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Sexually transmitted infection (STI) testing health services, sexual behaviours, and substance use are all key parts of maintaining sexual health for undergraduate students. The author compares results on these factors from the 2012 Maritime Undergraduate Student Sexual Health Services Survey with those from a 2021 survey at one of the universities that was included in the original survey. Noteworthy changes in context between 2012 and 2021 include the onset of the COVID-19 pandemic and the 2018 legalization of cannabis. Findings indicate that while rates of binge drinking, peer perceptions of sexual activity while using substances, and condom use during sexual activity remained stable, rates of STI testing and cannabis use increased. Recommendations include increasing comprehensive, peer-led sexual education initiatives to continue to reduce stigma while educating students on sexually transmitted infections and substance use during sexual activity. KEYWORDS: Condom use, sexual health, STI testing, substance use, university students, Undergraduate students are highly susceptible to sexually transmitted infections (STIs). It has been reported that young adults aged 20 to 24 attending postsecondary institutions are most at risk of contracting [...]

We used concept-mapping methods to gain insights into promising HIV prevention intervention strategies from the collective experience of heterosexual Black men (HBM) in four cities of Ontario. We engaged 60 HBM in online group concept-mapping sessions. First, we held a brainstorming session where the HBM generated 226 statements anonymously on strategies to reduce HIV vulnerabilities. Te statements were condensed to 123. Second, the HBM (n = 45) sorted the 123 statements into self- created categories. Tird, the HBM rated the strategy statements by importance (n = 45) and feasibility (n = 41). Finally, cluster analysis and multidimensional scaling were used to describe data patterns. Te statements cluster tagged 'family and individual level interventions' had the highest mean rating in importance (4.061) and feasibility (3.610). Te policy interventions cluster solution was rated second highest in importance (IR = 4.058) and the sixth in feasibility (FR = 3.413). Other cluster solutions ratings were addressing racism (third highest in importance [IR = 4.030] and fourth highest in feasibility [FR = 3.514]); healthcare, research, and economic opportunities (fourth highest in importance [IR = 4.018] and third highest in feasibility [FR = 3.526]); sexual health awareness strategies (fifth highest in importance [IR = 3.993] and highest in feasibility [FR = 3.611]) and sex/HIV education (sixth highest in importance [IR = 3.975] and fifth highest in feasibility [FR = 3.442]); and individual and community empowerment (lowest in importance [IR = 3.846] and lowest in feasibility [FR = 3.375]). Intergenerational (family and individual), policy, and anti-racism interventions are the top three priority strategies for HIV prevention and care for HBM and communities in Ontario. KEYWORDS: Addressing racism, Black men, HIV vulnerability, intergenerational dialogues, policy interventions, resilience, The 2016 HIV Surveillance report indicates that Black people account for 21.9% of people living with HIV in Canada (Bourgeois et al., 2017; Haddad et al., 2018), even though they [...]

In response to increased HIV prevention efforts (PEP and PrEP), HIV rates in Ontario have decreased among gay men. By extension, the proportion of first-time HIV diagnoses in cis and trans women has increased, prompting concern for ongoing HIV transmissions. Presently, uptake of HIV prevention services among women is limited, largely due to variability of HIV-specific risk factors. To explore HIV prevention use among women, a retrospective review was completed of participants in a nurse-led HIV prevention service (PEP-RN and PrEP-RN) in Ottawa, Canada. Results showed 10% uptake for PEP and 3% uptake for PrEP among women. For PEP, 32 women presented for assessment, and 25 were initiated. Most PEP initiations were made following a potential sexual exposure to HIV, and 36% involved a partner who was HIV positive and not virally suppressed. For PrEP, offers for referral were made to 59 women; 28 declined, and 31 accepted. Among women who declined PrEP, 32% were HIV contacts, and among those who accepted, 80% were due to reported sexual or substance use practices. The highest PrEP engagement occurred among women receiving services in a safer opiate supply program. The high uptake of PEP suggests this could be a useful strategy to reducing HIV transmission rates in women. In addition, women receiving PrEP could benefit from a more supportive approach to care, including assistance with mediation use and regular contact with nurses. In using a more collaborative and gender-based approach to HIV prevention care, progress can be made in addressing ongoing HIV inequities among women. KEYWORDS: HIV pre-exposure prophylaxis (PrEP), HIV prevention, HIV postexposure prophylaxis (PEP), HIV priority populations, women, BACKGROUND Despite the availability of postexposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), human immunodeficiency virus (HIV) diagnoses continue to occur among certain populations in Canada (henceforth referred to as 'priority [...]

