A key barrier to improving trust in health care is a dearth of well-validated measures appropriate for diverse populations. Indeed, systematic reviews indicate a need to develop and test updated trust measures that are multidimensional and inclusive of relevant domains (e.g., fairness)., Objective: We developed three trust measures: the Trust in My Doctor (T-MD), Trust in Doctors in General (T-DiG), and Trust in the Health Care Team (T-HCT) scales., Methods: After developing an initial item pool, expert reviewers (n = 6) provided feedback on the face validity of each scale. We conducted cognitive interviews (n = 21) with a convenience sample of adults to ensure items were interpreted as intended. In 2020, we administered an online survey to a convenience sample of U.S. adults recruited through the Qualtrics Panel (n = 801) to assess scale reliability and validity., Results: Exploratory and confirmatory factor analyses indicated acceptable model fit for second order latent factor models for each scale (root mean square error of approximation: <0.07, comparative fit index: ≥0.98, and standardized root mean square residual: ≤0.03). The T-MD contained 25 items and six subscales: communication competency, fidelity, systems trust, confidentiality, fairness, and global trust. The T-DiG and T-HCT each contained 29 items and seven subscales (the same subscales in the T-MD plus an additional subscale related to stigma-based discrimination). Each scale was strongly correlated with existing trust measures and perceived racism in health care and was significantly associated with delayed health care seeking and receipt of a routine health exam., Conclusions: The multidimensional T-MD, T-DiG, and T-HCT scales have sound psychometric properties and may be useful for researchers evaluating trust-related interventions or conducting studies where trust is an important construct or main outcome., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: The acceptability of health interventions is centrally important to achieving their desired health outcomes. The construct of acceptability of mobile health interventions among adolescents is neither well-defined nor consistently operationalized., Objectives: Building on the theoretical framework of acceptability, these two studies developed and assessed the reliability and validity of a new scale to measure the acceptability of mobile health applications ("apps") among adolescents., Methods: We followed a structured scale development process including exploratory factor analyses (EFAs), confirmatory factor analyses (CFAs), and employed structural equation modeling (SEM) to assess the relationship between the scale and app usage. Adolescent participants used the Fooducate healthy eating app and completed the acceptability scale at baseline and one-week follow-up., Results: EFA ( n  = 182) determined that the acceptability of health apps was a multidimensional construct with six latent factors: affective attitude, burden, ethicality, intervention coherence, perceived effectiveness, and self-efficacy. CFA ( n  = 161) from the second sample affirmed the six-factor structure and the unidimensional structures for each of the six subscales. However, CFA did not confirm the higher-order latent factor model suggesting that the six subscales reflect unique aspects of acceptability. SEM indicated that two of the subscales-ethicality and self-efficacy-were predictive of health app usage at one-week follow-up., Conclusions: These results highlight the importance of ethicality and self-efficacy for health app acceptability. Future research testing and adapting this new acceptability scale will enhance measurement tools in the fields of mobile health and adolescent health., Competing Interests: Declaration of conflicting interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Biomedical advances in diagnostics, treatment and prevention increase the means available to reduce HIV transmission risk. Subsequent shifts in HIV status disclosure obligation and ethics may impact how those living with HIV view, enact and experience disclosure. We analysed focus group and interview data to explore how these changes are reflected in disclosure decision-making to sexual partners among young gay and bisexual men living with HIV in the USA. Three interrelated themes were identified: engaging with partners' varying HIV knowledge; attribution of blame; and negotiating disclosure-related harms. Participants experienced blame from partners that questioned the timing of HIV testing, status disclosure and sex events without regards for viral suppression or use of pre-exposure prophylaxis. Substantial HIV stigma was described in response to disclosure, mitigated in some cases by partners' higher HIV knowledge. Overall, an uneven diffusion of HIV treatment and prevention knowledge and continuing HIV stigma seemed to limit the translation of biomedical advances into improved disclosure experiences. Our findings suggest that young gay and bisexual men living with HIV may continue to perform much of the moral labour involved in disclosure by managing others' reactions, correcting inaccurate sexual health information, and negotiating the risks of disclosure-related harm.

