Publications by authors named "Dallas Swendeman"

92 Publications

Using Machine Learning to Predict Young People's Internet Health and Social Service Information Seeking.

Prev Sci 2021 May 11. Epub 2021 May 11.

University of California, UCLA Center for Community Health, 10920 Wilshire Blvd Suite 350, Los AngelesLos Angeles, CA, 90024, USA.

Machine learning creates new opportunities to design digital health interventions for youth at risk for acquiring HIV (YARH), capitalizing on YARH's health information seeking on the internet. To date, researchers have focused on descriptive analyses that associate individual factors with health-seeking behaviors, without estimating of the strength of these predictive models. We developed predictive models by applying machine learning methods (i.e., elastic net and lasso regression models) to YARH's self-reports of internet use. The YARH were aged 14-24 years old (N = 1287) from Los Angeles and New Orleans. Models were fit to three binary indicators of YARH's lifetime internet searches for general health, sexual and reproductive health (SRH), and social service information. YARH responses regarding internet health information seeking were fed into machine learning models with potential predictor variables based on findings from previous research, including sociodemographic characteristics, sexual and gender minority identity, healthcare access and engagement, sexual behavior, substance use, and mental health. About half of the YARH reported seeking general health and SRH information and 26% sought social service information. Areas under the ROC curve (≥ .75) indicated strong predictive models and results were consistent with the existing literature. For example, higher education and sexual minority identification was associated with seeking general health, SRH, and social service information. New findings also emerged. Cisgender identity versus transgender and non-binary identities was associated with lower odds of general health, SRH, and social service information seeking. Experiencing intimate partner violence was associated with higher odds of seeking general health, SRH, and social service information. Findings demonstrate the ability to develop predictive models to inform targeted health information dissemination strategies but underscore the need to better understand health disparities that can be operationalized as predictors in machine learning algorithms.
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http://dx.doi.org/10.1007/s11121-021-01255-2DOI Listing
May 2021

A qualitative study of antiretroviral therapy adherence interruptions among young Latino men who have sex with men with HIV: Project D.A.I.L.Y.

AIDS Care 2021 Jan 23:1-8. Epub 2021 Jan 23.

Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA.

Consistent antiretroviral therapy (ART) adherence is necessary for HIV viral suppression. However, adherence may fluctuate around daily routines and life events, warranting intervention support. We examined reasons for ART adherence interruptions, using in-depth, semi-structured qualitative interviews, among young (18-34-year-old) Latino men who have sex with men (YLMSM) with HIV. Interviews ( = 24) were guided by the Theory of Planned Behavior, the Information-Motivation-Behavioral Skills Theory, and the Socio-Ecological Model. Two coders independently coded transcripts using NVivo 12 software and synthesized codes into themes using Thematic Content Analysis. Results suggested 4 primary influences on ART adherence interruptions: (1) HIV diagnosis denial, (2) breaks in daily routine, (3) substance use, and (4) HIV status disclosure. Participant quotes highlighted routinization of pill-taking and planning ahead for breaks in routine as critically important. The narrative suggested modification of pill-taking routines during alcohol use, and that periods most vulnerable for long-term interruptions in ART adherence were following an HIV diagnosis and during periods of drug use. Support at the time of HIV diagnosis, including a plan for routinization of pill taking, and adaptive interventions incorporating real-time support during breaks in routines and substance use episodes may be one way to help YLMSM adhere to ARTs.
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http://dx.doi.org/10.1080/09540121.2021.1874277DOI Listing
January 2021

A pilot randomized controlled trial (RCT) of daily versus weekly interactive voice response calls to support adherence among antiretroviral treatment patients in India.

Mhealth 2020 5;6:35. Epub 2020 Oct 5.

Sonagachi Research & Training Institute, Durbar Mahila Samanwaya Committee, 12/5 Nilmoni Mitra Street, Kolkata, West Bengal, India.

Background: There are more than two million people living with HIV (PLH) in India, with more than 30% on antiretroviral treatment (ART) estimated to be non-adherent. This study aimed to (I) document adherence rates and related factors among ART patients in a large ART clinic in India, and (II) pilot test daily and weekly interactive voice response (IVR) calls to improve ART adherence and related outcomes.

Methods: ART patients reporting missing at least one dose in prior 6 months (N=362) were enrolled and assessed via self-report and medical record review. Participants were randomized to one of two conditions: (I) twice-daily IVR call reminders with self-management support messaging, plus a weekly IVR adherence assessment; or (II) an attention control, with only weekly IVR adherence assessment. Participants completed study assessments at baseline, 2-, 4-, and 6-months with high retention (88% to 96%).

Results: Intention-to-treat analyses found limited support for intervention effects for improving or maintaining ART adherence or CD4 counts between the two study arms over 6-months follow-up. Adherence increased significantly in the six months prior to baseline from about 65% to >95% with perfect adherence based on pill counts from medical records and consistent with patient self-report measures, which presented ceiling effects for detecting improvements in ART adherence in response to IVR intervention exposure. There was also limited support for intervention effects on secondary, self-management outcomes.

Conclusions: High levels of adherence were sustained throughout the 6-month RCT. IVR regulation changes in India delayed study launch for 6 months, which likely allowed mobilization of improved adherence at the clinic, provider and patient levels in anticipation of the study launch. Therefore, ceiling effects limited inferences on intervention effects to improve adherence. Results suggest that clinic-level adherence monitoring may be sufficient to mobilize adherence improvements by providers and patients.

Trial Registration: ClinicalTrials.gov registration #NCT02118454.
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http://dx.doi.org/10.21037/mhealth-19-248aDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793015PMC
October 2020

Optimizing screening for anorectal, pharyngeal, and urogenital C. trachomatis and N. gonorrhoeae infections in at risk adolescents and young adults in New Orleans, Louisiana and Los Angeles, California, USA.