: Introduction: Peruvian young transgender women (YTW) ages 16−24 years are a critical but understudied group for primary HIV prevention efforts, due to sharp increases in HIV prevalence among TW ages 25 years and older. Methods: Between February and July 2022, a cross‐sectional quantitative study with YTW ages 16−24 years in Peru (N = 211) was conducted consisting of a bio‐behavioural survey accompanied by laboratory‐based testing for HIV and sexually transmitted infections (STIs). Bivariate and multivariable Poisson regression models were used to estimate prevalence ratios between socio‐demographic and behavioural characteristics and HIV status. Results: HIV prevalence was 41.5% (95% CI: 33.9−49.4%), recent syphilis acquisition 19.4% (95% CI: 12.7−28.4), chlamydia 6.3% (95% CI: 3.1−11.1) and gonorrhoea 12.3% (95% CI: 7.9−18.7). Almost half (47.9%) reported condomless anal sex in the past 6 months, 50.7% reported sex work in the past 30 days and 13.7% reported accepting more money for condomless sex. There were no significant differences in reported sexual behaviours by HIV status. Only 60.8% of participants reported ever having been tested for HIV, and 25.6% reported a past 6‐month STI test. More than two‐thirds (67.8%) had not heard of antiretroviral pre‐exposure prophylaxis (PrEP) and only 4.7% had taken PrEP in the past month. Current moderate‐to‐severe psychological distress was endorsed by 20.3%, 10.0% reported attempting suicide in the past 6 months and 85.4% reported alcohol misuse. Conclusions: Findings show that the HIV epidemic for YTW in Lima, Peru is situated in the context of widespread social exclusion, including economic vulnerabilities, violence victimization and the mental health sequelae of transphobic stigma that starts early in life. Future research should aim to further understand the intersection of these vulnerabilities. Moreover, there is an urgent necessity to design and evaluate HIV prevention programmes that address the root systems driving HIV vulnerabilities in YTW and that focus on developmentally specific clusters of stigma‐related conditions., INTRODUCTION Globally, transgender women (TW) are at high risk for HIV acquisition with an estimated HIV prevalence, through a meta‐analysis combining available international data, of 19.1%, a nearly 50‐fold increased [...]

: Introduction: Identifying the optimal approaches to offering HIV prevention to meet the needs of those at risk is a high priority, particularly given the expanding toolkit of biomedical HIV prevention options. An ongoing study in rural East African communities evaluated the uptake of choices in product, testing mode and location of care delivery through a structured patient‐centred HIV prevention delivery model. In this qualitative study, we sought to understand clients’ experiences of this “dynamic choice prevention model” (DCP) and highlight pathways of action to inform HIV prevention delivery models. Methods: In‐depth semi‐structured interviews were conducted from November 2021 through March 2022 with a purposively selected sample of n = 56 participants in DCP trials (across outpatient departments, antenatal clinics and community settings), and n = 21 healthcare providers (total n = 77). A seven‐person multi‐regional team translated and inductively coded transcript data. We used a framework analysis approach to identify emergent themes. Results: Individuals taking up HIV pre‐exposure prophylaxis (PrEP) reported feelings of relief, liberation from fears of acquiring HIV and satisfaction with being able to take action despite partners’ behaviours. Couples used a range of approaches afforded by the study to persuade partners to get tested and opt for PrEP. Post‐exposure prophylaxis (PEP) use was less common, although women welcomed it in the event of sexual coercion or assault. Participants discussed switching from PEP to PrEP after familiarizing themselves with usage and ascertaining ongoing risk. Participants felt respected by providers, trusted them and appreciated being able to contact them directly for telephone support. Prevention uptake was hindered by stigma, limited experience with and knowledge of prevention methods, gendered and generational power dynamics within intimate partnerships and families, and negative perceptions of methods due to the products themselves. Participants anticipated long‐acting injectable PrEP could solve their challenges regarding pill size, daily pill burden and the likelihood of unwanted disclosure. Conclusions: Diverse preferences and barriers to uptake of prevention require a choice of HIV prevention options, locations and delivery modalities—but in addition, flexible, competent and friendly care provision is crucial to promote uptake. Helping clients feel valued, and addressing their unique needs and challenges, enables their agency to prioritize their health., INTRODUCTION Offering individuals a choice of HIV prevention options is a key element of patient‐centred care, and crucial for reaching HIV prevention goals [1–3]. Biomedical tools to prevent HIV acquisition [...]