Pre-exposure prophylaxis (PrEP) can reduce HIV transmission among gay and bisexual men (GBM). However, stigma can inhibit disclosure of PrEP use, which may limit uptake. This study's purpose was to explore PrEP disclosure experiences and how disclosure is associated with PrEP adherence among GBM at a sexual health clinic in Guatemala City. We conducted in-depth interviews with PrEP users (n = 18) and used an iterative content analysis approach. All participants had or planned to disclose their PrEP use to at least one person, most commonly friends and sex partners, though many were selective about who they told. Main reasons for disclosure were to educate others, gain social support, and clarify their HIV status. Concerns about stigma and emotional discomfort deterred disclosure. Disclosure facilitated PrEP access and adherence by enhancing emotional and instrumental support. Interventions providing opportunities for GBM to practice disclosure, including addressing others' misconceptions, could promote PrEP uptake and adherence., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Transgender and gender diverse individuals often face structural barriers to health care because of their gender minority status. The aim of this study was to examine the association between gender minority stress and access to specific health care services among transgender women and transfeminine people in China., Methods: This multicenter cross-sectional study recruited participants between January 1st and June 30th 2020. Eligible participants were 18 years or older, assigned male at birth, not currently identifying as male, and living in China. Gender minority stress was measured using 45 items adapted from validated subscales. We examined access to health care services and interventions relevant to transgender and gender diverse people, including gender affirming interventions (hormones, surgeries), human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). Multivariable regression was used to measure correlations between gender minority stress and access to health care service., Results: Three hundred and twenty-four people completed a survey and data from 277 (85.5%) people were analyzed. The mean age was 29 years old (standard deviation [SD] = 8). Participants used hormones (118/277, 42.6%), gender affirming surgery (26/277, 9.4%), HIV testing (220/277, 79.4%), STI testing (132/277, 47.7%), PrEP (24/276, 8.7%), and PEP (29/267, 10.9%). Using gender affirming hormones was associated with higher levels of discrimination (adjusted odds ratio [aOR] 1.41, 95% confidence interval [CI] 1.17-1.70) and internalized transphobia (aOR 1.06, 95%CI 1.00-1.12). STI testing was associated with lower levels of internalized transphobia (aOR 0.91, 95%CI 0.84-0.98)., Conclusions: Our data suggest that gender minority stress is closely related to using health services. Stigma reduction interventions and gender-affirming medical support are needed to improve transgender health., (© 2021. The Author(s).)

HIV incidence among young men who have sex with men (YMSM) is disproportionally high. Youth living with HIV demonstrate low rates of sustained virologic suppression (VS). Epic Allies, a theory-based behavioral intervention mobile app, utilizes self-management tools, gamification, and social support to improve engagement in care and antiretroviral adherence among YMSM living with HIV. A two-arm individually randomized-controlled trial enrolled 146 participants aged 16 to 24 years old to test the efficacy of Epic Allies to achieve VS. Both study arms showed improved VS at 26-weeks (62.9% intervention; 73.5% control; ARR = 0.93 (95% CI 0.73, 1.18)) and antiretroviral adherence; intervention effects were amplified in regular app users. Issues with recruitment and app usage metrics limit the ability to definitively say that the app was effective in causing behavior changes resulting in improved health outcomes. (ClinicalTrials.gov Identifier: NCT02782130).