Clin Infect Dis 2020 Dec 10. Epub 2020 Dec 10.

Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, California, USA.

Background: Public health organizations have inconsistent recommendations for screening adolescents and young adults for Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae) infections. Guidelines suggest different combinations of anorectal, pharyngeal, and urogenital testing based on age, sex, and sexual activity. Further evaluation of how identity and behaviors impact the anatomic distribution of C. trachomatis and N. gonorrhoeae infection is needed to optimize future screening practices.

Methods: We assessed the positivity of C. trachomatis and N. gonorrhoeae infections at different anatomic sites in a cohort of at-risk sexually active adolescents and young adults between 12-24 years old in New Orleans, Louisiana and Los Angeles, California. Participants were tested for C. trachomatis and N. gonorrhoeae at three sites (anorectum, pharynx, and urethral/cervix) every four months using self-collected swabs. We stratified anatomic distributions of infection into four gender and sexual behavior categories: (i) cisgender men who have sex with men and transgender women (MSMTW), (ii) cis-heterosexual males, (iii) cis-heterosexual females, and (iv) gender minorities assigned female at birth.

Results: While three-site testing detected all infections, two-site (anorectum and urethra/cervix) testing identified 92-100% of C. trachomatis or N. gonorrhoeae infections in participants assigned female at birth and cis-heterosexual males. For MSMTW, two site anorectal and pharyngeal testing versus single site anorectal testing increased the proportion of individuals with either infection from 74 to 93%.

Conclusion: Sexual behavioral and gender identity factors may influence detection of C. trachomatis and N. gonorrhoeae infections at specific anatomic testing sites. Testing guidelines should incorporate sexual behavior and gender identity.
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http://dx.doi.org/10.1093/cid/ciaa1838DOI Listing
December 2020

Predictors of Internet Health Information-Seeking Behaviors Among Young Adults Living With HIV Across the United States: Longitudinal Observational Study.

J Med Internet Res 2020 11 2;22(11):e18309. Epub 2020 Nov 2.

See Acknowledgments, .

Background: Consistent with young adults' penchant for digital communication, young adults living with HIV use digital communication media to seek out health information. Understanding the types of health information sought online and the characteristics of these information-seeking young adults is vital when designing digital health interventions for them.

Objective: This study aims to describe characteristics of young adults living with HIV who seek health information through the internet. Results will be relevant to digital health interventions and patient education.

Methods: Young adults with HIV (aged 18-34 years) self-reported internet use during an evaluation of digital HIV care interventions across 10 demonstration projects in the United States (N=716). Lasso (least absolute shrinkage and selection operator) models were used to select characteristics that predicted whether participants reported seeking general health and sexual and reproductive health (SRH) information on the internet during the past 6 months.

Results: Almost a third (211/716, 29.5%) and a fifth (155/716, 21.6%) of participants reported searching for general health and SRH information, respectively; 26.7% (36/135) of transgender young adults with HIV searched for gender-affirming care topics. Areas under the curve (>0.70) indicated success in building models to predict internet health information seeking. Consistent with prior studies, higher education and income predicted health information seeking. Higher self-reported antiretroviral therapy adherence, substance use, and not reporting transgender gender identity also predicted health information seeking. Reporting a sexual orientation other than gay, lesbian, bisexual, or straight predicted SRH information seeking.

Conclusions: Young adults living with HIV commonly seek both general health and SRH information online, particularly those exploring their sexual identity. Providers should discuss the most commonly sought SRH topics and the use of digital technology and be open to discussing information found online to better assist young adults with HIV in finding accurate information. Characteristics associated with health information-seeking behavior may also be used to develop and tailor digital health interventions for these young adults.
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http://dx.doi.org/10.2196/18309DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669436PMC
November 2020

Exercise and antiretroviral adherence in adults living with HIV: A systematic review.

J Health Psychol 2020 Oct 26:1359105320967421. Epub 2020 Oct 26.

University of California, Los Angeles, USA.

This systematic review assessed the relationship between exercise and ART adherence in adults living with HIV. A comprehensive search through June 2020 for relevant studies was conducted, and PRISMA guidelines were followed. To be included, studies had to meet the following criteria: (a) published in a peer-reviewed journal; and (b) examined the relationship between exercise and ART adherence. A total of 4310 studies were identified, and nine were included. The majority (five out of nine) of studies found a significant and positive relationship between exercise and ART adherence. Strengths, limitations, and future directions are discussed.
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http://dx.doi.org/10.1177/1359105320967421DOI Listing
October 2020

Qualitative Evaluation of Social Media and Mobile Technology Interventions Designed to Improve HIV Health Outcomes for Youth and Young Adults Living With HIV: A HRSA SPNS Initiative.

Health Promot Pract 2020 09 6;21(5):693-704. Epub 2020 Aug 6.

University of California, Los Angeles, Los Angeles, CA, USA.

Youth and young adults living with HIV (YYALH) are less likely to be engaged in HIV care, adhere to their medications, and achieve viral suppression compared to older adult populations. In the United States, the majority of YYALH belong to racial/ethnic, sexual, and gender minority groups. HIV care interventions are needed that specifically target YYALH and that exploit the use of social media and mobile technology (SMMT) platforms, where youth and young adults have a ubiquitous presence. We conducted a qualitative evaluation of SMMT interventions included in a Health Resources and Services Administration Special Projects of National Significance initiative designed to improve medical care engagement, retention, and medication adherence to achieve viral suppression among YYALH. However, in this study, only young adults living with HIV (YALH) ages 18 to 34 years participated. A total of 48 YALH were interviewed. The data were analyzed using thematic analysis and revealed three main themes supporting the usefulness of the SMMT interventions, which included (1) acceptability of SMMT interventions in managing HIV care with subthemes of medical information accessibility, reminders, and self-efficacy; (2) feelings of support and personal connection afforded by SMMT interventions; and (3) SMMT interventions help to alleviate negative feelings about status and mitigate HIV-related stigma. A few participants identified problems with using their respective intervention, primarily related to the functionality of the technologies. Overall, findings from our qualitative evaluation suggest that SMMT-based interventions have the potential to increase engagement and retention in care, support YALH in adhering to medication, and help them adjust to their diagnosis.
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http://dx.doi.org/10.1177/1524839920938704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646559PMC
September 2020

Special Projects of National Significance Social Media Initiative: Improving Health Outcomes Along the HIV Care Continuum in Youth and Young Adults Living With HIV.