: Introduction: Community‐based cohort studies of HIV seroconversion can identify important avenues for enhancing HIV prevention efforts in the era of pre‐exposure prophylaxis (PrEP). Within individuals, one can assess exposure and outcome variables repeatedly and with increased certainty regarding temporal ordering. This cohort study examined the association of several risk factors with subsequent HIV seroconversion. Methods: We report data from a 4‐year study (2017−2022) of 6059 HIV seronegative sexual and gender minority individuals who have sex with men who had indications for‐, but were not using‐, PrEP at enrolment. Participants completed repeat exposure assessments and self‐collection of biospecimens for HIV testing. We examined the roles of race and ethnicity, socio‐economic status, methamphetamine use and PrEP uptake over the course of follow‐up in relation to HIV seroconversion. Results: Over 4 years, 303 of the participants seroconverted across 18,421 person‐years (incidence rate = 1.64 [95% CI: 1.59−1.70] per 100 person‐years). In multivariable discrete‐time survival analysis, factors independently associated with elevated HIV seroconversion risk included being Black/African American (adjusted risk ratio [aRR]: 2.44, 1.79−3.28), Hispanic/Latinx (1.53, 1.19−1.96), housing instability (1.58, 1.22−2.05) and past year methamphetamine use (3.82, 2.74−5.33). Conversely, time since study enrolment (24 vs. 12 months, 0.67, 0.51−0.87; 36 months, 0.60, 0.45−0.80; 48 months, 0.48, 0.35−0.66) and higher education (master's degree or higher vs. less than or equal to high school, 0.36, 0.17−0.66) were associated with reduced seroconversion risk. Compared to non‐PrEP users in the past 2 years without a current clinical indication, those who started PrEP but then discontinued had higher seroconversion risk, irrespective of clinical indication (3.23, 1.74−6.46) or lack thereof (4.30, 1.85−9.88). However, those who initiated PrEP in the past year (0.14, 0.04−0.39) or persistently used PrEP in the past 2 years (0.33, 0.14−0.74) had a lower risk of seroconversion. Of all HIV seroconversions observed during follow‐up assessments (12, 24, 36 and 48 months), methamphetamine was reported in the 12 months prior 128 (42.2%) times (overall). Conclusions: Interventions that acknowledge race and ethnicity, economic variables such as education and housing instability, and methamphetamine use are critically needed. Not only are interventions to engage individuals in PrEP care needed, but those that retain them, and re‐engage those who may fall out of care are essential, given the exceptionally high risk of seroconversion in these groups., INTRODUCTION Sexual minority individuals represent 2−5% of the United States, yet account for more than two‐thirds of new HIV acquisitions [1−4]. Meanwhile, gender minority individuals (transgender [trans] men and trans [...]

: Introduction: High levels of HIV stigma as well as stigma directed towards sexual and/or gender minorities (SGMs) are well documented in the African setting. These intersecting stigmas impede psychosocial wellbeing and HIV prevention and care. Yet, there are few if any evidence‐based interventions that focus on reducing internalized stigma and promoting mental health and HIV wellness for SGMs in Africa. We developed and evaluated a group‐based intervention drawing on cognitive behavioural therapy (CBT) strategies for men who have sex with men (MSM) and transgender women (TGW) at risk for or living with HIV in Lagos, Nigeria. Methods: The intervention comprised four weekly in‐person group sessions facilitated by community health workers. We conducted a delayed intervention group randomized controlled trial (April−September 2022), with pre‐post surveys plus 3‐month follow‐up (immediate group only), as well as qualitative research with participants and programme staff. Outcomes included internalized stigma related to SGM and HIV status, depression, resiliency/coping and pre‐exposure prophylaxis (PrEP)/HIV treatment use. Results: Mean age of the 240 participants was 26 years (range 18−42). Seventy‐seven percent self‐identified as MSM and 23% TGW; 27% were people with HIV. Most (88%) participants attended all four sessions, and 98% expressed high intervention satisfaction. There was significant pre‐post improvement in each psychosocial outcome, in both the immediate and delayed arms. There were further positive changes for the immediate intervention group by 3‐month follow‐up (e.g. in intersectional internalized stigma, depression). While baseline levels of ever‐PrEP use were the same, 75% of immediate‐group participants reported currently using PrEP at 3 months post‐intervention versus 53% of delayed‐group participants right after the intervention (p Conclusions: This study demonstrated the feasibility and acceptability of a group‐based CBT model for MSM and TGW in Nigeria. There were also some indications of positive shifts related to stigma, mental health and PrEP, despite issues with maintaining the randomized design in this challenging environment., INTRODUCTION High levels of HIV stigma as well as stigma directed towards sexual and gender minorities (SGMs) are well documented globally, and increasingly in sub‐Saharan Africa (SSA) [1–8]. The experience [...]