Background: U.S. sexual and gender minority youth experience individual, interpersonal, and structural-level barriers to HIV prevention and care. Innovative, youth-driven approaches to mobile and electronic interventions that support use of new biomedical prevention, testing, and treatment options may address these barriers. Adapting evidence-based interventions for youth must balance core intervention components with responsiveness to the distinct needs of end-users., Methods: The UNC/Emory Center for Innovative Technology (iTech) adapts and evaluates technology-based interventions for youth living with or at risk for HIV. We analyzed formative research (focus groups and individual usability sessions) across five iTech studies: two apps promoting HIV testing and pre-exposure prophylaxis (PrEP), one app promoting behavioral risk reduction and PrEP, one PrEP adherence app, and one mobile-optimized website for increasing viral suppression, with the aim of informing best practices for technology-based intervention development. Each study presented prototypes of adapted mHealth interventions to samples of their target end-user population for use and/or evaluation., Results: One hundred and thirty-eight youth across seven geographically diverse sites provided feedback during the intervention adaptation process. We found high interest in and acceptability of all five intervention prototypes. Cross-study themes included: (I) Desire for multiple privacy protections (e.g., password, fingerprint) to keep HIV status, sexual identity, and sexual behavior confidential. (II) Strong but varied preferences for the look and feel of platforms. Imagery should be discrete but representative. Participants valued customizable platforms and positive themes, motivational language, and humor. Youth wanted information presented using multiple modalities (e.g., text, video, image) to increase engagement. (III) Youth preferred engagement features and functions consistent with familiar platforms (e.g., Snapchat, Instagram). Gamification features that resulted in tangible versus virtual rewards were predicted to increase engagement. Intervention messaging functions were perceived as useful; customization was desired as a way to control frequency, mode (e.g., SMS, in-app message, push notification), and content. (IV) Youth voiced varied preferences for platform content including: featuring young role models from the lesbian, gay, bisexual, transgender, queer and/or questioning (LGBTQ) community, incorporating mental health resources, and maintaining a holistic health-focus (not HIV-centric)., Conclusions: We found high acceptability and consistent feedback in youths' evaluations of these mHealth interventions; divergence was most commonly found in preferred content versus features and functions. Identifying broadly accepted aspects of mHealth interventions for youth supports the feasibility of adaptation (versus de novo creation) and should guide the focus of future formative research phases. Continued research is needed to better understand how to balance usability preferences with finite resources for customization., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/mhealth-20-43). The series “Technology-based Interventions in HIV Prevention and Care Continuum among American Youth” was commissioned by the editorial office without any funding or sponsorship. LHW served as the unpaid Guest Editor of the series. DG, KEM, CH, KBB, AYL, KJH, JMG, CJR, and LHW report grants from National Institutes of Health, during the conduct of the study; AYL reports grants and other from Gilead Sciences and grants from Viiv Healthcare, outside the submitted work. The authors have no other conflicts of interest to declare., (2021 mHealth. All rights reserved.)

Multiple intersecting stigmas and discrimination related to sex, gender, HIV, and race/ethnicity may challenge HIV prevention and treatment service utilization, particularly among youth. This scoping review describes recent and ongoing innovative mobile health (mHealth) interventions among youth in the United States that aim to reduce stigma as an outcome or as part of the intervention model. To identify examples of stigma-mitigation via mHealth, we searched peer-reviewed published literature using keyword strategies related to mHealth, HIV, stigma, and youth (ages 10 to 29). We identified eleven articles that met our inclusion criteria, including three describing data from two randomized controlled trials (RCTs), five describing pilot studies, one describing the process evaluation of an ongoing intervention, one describing formative work for intervention development, and one published study protocol for an ongoing intervention. We review these articles, grouped by HIV prevention and care continuum stages, and describe the mHealth approach used, including telehealth, simulation video games, motion comics, smartphone applications (apps), social media forums, online video campaigns, video vignettes, and a computerized behavioral learning module. Four studies focused on preventing primary acquisition through individual-level behavior change (e.g., reducing condomless anal intercourse), three focused on increasing HIV testing, three focused on linking to prevention services [e.g., pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)] and one focused on promoting adherence to antiretroviral therapy (ART). Our review did not identify any published studies using mHealth with a primary aim to reduce stigma as a way to improve care engagement and increase viral suppression among youth in the United States. Additional RCTs and implementation studies examining the effectiveness of mHealth stigma-reduction interventions on HIV-related outcomes are needed to end the HIV epidemic among youth. mHealth offers unique advantages to address the complex intersecting stigma barriers along the HIV continuum to improve HIV-related outcomes for youth., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form. (available at http://dx.doi.org/10.21037/mhealth-20-68). MIM reports grants from the Duke University School of Nursing during the conduct of the study. LBHW reports grants from University of North Carolina at Chapel Hill during the conduct of the study. KEM reports grants from University of North Carolina at Chapel Hill during the conduct of the study. The authors have no conflicts of interest to declare., (2021 mHealth. All rights reserved.)

Gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by mental health problems and human immunodeficiency virus (HIV). Health navigation has the potential to improve both HIV and mental health outcomes; however, few studies have measured the impact of navigation on mental health among people living with HIV. We analyzed longitudinal data from a sociobehavioral survey and navigation monitoring system with GBMSM living with HIV in Guatemala ( n  = 346) that participated in a 12-month differentiated care intervention. We examined relationships between navigation characteristics (frequency, duration, mode of interactions, and level of emotional, instrumental, and informational navigation support) and anxiety and depression using fixed-effects regression. We also examined if these relationships were moderated by baseline social support. We found that as navigation interactions increased, anxiety significantly improved [ B  = -0.03, standard error (SE) = 0.01 p  = 0.05]. Participants who received high levels of informational navigator support also experienced a significant improvement in anxiety compared with those receiving low levels of informational support ( B  = -0.81, SE = 0.40, p  = 0.04). Unexpectedly, we found that as the proportion of in-person navigation interactions increased, anxiety worsened ( B  = 1.12, SE = 0.54, p  = 0.04). No aspects of navigation were significantly associated with depression and baseline social support did not moderate the relationship between navigation and anxiety and depression. To improve the mental health of key populations affected by HIV, health navigation programs should prioritize frequent interaction and informational navigation support for clients with anxiety while considering other strategies that specifically target reducing depressive symptoms, including other cost-effective modalities, such as mobile apps.

Objective: To examine how neighborhood characteristics are associated with health outcomes among older adults with osteoarthritis., Methods: In multilevel, cross-sectional, and longitudinal analyses we examined whether 4 neighborhood characteristics were associated with depressive symptoms and reported knee impact scores, and whether the neighborhood characteristics interacted with race/ethnicity among older adults with radiographic knee osteoarthritis (n = 656 for cross-sectional analyses and n = 434 for longitudinal analyses). The data came from the Johnston County Osteoarthritis Project, a prospective cohort study in North Carolina designed to examine risk factors for osteoarthritis., Results: Although few longitudinal associations were found, cross-sectional results suggested that greater perceived neighborhood social cohesion (B = -0.04, P < 0.001) and perceived neighborhood resources for physical activity and walking (B = -0.03, P < 0.001) were associated with fewer depressive symptoms, and that greater perceived neighborhood resources for physical activity and walking were associated with higher (better) knee impact scores (B = 0.48, P = 0.008). We also observed 2 significant interactions among neighborhood characteristics and race/ethnicity related to depressive symptoms (P < 0.01); for African American adults, greater perceived neighborhood resources for physical activity and walking were associated with fewer depressive symptoms (B = -0.03, P < 0.001), but for White adults, greater perceived neighborhood safety was associated with fewer depressive symptoms (B = -0.04, P = 0.003)., Conclusion: In a sample of older adults with radiographic knee osteoarthritis, neighborhood context mattered, but in nuanced ways. Interventions aiming to improve mental and physical functioning of older adults with knee osteoarthritis can look to this study as evidence for the importance of neighborhood characteristics., (© 2019, American College of Rheumatology.)