Health Promot Pract 2020 09 6;21(5):690-692. Epub 2020 Aug 6.

U.S. Department of Health and Human Services, Rockville, MD, USA.

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http://dx.doi.org/10.1177/1524839920944806DOI Listing
September 2020

Feasibility and Acceptability of Mobile Phone Self-monitoring and Automated Feedback to Enhance Telephone Coaching for People With Risky Substance Use: The QUIT-Mobile Pilot Study.

J Addict Med 2021 Apr;15(2):120-129

Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, CA (DS, SS, WSC); Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA (EG, LG); Department of Epidemiology, School of Public Health, University of California, Los Angeles, California (PMG, DS).

Objectives: This study evaluates the feasibility, acceptability, and perceived benefits of mobile-phone delivered self-monitoring queries and feedback integrated into the evidence-based Quit Using Drugs Intervention Trial (QUIT) screening and brief telephone health coaching intervention to prevent progression from risky drug use to addiction as the QUIT-Mobile intervention.

Methods: Participants (n = 20) were primarily Black/African American and Latino men in Los Angeles with risky substance use. Self-monitoring surveys were sent by text-message twice-weekly for 6 weeks and once-weekly from 6 to 12-weeks. Surveys consisted of 10 questions regarding drug and alcohol use (ie, # days of use) and cravings, quality of life, and medication adherence. Feedback messages praised or encouraged drug use reductions. Coaches monitored patient responses and discussed them in QUIT's telephone coaching sessions. Participants' experiences were assessed qualitatively at 3-month follow-up.

Results: Nineteen out of 20 participants that completed the qualitative evaluation from the 12-week follow-up reported: (1) self-monitoring surveys helped them adhere to drug use reduction goals and reflect on associations between self-monitoring domains; (2) preference for higher frequency (twice-weekly) self-monitoring during the 6-week coaching period, and then weekly surveys thereafter but not monthly; and (3) self-monitoring and coaching were mutually reinforcing for their drug use reduction goals.

Conclusions: Results are consistent with prior similar research suggesting that mobile phone self-monitoring of drug use and related factors is feasible and acceptable among diverse adults with risky drug use. Findings also suggest the potential benefits of integrating electronic self-monitoring and feedback into substance use reduction interventions such as QUIT to enhance patient self-management and coaching or counseling intervention components.
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http://dx.doi.org/10.1097/ADM.0000000000000707DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855429PMC
April 2021

Gender, justice and empowerment: creating the world we want to see.

Cult Health Sex 2020 04;22(sup1):1-12

Women's Health, Gender and Empowerment Center of Expertise, University of California Global Health Institute, San Francisco, CA, USA.

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http://dx.doi.org/10.1080/13691058.2020.1736843DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8155812PMC
April 2020

A Tale of Two Cities: Exploring the Role of Race/Ethnicity and Geographic Setting on PrEP Use Among Adolescent Cisgender MSM.

AIDS Behav 2021 Jan;25(1):139-147

Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.

Although pre-exposure prophylaxis (PrEP) could substantially reduce the risk of HIV acquisition among adolescent cisgender men who have sex with men (cisMSM), various barriers faced by people of color, particularly within the southern region of the U.S., may lead to racial disparities in the utilization of PrEP. Few studies, however, have explored racial/ethnic differences in PrEP use by geographic setting among adolescent cisMSM. We conducted a cross-sectional analysis examining racial disparities in PrEP use among cisMSM ages 15-24 years in New Orleans, Louisiana, and Los Angeles, California recruited between May, 2017 and September, 2019. The odds of PrEP use among AA adolescents were considerably lower than White adolescents in New Orleans (OR (95% CI): 0.24 (0.10, 0.53)), although we did not find evidence of differences in Los Angeles. Our findings underscore the need for targeted interventions to promote PrEP use among adolescent MSM, particularly among AA adolescent cisMSM living in the southern region of U.S.
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http://dx.doi.org/10.1007/s10461-020-02951-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759578PMC
January 2021

Smartphone Self-Monitoring by Young Adolescents and Parents to Assess and Improve Family Functioning: Qualitative Feasibility Study.

JMIR Form Res 2020 Jun 23;4(6):e15777. Epub 2020 Jun 23.

The Methodology Center, Department of Behavioral Health, The Pennsylvania State University, University Park, PA, United States.

Background: The natural integration of mobile phones into the daily routines of families provides novel opportunities to study and support family functioning and the quality of interactions between family members in real time.

Objective: This study aimed to examine user experiences of feasibility, acceptability, and reactivity (ie, changes in awareness and behaviors) of using a smartphone app for self-monitoring of family functioning with 36 participants across 15 family dyads and triads of young adolescents aged 10 to 14 years and their parents.

Methods: Participants were recruited from 2 family wellness centers in a middle-to-upper income shopping area and a low-income school site. Participants were instructed and prompted by alarms to complete ecological momentary assessments (EMAs) by using a smartphone app over 2 weeks 4 times daily (upon waking in the morning, afternoon, early evening, and end of day at bedtime). The domains assessed included parental monitoring and positive parenting, parent involvement and discipline, parent-child conflict and resolution, positive interactions and support, positive and negative affect, sleep, stress, family meals, and general child and family functioning. Qualitative interviews assessed user experiences generally and with prompts for positive and negative feedback.