Reports of bacterial sexually transmitted infections (STIs) (e.g., chlamydia, gonorrhea, and syphilis) in the United States are at the highest level in several decades (1). A useful tool for preventing [...]

The number of new HIV acquisitions globally has declined, but not rapidly enough to meet the 2030 targets set by UNAIDS and the United Nations Sustainable Development Goals (SDGs) [1, [...]

: Introduction: Adolescent girls and young women (AGYW), a priority population for HIV prevention in Africa, show high interest but difficulty in sustained effective use of pre‐exposure prophylaxis (PrEP). With ongoing PrEP scale‐up focused on increasing access, it is important to understand what influences AGYW's choice of PrEP delivery platforms. Methods: The POWER implementation study in Cape Town provided PrEP between 2017 and 2020 to AGYW (16−25 years) from four differentiated delivery platforms: mobile clinic, government facility, courier delivery or community‐based youth club. Healthcare providers at government and mobile clinics provided PrEP (initiation and refills) as part of comprehensive, integrated sexual and reproductive health services. Courier and youth club platforms provided light‐touch PrEP refill services incorporating rapid HIV self‐testing. We conducted in‐depth interviews with a purposive sample of AGYW who had ≥3 months of PrEP‐use and accessed ≥2 PrEP delivery platforms. The thematic analysis explored AGYW's preferences, decision‐making and habits related to PrEP access to inform market segmentation. Results: We interviewed 26 AGYW (median age 20) PrEP‐users between November 2020 and March 2021. AGYW PrEP‐users reported accessing different services with, 24 accessing mobile clinics, 17 courier delivery, 9 government health facilities and 6 youth clubs for their PrEP refills. Qualitative findings highlighted four potential behavioural profiles. The “Social PrEP‐user” preferred PrEP delivery in peer spaces, such as youth clubs or adolescent‐friendly mobile clinics, seeking affirmation and social support for continued PrEP use. The “Convenient PrEP‐user” favoured PrEP delivery at easily accessible locations, providing quick (courier) or integrated contraception‐PrEP refill visits (mobile and government clinic). The “Independent PrEP‐user” preferred PrEP delivery that offered control over delivery times that fit into their schedule, such as the courier service. The “Discreet PrEP‐user” highly valued privacy regarding their PrEP use (courier delivery) and avoided delivery options where unintentional disclosure was evident (youth club). Comfort with HIV self‐testing had minimal influence on PrEP delivery choice. Conclusions: Market segmentation of AGYW characterizes different types of PrEP‐users and has the potential to enhance tailored messaging and campaigns to reach specific segments, with the aim of improving sustained PrEP use and HIV prevention benefits., INTRODUCTION The past 5 years have seen the global inclusion of oral pre‐exposure prophylaxis (PrEP) into national guidelines as a key biomedical HIV prevention method, with many countries planning to [...]