Introduction: Youth engagement in HIV research is generally recognized as essential, but often neglected or minimally implemented in practice. Engagement is a process of working collaboratively with diverse groups of people to address common issues. We conducted a scoping review of youth HIV prevention interventions in sub-Saharan Africa to identify and categorize forms and levels of youth engagement across the lifespan of intervention research., Methods: We followed Arksey and O'Malley's framework for organizing a scoping review. We searched seven databases for related articles on identified intervention studies through May 28 th 2020. Included studies focused on youth (10 to 24 years old) HIV prevention interventions in sub-Saharan Africa. Two reviewers independently examined citations and full manuscripts for inclusion. Data were extracted on study characteristics, location, description of youth engagement and extent of engagement. Youth engagement approaches were categorized based on Hart's ladder as substantial engagement (strong youth decision-making power), moderate engagement (shared decision making with adults), minimal engagement (no youth decision-making power) or no engagement., Results: We identified 3149 citations and included 112 studies reporting on 74 unique HIV interventions. Twenty-two interventions were in low-income countries, 49 in middle-income countries, and three were in both. Overall, only nine interventions (12%) had substantial or moderate youth engagement, two-thirds (48, 65%) had minimal youth engagement and 17 interventions (23%) had no youth engagement. We also identified specific engagement strategies (e.g. youth-led research, crowdsourcing) that were feasible in multiple settings and resulted in substantial engagement., Conclusions: We found limited youth engagement in youth HIV prevention intervention studies in sub-Saharan Africa. However, several activities resulted in substantial youth engagement and could be relevant in many low-and-middle-income-country (LMIC) settings., (© 2021 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Understanding how Chinese gay, bisexual, and other men who have sex with men (GBMSM) cope with HIV care-related stressors could improve their care engagement. Qualitative semistructured interviews were conducted with 30 GBMSM living with HIV recruited through clinics and a community-based organization (CBO) in Chengdu, China. Interviews focused on treatment-related stress, coping strategies, social support, and well-being. Half reported symptoms consistent with mild or moderate depression as measured by the PHQ-9 scale. HIV care-related stressors included side effects, difficulty with adherence, and fear of drug resistance. Challenges to coping include navigating contradictory information about HIV and treatment, experiencing stigma and discrimination within medical and nonmedical settings, and managing financial concerns. CBOs, peer groups, and providers were salient sources of social support benefitting coping. To improve sustained HIV care that meets the needs of Chinese GBMSM living with HIV, tailored interventions that address the above-mentioned stressors and coping challenges are likely needed.

Background: Young people in low- and middle-income countries are often neglected in designing youth-friendly health services, especially HIV testing and preventive services. Designathons, which are time-bounded co-creation events where individuals gather in teams to develop solutions to a problem, could promote youth participation and ownership of health services., Objective: The purpose of this study is to examine youth participation in a designathon to create youth-friendly health services in Nigeria., Methods: Our designathon was based on crowdsourcing principles and informed by a human-centered design approach. The designathon included an open call for Nigerian youths between 14 and 24 years to share ideas on how to promote uptake of HIV self-testing services and a three-day sprint event that brought together diverse teams to develop strategies enhancing linkage to care. Teams pitched their solutions to a panel of five independent experts who scored ideas based on the desirability, feasibility, potential impact, and teamwork. We used descriptive statistics to summarize participants' demographics and conducted a content analysis to synthesize themes from youth proposals., Results: Nine hundred seventy-six youth across Nigeria applied to join the designathon. Forty-eight youth in 13 teams participated in the designathon with a median age of 20 years (IQR: 17-22]. Boys and young men were 48.5% (446/919) of the total applicants, 62.5% (30/48) of the designathon participants, and 63.6% (7/11) of the finalists. Students, from all educational levels, represented 91.2% (841/922) of the total applicants, 88.4% (38/43) of the designathon participants, and 90.0% (9/10) of the finalists. About twenty-three percent (3/13) of the final proposals were top ranked. The three finalist approaches to optimize youth-friendly health services centered on decentralizing service delivery to young people through mobile health technologies, use of mobile tents, or peer support services., Conclusions: Our open call engaged diverse groups of Nigerian youth, including young women and students. Our data suggest that designathons may be useful for developing tailored youth-friendly health services. Further research is needed to understand the designathon process and the effectiveness of the finalist submissions.