Results: The participants were primarily white and Latino of mixed-income- and education levels. Children were aged 10 to 14 years, and parents had a mean age of 45 years (range 37-50). EMA response rates were high (95% to over 100%), likely because of cash incentives for EMA completion, engaging content per user feedback, and motivated sample from recruitment sites focused on social-emotional programs for family wellness. Some participants responded for up to 19 days, consistent with some user experience interview feedback of desires to continue participation for up to 3 or 4 weeks. Over 80% (25/31) of participants reported increased awareness of their families' daily routines and functioning of their families. Most also reported positive behavior changes in the following domains: decision making, parental monitoring, quantity and quality of time together, communication, self-regulation of stress and conflict, discipline, and sleep.

Conclusions: The results of this study support the feasibility and acceptability of using smartphone EMA by young adolescents and parents for assessing and self-monitoring family daily routines and interactions. The findings also suggest that smartphone self-monitoring may be a useful tool to support improvement in family functioning through functions of reflection on antecedents and consequences of situations, prompting positive and negative alternatives, seeding goals, and reinforcement by self-tracking for self-correction and self-rewards. Future studies should include larger samples with more diverse and higher-risk populations, longer study durations, the inclusion of passive phone sensors and peripheral biometric devices, and integration with counseling and parenting interventions and programs.
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http://dx.doi.org/10.2196/15777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381003PMC
June 2020

Community-based Implementation of Centers for Disease Control and Prevention's Recommended Screening for Sexually Transmitted Infections Among Youth at High Risk for HIV Infection in Los Angeles and New Orleans.

Sex Transm Dis 2020 07;47(7):481-483

From the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.

We examined whether the implementation of the Centers for Disease Control and Prevention's recommended screening of Chlamydia trachomatis/Neisseria gonorrhoeae with proactive follow-up among high-risk youth recruited from community and clinic settings reduced future C. trachomatis/N. gonorrhoeae diagnoses. After the Centers for Disease Control and Prevention's recommendations demonstrated a 41% decline in sexually transmitted infections; 3 tests in 1 year resulted in a 10% decline.
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http://dx.doi.org/10.1097/OLQ.0000000000001171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371266PMC
July 2020

Correction to: Mobile Link - a theory-based messaging intervention for improving sexual and reproductive health of female entertainment workers in Cambodia: study protocol of a randomized controlled trial.

Trials 2019 12 9;20(1):695. Epub 2019 Dec 9.

Public Health Program, College of Education and Health Sciences, Touro, University California, Vallejo, CA, USA.

After publication of our article [1] we became aware that several sections of text in our Methods section were copied from a previously published article [2]. We would like to formally apologize and give credit to the authors of that article [2]: Chris Smith, Uk Vannak, Ly Sokhey, Thoai D Ngo, Judy Gold, Khemrin Khut, Phil Edwards, Tung Rathavy and Caroline Free.
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http://dx.doi.org/10.1186/s13063-019-3941-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902541PMC
December 2019

"We Cannot Avoid Drinking": Alcohol Use among Female Entertainment Workers in Cambodia.

Subst Use Misuse 2020 25;55(4):602-612. Epub 2019 Nov 25.

KHANA Center for Population Health Research, Phnom Penh, Cambodia.

Female entertainment workers (FEWs) in Cambodia work in predominantly alcohol-based venues and therefore may face occupational risks. Studies have suggested that FEWs are pressured to consume alcohol while at the workplace, which may have adverse health outcomes. This study aims to explore the experiences of alcohol use among FEWs in Cambodia. Twenty-seven focus group discussions (FGDs) with FEWs were conducted across five sites in four provinces in Cambodia. FGD participants were FEWs who worked at entertainment venues, including karaoke TV bars, beer gardens, and massage parlors, as well as women who worked as on-call or street-based sex workers, and women across entertainment venues who were parenting. The authors modified a conceptual model to create a framework based on the major themes identified within the FGDs on autonomy in alcohol use among FEWs. The framework and thematic components highlight the continuum of autonomy from pressured or coerced alcohol use to, economically or socially rational alcohol use to voluntary alcohol use. Factors that impacted alcohol use across the spectrum include experiencing an economic shock, needing to maintain a livelihood, experiencing psychological distress, having the desire to thrive in employment environment and drinking socially for personal enjoyment. Much of the motivation behind alcohol use is related to the need for economic security. For women who do not have other employment or income-generating options, individual behavior change programing is unlikely to be effective. Structural changes are needed to improve the health and safety of FEWs in Cambodia.
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http://dx.doi.org/10.1080/10826084.2019.1691596DOI Listing
June 2021

Childhood conditions, pathways to entertainment work and current practices of female entertainment workers in Cambodia: Baseline findings from the Mobile Link trial.

PLoS One 2019 15;14(10):e0216578. Epub 2019 Oct 15.

Public Health Program, College of Education and Health Sciences, Touro University California, Vallejo, CA, United States of America.

Background: Entertainment venues have been identified as an important location for HIV prevention due to the increasing number of young female entertainment and sex workers at these venues. The purpose of this study is to increase understanding of the childhood conditions, pathways to entertainment work and current practices of female entertainment workers (FEWs) in Cambodia.

Methods: Data used for this study were collected in April 2018 as part of the baseline survey of the Mobile Link, a randomized controlled trial to improve sexual and reproductive health of FEWs in Cambodia. We used a stratified random sampling method to recruit 600 FEWs for face-to-face interviews using a structured questionnaire. Descriptive analyses were performed.