: Introduction: HPTN 083 demonstrated the superiority of long‐acting cabotegravir (CAB‐LA) versus daily oral emtricitabine/tenofovir disoproxil fumarate (TDF/FTC) as pre‐exposure prophylaxis (PrEP) among cisgender men and transgender women who have sex with men (MSM/TGW). HPTN 083 provided the first opportunity to understand experiences with injectable PrEP in a clinical trial. Methods: Participants from two US sites (Chicago, IL and Atlanta, GA) and one international site (Rio de Janeiro, Brazil) were purposively sampled for individual qualitative interviews (N = 40), between November 2019 and March 2020, to explore trial experiences, barriers to adherence and other factors that may have impacted study implementation or outcomes. The blinded phase ended early due to efficacy; this analysis includes interviews conducted prior to unblinding with three groups defined by adherence (i.e. injection visit attendance): adherent (n = 27), non‐adherent (n = 12) and early discontinuers (n = 1). Data were organized using NVivo software and analysed using content analysis. Results: Participants (mean age: 27) were primarily cisgender MSM (90%) and Black/African American (60%). Reasons for trial enrolment and PrEP use included a preference for using HIV prevention medication versus treatment in the event of HIV acquisition; the ability to enhance health via study‐related education and services; access to a novel, convenient HIV prevention product at no cost; and contributing to MSM/TGW communities through research. Participants contrasted positive experiences with study staff with their routine clinical care, and emphasized increased scheduling flexibility, thorough communication, non‐judgemental counselling and open, affirming environments (e.g. compassion, less stigma) as adherence facilitators. Injection experiences were positive overall; some described early injection‐related anxiety, which abated with time and when given some measure of control (e.g. pre‐injection countdown), and minimal injection site discomfort. Some concerns and misperceptions about injectable PrEP were reported. Barriers to adherence, across all adherence categories, included structural factors (e.g. financial constraints, travel) and competing demands (e.g. work schedules). Conclusions: Respondents viewed injectable PrEP trial participation as a positive experience and a means of enhancing wellbeing. Study site flexibility and affirming clinic environments, inclusive of non‐judgemental counselling, were key facilitators of adherence. To support injection persistence, interventions that address structural barriers and promote flexible means of injection delivery may be most effective., INTRODUCTION HIV Prevention Trials Network (HPTN) 083 was the first large‐scale, randomized, double‐blind efficacy trial of long‐acting injectable cabotegravir (CAB‐LA) versus daily oral emtricitabine/tenofovir disoproxil fumarate (TDF/FTC) as pre‐exposure prophylaxis [...]

: Introduction: South African men face a substantial burden of HIV and are less likely to test for HIV and initiate antiretroviral therapy if tested positive and more likely to die from AIDS‐related causes than women. In addition to condoms and circumcision, guidelines provide for the use of daily oral pre‐exposure prophylaxis (PrEP) as an HIV prevention intervention for any men who recognize their need and request PrEP. However, heterosexual men have not been a focus of PrEP programmes, and since its introduction, there is limited literature on PrEP use among men in South Africa. This study explores the experiences, motivators and barriers to oral PrEP use among heterosexual men accessing primary healthcare services in South Africa. Methods: This study forms part of a mixed‐methods implementation science study aimed at generating evidence for oral PrEP introduction and conducted in primary healthcare clinics in South Africa since 2018. Men aged ≥15 years who initiated oral PrEP and enrolled in a parent cohort study were purposefully invited to participate in an in‐depth interview (IDI). Between March 2020 and May 2022, 30 men participated in IDIs exploring their motivators for PrEP use, and experiences with accessing health services. Interviews were audio recorded, transcribed and analysed thematically. Results: The final analysis included 28 heterosexual men (18–56 years old). Motivations to initiate PrEP included fear of acquiring HIV, self‐perceived vulnerability to HIV and mistrust in relationships; health systems factors which motivated PrEP use included the influence of healthcare providers, educational materials and mobile services. Perceived reduction in HIV vulnerability and changing proximity to partners were reasons for PrEP discontinuation. Side effects, daily‐pill burden and stigma were noted as challenges to PrEP use. Health system barriers to PrEP use included limited PrEP availability, school and work demands, and inconsistent mobile clinic schedules. Conclusions: Our study reports on the experiences of heterosexual men accessing oral PrEP in real‐world settings and contributes to the limited literature among this population. We highlight multiple levels which could be strengthened to improve men's PrEP use, including individual support, education among partners and communities, and addressing health system barriers to access., INTRODUCTION South Africa had an estimated 7.6 million people living with HIV in 2022, of whom 2.6 million (34%) are men aged ≥15 years [1]. Despite the implementation of the [...]