Background: Stigma and discrimination related to sexuality, race, ethnicity, and HIV status negatively impact HIV testing, engagement in care, and consistent viral suppression (VS) among young Black and Latinx men who have sex with men and transgender women who have sex with men (YBLMT). Few interventions address the effects of intersectional stigma among youth living with HIV and those at risk for HIV within the same virtual space., Objective: Building on the success of the HealthMpowerment (HMP) mobile health (mHealth) intervention (HMP 1.0) and with the input of a youth advisory board, HMP 2.0 is an app-based intervention that promotes user-generated content and social support to reduce intersectional stigma and improve HIV-related outcomes among YBLMT. The primary objective of this study is to test whether participants randomized to HMP 2.0 report improvement in HIV prevention and care continuum outcomes compared with an information-only control arm. We will also explore whether participant engagement, as measured by paradata (data collected as users interact with an mHealth intervention, eg, time spent using the intervention), mediates stigma- and HIV care-related outcomes. Finally, we will assess whether changes in intersectional stigma and improvements in HIV care continuum outcomes vary across different types of social networks formed within the intervention study arms., Methods: We will enroll 1050 YBLMT aged 15 to 29 years affected by HIV across the United States. Using an HIV-status stratified, randomized trial design, participants will be randomly assigned to 1 of the 3 app-based conditions (information-only app-based control arm, a researcher-created network arm of HMP 2.0, or a peer-referred network arm of HMP 2.0). Behavioral assessments will occur at baseline, 3, 6, 9, and 12 months. For participants living with HIV, self-collected biomarkers (viral load) are scheduled for baseline, 6, and 12 months. For HIV-negative participants, up to 3 HIV self-testing kits will be available during the study period., Results: Research activities began in September 2018 and are ongoing. The University of Pennsylvania is the central institutional review board for this study (protocol #829805) with institutional reliance agreements with the University of North Carolina at Chapel Hill, Duke University, and SUNY Downstate Health Sciences University. Study recruitment began on July 20, 2020. A total of 205 participants have been enrolled as of November 20, 2020., Conclusions: Among a large sample of US-based YBLMT, this study will assess whether HMP 2.0, an app-based intervention designed to ameliorate stigma and its negative sequelae, can increase routine HIV testing among HIV-negative participants and consistent VS among participants living with HIV. If efficacious and brought to scale, this intervention has the potential to significantly impact the disproportionate burden of HIV among YBLMT in the United States., Trial Registration: ClinicalTrials.gov NCT03678181; https://clinicaltrials.gov/ct2/show/study/NCT03678181., International Registered Report Identifier (irrid): DERR1-10.2196/24043., (©Kathryn Elizabeth Muessig, Jesse M Golinkoff, Lisa B Hightow-Weidman, Aimee E Rochelle, Marta I Mulawa, Sabina Hirshfield, A Lina Rosengren, Subhash Aryal, Nickie Buckner, M Skye Wilson, Dovie L Watson, Steven Houang, José Arturo Bauermeister. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 16.12.2020.)

HIV care in China is shifting toward a community-based model involving a wide range of stakeholders. We aimed to understand key stakeholders' perceived challenges of providing high-quality care for men who have sex with men (MSM) living with HIV. In-depth interviews were conducted with a diverse sample of stakeholders ( N  = 17) in two Chinese cities, including providers, policymakers, and community workers. Interviews focused on stakeholders' challenges in HIV-related work and perceived barriers for MSM in accessing and maintaining HIV care. Thematic analysis strategies were used. Three cross-cutting themes related to accessibility and quality of care (QoC) emerged. First, MSM- and HIV-related stigma were perceived to increase the risk of MSM dropping out of care. While acknowledging stigma, some providers also expressed discriminatory views such as stereotypes of the MSM community. Second, stakeholders expressed concerns about QoC including healthcare workforce shortages, limited training opportunities, and high work stress while facing increasingly unmet needs from clients. Third, stakeholders shared challenges in mobilizing community resources to expand HIV care including unclear division of responsibility and strict auditing. Supportive policies and resources may be needed to bolster China's primary care workforce and MSM-competent care and, more broadly, high QoC for sexual and gender minority patients.