Results: Most participants came from childhood homes without electricity (82.0%) or running water (87.0%). Most women moved to the city in the last ten years (80.5%) for economic reasons (43.7%). About a third worked in the garment industry prior to the entertainment industry (36.7%). Participation in transactional sex in the past three months was reported by 36.0%. Women reported low condom use practices with non-paying partners (23.4% used a condom at last sex), excessive and forced alcohol use at work (33.1% reported being forced to drink alcohol at work more than once a month), low modern contraception use (31.4% was using modern contraception), and experiences of gender-based violence (23.3% reported verbal threats, physical abuse or forced sex in the past six months).

Conclusions: This information will help to support the development of future individual and structural level interventions for the safety and support of FEWs. In addition, these results may contribute to an evidence base that can inform policy level changes intended to support the realization of full human rights for entertainment works in Cambodia including the rights to health, safety and respectful employment.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0216578PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6793882PMC
March 2020

Improving the Youth HIV Prevention and Care Cascades: Innovative Designs in the Adolescent Trials Network for HIV/AIDS Interventions.

AIDS Patient Care STDS 2019 09;33(9):388-398

Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California.

Dramatic decreases in HIV transmission are achievable with currently available biomedical and behavioral interventions, including antiretroviral therapy and pre-exposure prophylaxis. However, such decreases have not yet been realized among adolescents and young adults. The Adolescent Medicine Trials Network (ATN) for HIV/AIDS interventions is dedicated to research addressing the needs of youth at high risk for HIV acquisition as well as youth living with HIV. This article provides an overview of an array of efficient and effective designs across the translational spectrum that are utilized within the ATN. These designs maximize methodological rigor and real-world applicability of findings while minimizing resource use. Implementation science and cost-effectiveness methods are included. Utilizing protocol examples, we demonstrate the feasibility of such designs to balance rigor and relevance to shorten the science-to-practice gap and improve the youth HIV prevention and care continua.
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http://dx.doi.org/10.1089/apc.2019.0095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6745528PMC
September 2019

Authorship Correction: Promising Approaches for Engaging Youth and Young Adults Living with HIV in HIV Primary Care Using Social Media and Mobile Technology Interventions: Protocol for the SPNS Social Media Initiative.

JMIR Res Protoc 2019 Sep 9;8(8):e15660. Epub 2019 Sep 9.

Department of Family Medicine, University of California, Los Angeles, Los Angeles, CA, United States.

[This corrects the article DOI: 10.2196/10681.].
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http://dx.doi.org/10.2196/15660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6778393PMC
September 2019

Text-Messaging, Online Peer Support Group, and Coaching Strategies to Optimize the HIV Prevention Continuum for Youth: Protocol for a Randomized Controlled Trial.

JMIR Res Protoc 2019 08 9;8(8):e11165. Epub 2019 Aug 9.

University of California, Los Angeles, Department of Psychiatry & Biobehavioral Sciences, Los Angeles, CA, United States.

Background: America's increasing HIV epidemic among youth suggests the need to identify novel strategies to leverage services and settings where youth at high risk (YAHR) for HIV can be engaged in prevention. Scalable, efficacious, and cost-effective strategies are needed, which support youth during developmental transitions when risks arise. Evidence-based behavioral interventions (EBIs) have typically relied on time-limited, scripted, and manualized protocols that were often delivered with low fidelity and lacked evidence for effectiveness.

Objective: This study aims to examine efficacy, implementation, and cost-effectiveness of easily mountable and adaptable, technology-based behavioral interventions in the context of an enhanced standard of care and study assessments that implement the guidelines of Centers for Disease Control and Prevention (CDC) for routine, repeat HIV, and sexually transmitted infection (STI) testing for high-risk youth.

Methods: Youth aged between 12 and 24 years (n=1500) are being recruited from community-based organizations and clinics serving gay, bisexual, and transgender youth, homeless youth, and postincarcerated youth, with eligibility algorithms weighting African American and Latino youth to reflect disparities in HIV incidence. At baseline and 4-month intervals over 24 months (12 months for lower-risk youth), interviewers monitor uptake of HIV prevention continuum steps (linkage to health care, use of pre- or postexposure prophylaxis, condoms, and prevention services) and secondary outcomes of substance use, mental health, and housing security. Assessments include rapid diagnostic tests for HIV, STIs, drugs, and alcohol. The study is powered to detect modest intervention effects among gay or bisexual male and transgender youth with 70% retention. Youth are randomized to 4 conditions: (1) enhanced standard of care of automated text-messaging and monitoring (AMM) and repeat HIV/STI testing assessment procedures (n=690); (2) online group peer support via private social media plus AMM (n=270); (3) coaching that is strengths-based, youth-centered, unscripted, based on common practice elements of EBI, available over 24 months, and delivered by near-peer paraprofessionals via text, phone, and in-person, plus AMM (n=270); and (4) online group peer support plus coaching and AMM (n=270).

Results: The project was funded in September 2016 and enrollment began in May 2017. Enrollment will be completed between June and August 2019. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019.

Conclusions: This hybrid implementation-effectiveness study examines alternative models for implementing the CDC guidelines for routine HIV/STI testing for YAHR of acquiring HIV and for delivering evidence-based behavioral intervention content in modular elements instead of scripted manuals and available over 24 months of follow-up, while also monitoring implementation, costs, and effectiveness. The greatest impacts are expected for coaching, whereas online group peer support is expected to have lower impact but may be more cost-effective.

Trial Registration: ClinicalTrials.gov NCT03134833; https://clinicaltrials.gov/ct2/show/NCT03134833 (Archived by WebCite at http://www.webcitation.org/76el0Viw9).

International Registered Report Identifier (irrid): DERR1-10.2196/11165.
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http://dx.doi.org/10.2196/11165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707028PMC
August 2019

The Experiences of Young Men, Their Families, and Their Coaches Following a Soccer and Vocational Training Intervention to Prevent HIV and Drug Abuse in South Africa.