: Introduction: Injection drug networks may influence their network members’ health‐seeking behaviours. Using data from a sociometric injecting partner network of people who inject drugs (PWID) in New Delhi, India, we assessed the role of injecting partner (alter) behaviours on individual engagement in HIV prevention services. Methods: We enumerated injecting partner linkages among 2512 PWID using coupon referrals and biometric data from November 2017 to March 2020. Participants completed interviewer‐administered questionnaires and provided information on injection behaviours, injecting partners, HIV/hepatitis C (HCV) testing and service engagement. Multilevel multiple‐membership models (MMMM) evaluated individual PWID HIV testing, medication for opioid use disorder (MOUD) and syringe service engagement as a function of alter attributes, accounting for membership across multiple ego‐networks. Logistic regression models assessed parallel associations among socially proximal injecting peers, defined as PWID ≤3 path length from ego. Results: Median age was 26 years; 99% were male. PWID had median 2 injecting partners and 8 socially proximal peers; 14% reported HIV testing, 33% accessed MOUD and 13% used syringe services 6 months prior. In MMMM analyses, PWID with ≥1 versus 0 injecting partners who received HIV testing were significantly more likely to report HIV testing (adjusted odds ratio [aOR]: 2.27, 95% confidence interval [CI]: 1.68–3.16), MOUD (aOR: 1.99, 95% CI: 1.60–2.53) and syringe service use (aOR: 1.66, 95% CI: 1.21–2.39). We observed similar findings for individual MOUD and syringe service use. Having ≥1 versus 0 HIV‐positive partners was associated with decreased HIV testing and MOUD but increased syringe service use (aOR: 1.54, 95% CI: 1.09–2.17). PWID with ≥1 versus 0 socially proximal peers who used non‐sterile injection equipment reported increased HIV testing (aOR: 1.39, 95% CI: 1.01–1.92), MOUD (aOR: 1.40, 95% CI: 1.10–1.77) and syringe service use (aOR: 1.82, 95% CI: 1.23–2.68). Conclusions: We found differential associative relationships between individual HIV prevention service engagement and the health or risk behaviours of direct and indirect alters. Characterizing network exposure beyond direct injecting partnerships provided important context on possible mechanisms of behavioural influence. Findings could be leveraged to design peer‐based interventions that promote network diffusion of health‐seeking behaviours., INTRODUCTION Globally, injection drug use drives some of the fastest‐growing HIV epidemics [1]. The National AIDS Control Organization (NACO) in India estimates that 9.3% of people who inject drugs (PWID) [...]

: Introduction: Disability and HIV are intricately linked, as people with disabilities are at higher risk of contracting HIV, and living with HIV can lead to impairments and disability. Despite this well‐established relationship, there remains limited internationally comparable evidence on HIV knowledge and access to testing for people with disabilities. Methods: We used cross‐sectional data from 37 Multiple Indicator Cluster Surveys. Surveys were from six UNICEF regions, including East Asia and Pacific (n = 6), East and Central Asia (n = 7), Latin America and the Caribbean (n = 6), Middle East and North Africa (n = 4), South Asia (n = 2) and sub‐Saharan Africa (n = 12). A total of 513,252 people were eligible for inclusion, including 24,695 (4.8%) people with disabilities. We examined risk ratios and 95% confidence intervals for key indicators on HIV knowledge and access to testing for people with disabilities by sex and country. We also conducted a meta‐analysis to get a pooled estimate for each sex and indicator. Results: Men and women with disabilities were less likely to have comprehensive knowledge about HIV prevention (aRR: 0.74 [0.67, 0.81] and 0.75 [0.69, 0.83], respectively) and to know of a place to be tested for HIV (aRR: 0.95 [0.92, 0.99] and 0.94 [0.92, 0.97], respectively) compared to men and women without disabilities. Women with disabilities were also less likely to know how to prevent mother‐to‐child transmission (aRR: 0.87 [0.81, 0.93]) and ever have been tested for HIV (aRR: 0.90 [0.85, 0.94]). Conclusions: Men and women with disabilities have lower overall HIV knowledge and in particular women with disabilities also indicate lower testing rates. Governments must include people with disabilities in HIV programmes by improving disability‐inclusion and accessibility to HIV‐related information, education and healthcare services., INTRODUCTION Globally, there are 1.3 billion people with disabilities [1]. There is a close relationship between HIV and disability, as research suggests that people with disabilities are at higher risk [...]