AIDS Educ Prev 2019 06;31(3):224-236

Department of Family Medicine, University of California Los Angeles.

Young men in South Africa are at high-risk for HIV, substance abuse, and gender-based violence. This article presents qualitative results from a pilot study testing soccer leagues and vocational training to engage young-adult township men to deliver preventive interventions, including rapid HIV and alcohol/drug testing, shifting attitudes toward gender-based violence, and promoting other prosocial behaviors. Three groups participated in focus groups and in-depth interviews on experiences with the program: (1) a subset of 15 participants, (2) 15 family members, and (3) five intervention coaches. Results suggest that participants first reduced substance use on tournament days and then gradually reduced to practice days and beyond. Families suggested that "keeping young men occupied" and encouragement of prosocial behaviors was critical to risk reduction and led to increased community respect for the men. Coaches noted that behavioral and attitudinal changes were incremental and slow. The use of incentives was problematic and more research is needed to understand how incentives can be used in interventions of this nature.
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http://dx.doi.org/10.1521/aeap.2019.31.3.224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192051PMC
June 2019

Associations between sociodemographic characteristics and substance use disorder severity among methamphetamine-using men who have sex with men.

Subst Use Misuse 2019 10;54(11):1763-1773. Epub 2019 May 10.

a David Geffen School of Medicine , Semel Institute for Neuroscience and Human Behavior, University of California , Los Angeles , CA , USA.

: Men who have sex with men (MSM) have elevated rates of substance use disorders (SUDs) and differences across sociodemographic sub-groups of MSM are associated with a greater risk of deleterious outcomes. Although studies have shown that MSM report greater rates of polysubstance use relative to other adult populations, the associations between sociodemographic characteristics and both acute substance use and substance use severity among methamphetamine-using MSM are unknown. : The present study examines associations between sociodemographic characteristics and (a) recent substance use and (b) SUD severity. : From March 2014 to January 2016, 286 methamphetamine-using MSM were recruited to complete a baseline Audio Computer-Assisted Self-Interview (ACASI) assessment and the SCID MINI. Multivariable analyses employed generalized structural equation modeling given the non-continuous nature of the endogenous variables. : All measured sociodemographic characteristics except gay self-identification were significantly associated with recent substance use (all s ≤ .05), and all characteristics except current homelessness were significantly associated with diagnostic SUD severity (all s ≤ .05). However, nuanced risks were observed in participants' use of specific substances regarding recent substance use and substance use severity. : These results suggest that multiple factors contribute to the risks of SUD severity among methamphetamine-using MSM. As such, these results are useful in the tailoring of clinical and psychosocial intervention strategies that serve this and other high-risk populations.
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http://dx.doi.org/10.1080/10826084.2019.1610445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6644069PMC
May 2020

The Stepped Care Intervention to Suppress Viral Load in Youth Living With HIV: Protocol for a Randomized Controlled Trial.

JMIR Res Protoc 2019 02 27;8(2):e10791. Epub 2019 Feb 27.

Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States.

Background: Among youth living with HIV (YLH) aged 12-24 years who have health care in the United States, only 30% to 40% are virally suppressed. YLH must achieve viral suppression in order to reduce the probability of infecting others as well as increasing the length and quality of their own life.

Objective: This randomized controlled trial aimed to evaluate the efficacy of an Enhanced Standard Care condition (n=110) compared to an Enhanced Stepped Care intervention condition (n=110) to increase viral suppression among YLH aged 12-24 years with established infection (not acutely infected).

Methods: YLH (N=220) who are not virally suppressed will be identified at homeless shelters, health clinics, and gay-identified community-based organizations in Los Angeles, CA, and New Orleans, LA. Informed consent will be obtained from all participants. YLH will be randomly assigned to one of two study conditions: Enhanced Standard Care, which includes standard clinical care plus an automated messaging and monitoring intervention (AMMI), or an Enhanced Stepped Care, which includes three levels of intervention (AMMI, Peer Support via social media plus AMMI, or Coaching plus Peer Support and AMMI). The primary outcome is viral suppression of HIV, and YLH will be assessed at 4-month intervals for 24 months. For the Enhanced Stepped Care intervention group, those who do not achieve viral suppression (via blood draw, viral load<200 copies/mL) at any 4-month assessment will "step up" to the next level of intervention. Secondary outcomes will be retention in care, antiretroviral therapy adherence, alcohol use, substance use, sexual behavior, and mental health symptoms.

Results: Recruitment for this study began in June 2017 and is ongoing. We estimate data collection to be completed by the end of 2020.

Conclusions: This is the first known application of an Enhanced Stepped Care intervention model for YLH. By providing the lowest level of intervention needed to achieve viral suppression, this model has the potential to be a cost-effective method of helping YLH achieve viral suppression and improve their quality of life.

Trial Registration: ClinicalTrials.gov NCT03109431; https://clinicaltrials.gov/ct2/show/NCT03109431.

International Registered Report Identifier (irrid): DERR1-10.2196/10791.
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http://dx.doi.org/10.2196/10791DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6414817PMC
February 2019

Promising Approaches for Engaging Youth and Young Adults Living with HIV in HIV Primary Care Using Social Media and Mobile Technology Interventions: Protocol for the SPNS Social Media Initiative.

JMIR Res Protoc 2019 01 31;8(1):e10681. Epub 2019 Jan 31.

Department of Family Medicine, University of California, Los Angeles, Los Angeles, CA, United States.

Background: In the United States, disparities in the rates of HIV care among youth and young adults result from the intersections of factors that include stigma, substance use, homelessness or marginal housing, institutional neglect, and mental health issues. Novel interventions are needed that are geared to youth and young adults.

Objective: In this paper, we aim to describe the interventions used by participating sites for Using Social Media initiative, the process for classifying the intervention components, and the methods for conducting a comprehensive evaluation of the interventions.

Methods: In 2015, the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau, Special Projects of National Significance (SPNS) funded the Evaluation and Technical Assistance Center (ETAC) at the University of California, Los Angeles and 10 demonstration projects at sites across the United States that incorporated innovative approaches using a variety of social media and mobile technology strategies designed specifically for youth and young adults living with HIV. The ETAC developed a typology, or a classification system, that systematically summarizes the principal components of the interventions into broader groups and developed a multisite, mixed-methods approach to evaluate them based on the Department of Health and Human Services HIV health outcomes along the HIV care continuum. The mixed-methods approach is key to remove potential biases in assessing the effectiveness of demonstration projects.

Results: This SPNS project was funded in September 2015, and enrollment was completed on May 31, 2018. A total of 984 participants have been enrolled in the multisite evaluation. Data collection will continue until August 2019. However, data analysis is currently underway, and the first results are expected to be submitted for publication in 2019.

Conclusions: This HRSA-funded initiative seeks to increase engagement in HIV medical care, improve health outcomes for people living with HIV, and reduce HIV-related health disparities and health inequities that affect HIV-positive youth and young adults.

International Registered Report Identifier (irrid): DERR1-10.2196/10681.
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http://dx.doi.org/10.2196/10681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6374729PMC
January 2019

Time Series Visualizations of Mobile Phone-Based Daily Diary Reports of Stress, Physical Activity, and Diet Quality in Mostly Ethnic Minority Mothers: Feasibility Study.

JMIR Form Res 2018 Nov 5;2(2):e11062. Epub 2018 Nov 5.

Nexleaf Analytics, Los Angeles, CA, United States.

Background: Health behavior patterns reported through daily diary data are important to understand and intervene upon at the individual level in N-of-1 trials and related study designs. There is often interest in relationships between multiple outcomes, such as stress and health behavior. However, analyses often utilize regressions that evaluate aggregate effects across individuals, and standard analyses target single outcomes.

Objective: This paper aims to illustrate how individuals' daily reports of stress and health behavior (time series) can be explored using visualization tools.

Methods: Secondary analysis was conducted on 6 months of daily diary reports of stress and health behavior (physical activity and diet quality) from mostly ethnic minority mothers who pilot-tested a self-monitoring mobile health app. Time series with minimal missing data from 14 of the 44 mothers were analyzed. Correlations between stress and health behavior within each time series were reported as a preliminary step. Stress and health behavior time series patterns were visualized by plotting moving averages and time points where mean shifts in the data occurred (changepoints).

Results: Median correlation was small and negative for associations of stress with physical activity (r=-.14) and diet quality (r=-.08). Moving averages and changepoints for stress and health behavior were aligned for some participants but not for others. A third subset of participants exhibited little variation in stress and health behavior reports.

Conclusions: Median correlations in this study corroborate prior findings. In addition, time series visualizations highlighted variations in stress and health behavior across individuals and time points, which are difficult to capture through correlations and regression-based summary measures.
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http://dx.doi.org/10.2196/11062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6334694PMC
November 2018

Strategies to Treat and Prevent HIV in the United States for Adolescents and Young Adults: Protocol for a Mixed-Methods Study.

JMIR Res Protoc 2019 Jan 21;8(1):e10759. Epub 2019 Jan 21.

Department of Pediatrics, School of Medicine, Tulane University, New Orleans, LA, United States.

Background: Over 20% of HIV diagnoses in the United States are among youth aged 12-24 years. Furthermore, youth have the lowest rates of uptake and adherence to antiretroviral (ARV) medications and are least aware of their HIV status.

Objective: Our objective was to design a set of interrelated studies to promote completion of each step of the HIV Prevention Continuum by uninfected youth at high risk (YHR), as well as completion of steps in the Treatment Continuum by youth living with HIV (YLH).

Methods: Gay, bisexual, and transgender youth; homeless youth; substance-abusing youth; youth with criminal justice contact; and youth with significant mental health challenges, particularly black and Latino individuals, are being recruited from 13 community-based organizations, clinics, drop-in centers, and shelters in Los Angeles and New Orleans. Youth are screened on the basis of self-reports and rapid diagnostic tests for HIV, drug use, and sexually transmitted infections and, then, triaged into one of 3 studies: (1) an observational cohort of YLH who have never received ARV medications and are then treated-half initially are in the acute infection period (n=36) and half with established HIV infection (n=36); (2) a randomized controlled trial (RCT) for YLH (N=220); and (3) an RCT for YHR (N=1340). Each study contrasts efficacy and costs of 3 interventions: an automated messaging and weekly monitoring program delivered via text messages (short message service, SMS); a peer support intervention delivered via social media forums; and coaching, delivered via text message (SMS), phone, and in-person or telehealth contacts. The primary outcomes are assessing youths' uptake and retention of and adherence to the HIV Prevention or Treatment Continua. Repeat assessments are conducted every 4 months over 24 months to engage and retain youth and to monitor their status.

Results: The project is funded from September 2016 through May 2021. Recruitment began in May 2017 and is expected to be completed by June 2019. We expect to submit the first results for publication by fall 2019.

Conclusions: Using similar, flexible, and adaptable intervention approaches for YLH and YHR, this set of studies may provide a roadmap for communities to broadly address HIV risk among youth. We will evaluate whether the interventions are cost-efficient strategies that can be leveraged to help youth adhere to the actions in the HIV Prevention and Treatment Continua.

International Registered Report Identifier (irrid): DERR1-10.2196/10759.
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http://dx.doi.org/10.2196/10759DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360384PMC
January 2019

Development of an Electronic Data Collection System to Support a Large-Scale HIV Behavioral Intervention Trial: Protocol for an Electronic Data Collection System.

JMIR Res Protoc 2018 Dec 14;7(12):e10777. Epub 2018 Dec 14.

Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States.

Background: Advancing technology has increased functionality and permitted more complex study designs for behavioral interventions. Investigators need to keep pace with these technological advances for electronic data capture (EDC) systems to be appropriately executed and utilized at full capacity in research settings. Mobile technology allows EDC systems to collect near real-time data from study participants, deliver intervention directly to participants' mobile devices, monitor staff activity, and facilitate near real-time decision making during study implementation.

Objective: This paper presents the infrastructure of an EDC system designed to support a multisite HIV biobehavioral intervention trial in Los Angeles and New Orleans: the Adolescent Medicine Trials Network "Comprehensive Adolescent Research & Engagement Studies" (ATN CARES). We provide an overview of how multiple EDC functions can be integrated into a single EDC system to support large-scale intervention trials.

Methods: The CARES EDC system is designed to monitor and document multiple study functions, including, screening, recruitment, retention, intervention delivery, and outcome assessment. Text messaging (short message service, SMS) and nearly all data collection are supported by the EDC system. The system functions on mobile phones, tablets, and Web browsers.

Results: ATN CARES is enrolling study participants and collecting baseline and follow-up data through the EDC system. Besides data collection, the EDC system is being used to generate multiple reports that inform recruitment planning, budgeting, intervention quality, and field staff supervision. The system is supporting both incoming and outgoing text messages (SMS) and offers high-level data security. Intervention design details are also influenced by EDC system platform capabilities and constraints. Challenges of using EDC systems are addressed through programming updates and training on how to improve data quality.

Conclusions: There are three key considerations in the development of an EDC system for an intervention trial. First, it needs to be decided whether the flexibility provided by the development of a study-specific, in-house EDC system is needed relative to the utilization of an existing commercial platform that requires less in-house programming expertise. Second, a single EDC system may not provide all functionality. ATN CARES is using a main EDC system for data collection, text messaging (SMS) interventions, and case management and a separate Web-based platform to support an online peer support intervention. Decisions need to be made regarding the functionality that is crucial for the EDC system to handle and what functionality can be handled by other systems. Third, data security is a priority but needs to be balanced with the need for flexible intervention delivery. For example, ATN CARES is delivering text messages (SMS) to study participants' mobile phones. EDC data security protocols should be developed under guidance from security experts and with formative consulting with the target study population as to their perceptions and needs.

International Registered Report Identifier (irrid): DERR1-10.2196/10777.
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http://dx.doi.org/10.2196/10777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6315223PMC
December 2018

Gender disparities in depression severity and coping among people living with HIV/AIDS in Kolkata, India.

PLoS One 2018 21;13(11):e0207055. Epub 2018 Nov 21.

Sonagachi Research & Training Institute, Durbar Mahila Samanwaya Committee, Kolkata, India.

People living with HIV/AIDS (PLH) experience high rates of depression and related psychosocial risk factors that vary by gender. This study examines gender differences in depression severity among antiretroviral therapy (ART) patients (n = 362) from a large government ART clinic in Kolkata, India. Hypotheses for multiple linear regression models were guided by an integrated gendered stress process model focusing on variables reflecting social status (age, partner status), stressors (stigma), and resources (income, social support). Depressive symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS); 22% of the sample reached the cutoff for severe depression, 56% moderate, and 13% mild depression. Compared to men, women reported lower income, education (50% no formal education vs. 20% men), availability of emotional and instrumental support, and were less likely to be married or cohabiting (53% women vs. 72% of men). However, more women had partners who were HIV-positive (78% women vs. 46% men). Overall, depression severity was negatively associated with availability of emotional support and self-distraction coping, and positively associated with internalized HIV/AIDS stigma, availability of instrumental support, and behavioral disengagement coping. Interactions for instrumental support by income and partner status by age varied significantly by gender. Analyses stratified by gender indicated that: 1) Frequently seeking instrumental support from others was protective for men at all income levels, but only for high-income women; and 2) having a partner was protective for men as they aged, but not for women. These results suggest that gender disparities in depression severity are created and maintained by women's lower social status and limited access to resources. The effect of stigma on depression severity did not vary by gender. These findings may inform the tailoring of future interventions to address mental health needs of PLH in India, particularly gender disparities in access to material and social resources for coping with HIV. Trial Registration: ClinicalTrials.gov registration #NCT02118454, registered April 2014.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0207055PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248946PMC
April 2019

The pull of soccer and the push of Xhosa boys in an HIV and drug abuse intervention in the Western Cape, South Africa.

SAHARA J 2018 12;15(1):187-199

b Center of Expertise on Women's Health, Gender and Empowerment , University of California Global Health Institute , San Francisco , CA , USA.

There is growing interest in engaging men and boys in health and development programmes targeting the intersection of HIV risk, substance abuse, and violence. Understanding the conceptualisations of masculinities or masculine identities that shape both behaviours and opportunities for intervention is central to advancing the global agenda to engage men in health and development interventions. This paper examines an intervention using soccer and job training to engage and deliver activities for HIV prevention, substance abuse, and gender-based violence in a South African township. A literature review provides theoretical, historical and social context for the intersection of gender, masculinity, soccer, violence, and sexual relationships. Qualitative data from in-depth interviews and focus groups is analysed using theoretical and contextual frames to elucidate the negotiation of shifting, contradictory, and conflicting masculine roles. Results highlight how changing risky, normative behaviours among young men is a negotiated process entailing men's relationships with women and with other men.
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http://dx.doi.org/10.1080/17290376.2018.1541024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6237168PMC
December 2018

Getting to Zero HIV Among Youth: Moving Beyond Medical Sites.

JAMA Pediatr 2018 12;172(12):1117-1118

Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles.

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http://dx.doi.org/10.1001/jamapediatrics.2018.3672DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6364560PMC
December 2018