Publications by authors named "Laura M Bogart"

181 Publications

Role of Support Reciprocity in HIV Viral Suppression Among People Living with HIV and Their Treatment Partners in Botswana.

Int J Behav Med 2021 Sep 7. Epub 2021 Sep 7.

University of Botswana, Gaborone, Botswana.

Background: Social support reciprocity (the extent to which people exchange mutual support) is associated with long-term health.

Method: We examined whether overall social support and reciprocity of support between people living with HIV and their treatment partners (informal caregivers selected from patients' social networks to support adherence) are associated with HIV viral suppression. A total of 130 patients living with HIV and their treatment partners were recruited from a clinic in Gaborone, Botswana, from May 2016 to April 2017. Participants completed surveys assessing sociodemographic and social network characteristics. Patients and treatment partners rated their emotional closeness to each other (not at all close = 0, somewhat close = 1, very close = 2).

Results: Multivariable logistic regressions indicated a significantly higher likelihood of viral suppression among patients who reported greater average emotional closeness to social network members. The likelihood of viral suppression was lower in asymmetric relationships in which patients felt closer to treatment partners than treatment partners felt to them (compared to when treatment partners felt closer to patients); this negative effect was strongest in dyads with female treatment partners and male patients. Follow-up analyses additionally indicated that asymmetric relationships in which treatment partners felt closer to patients were as protective as symmetric relationships, in which patients and treatment partners felt equally close.

Conclusion: Perceptions around reciprocity may matter as much as overall relationship closeness in patients' health outcomes. Interventions to improve the support of informal caregivers could help to improve relationship quality and health outcomes among people with HIV.
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http://dx.doi.org/10.1007/s12529-021-10021-1DOI Listing
September 2021

Association Between HIV Testing and HIV-Related Risk Behaviors Among US and Non-US Born Black Individuals Living in the US: Results From the National Survey on HIV in the Black Community (NSHBC).

J Immigr Minor Health 2021 Jul 16. Epub 2021 Jul 16.

Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Despite improvements in HIV prevention and treatment, Black individuals continue to be disproportionately affected by the HIV epidemic in the US. Using data from the National Survey on HIV in the Black Community, we examined the differences in demographic characteristics, risk behaviors, and HIV testing between US and non-US born Black adults. 868 individuals completed the survey and provided baseline data on sexual risk. Participants were grouped as US-born (N = 763) and non-US born (N = 101) based on self-reported place of birth. Amongst US-born participants, males were less likely to test for HIV, whereas those who reported a lifetime history of anal sex and sexually transmitted infections (STIs) were more likely to test for HIV. Non-US born participants who reported a single marital status were less likely to test for HIV, whereas those who reported a lifetime history of STIs were more likely to test for HIV. Some differences in predictors of HIV testing exist by place of birth. Understanding these differences is needed to develop HIV/AIDS prevention and treatment programs for US and non-US born Black individuals.
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http://dx.doi.org/10.1007/s10903-021-01244-1DOI Listing
July 2021

Feasibility and Acceptability of a Theater-Based HIV Prevention Workshop Developed by and for LGBTQ Youth.

Prog Community Health Partnersh 2021 ;15(2):189-201

Background: Lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth may have limited exposure to sexuality education programming that is affirming of their identities and unique experiences.

Objective: To develop and evaluate the feasibility and acceptability of a theater-based HIV prevention workshop for LGBTQ youth.

Methods: The 3-hour-long workshop (piloted 2014-2015; n = 20 LGBTQ youth, 14-22 years old) consisted of instruction in HIV risk and prevention, humorous role plays, and analysis of HIV prevention strategies using a forum theater format. A mixed methods evaluation focused on feasibility and acceptability, with survey assessment data collected for preliminary efficacy (e.g., HIV knowledge, safer sex self-efficacy).

Results: Participants perceived the forum theater format, humor, and reality of the scenes as strengths. The language of workshop scripts and evaluation materials could be further modified to better affirm gender and sexual diversity.

Conclusion: Preliminary evidence of feasibility and acceptability were demonstrated. Future iterations of the intervention require rigorous quantitative evaluation for efficacy.
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http://dx.doi.org/10.1353/cpr.2021.0021DOI Listing
January 2021

COVID-19 Vaccine Intentions and Mistrust in a National Sample of Black Americans.

J Natl Med Assoc 2021 Jun 19. Epub 2021 Jun 19.

Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, United States; Infectious Disease Division, Massachusetts General Hospital, Boston, MA, United States; Division of Global Health Equity, Harvard Medical School, Boston, MA, United States.

Background: National data indicate low intentions for COVID-19 vaccination among a substantial minority of Black Americans, and disproportionately lower vaccination rates among Black Americans than White Americans.

Methods: A total of 207 of the 318 Black participants (65%) in the RAND American Life Panel, a nationally representative internet panel, were surveyed about COVID-19 vaccine intentions in November-December 2020. Participants' census tracts were geocoded using the Centers for Disease Control and Prevention's Social Vulnerability Index.

Results: Overall, 35% agreed or strongly agreed that they would not get a COVID-19 vaccine, 40% agreed or strongly agreed that they would get vaccinated, and 25% reported "don't know." Significant multivariable predictors of not wanting to get vaccinated included high mistrust of the vaccine itself (e.g., concerns about harm and side effects), OR (95% CI) = 2.2 (1.2-3.9), p = .007, and weak subjective norms for vaccination in one's close social network, OR (95% CI) = 0.6 (0.4-0.7), p < .001. Residence in an area of higher socioeconomic vulnerability was a marginally significant predictor, OR (95% CI) = 3.1 (0.9-11.0), p = .08.

Conclusions: High mistrust around COVID-19 vaccines may lower vaccine confidence. Social network members' attitudes can be influential in encouraging vaccination. Public health communications could use transparent and clear messaging on safety and efficacy, and acknowledge historical and ongoing discrimination and racism as understandable reasons for low confidence in COVID-19 vaccines. Future research is needed to consider vaccine access challenges in tandem with mistrust as contributing to low vaccination rates across health conditions.
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http://dx.doi.org/10.1016/j.jnma.2021.05.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214755PMC
June 2021

Associations of HCV Knowledge and Medical Mistrust with Being Screened for HCV and Offered HCV Treatment among People with HIV.

J Health Care Poor Underserved 2021 ;32(2):1019-1033

An estimated one-fourth of people with HIV in the U.S. are coinfected with hepatitis C virus (HCV). We examined patient-related correlates of HCV screening and treatment in a convenience sample of 1,853 HIV-positive adults in Connecticut, Louisiana, New York, North Carolina, Pennsylvania, and Texas. Overall, 85.1% reported being screened for HCV, and 30.8% reported ever being offered treatment. In multivariate logistic regressions, greater HCV knowledge, lower HCV-related medical mistrust, older age, and prior substance use treatment were associated with higher screening and treatment likelihoods. For screening, Ryan White HIV/AIDS Program eligibility, having a high school education or less, and identifying as "other" race/ethnicity were additionally significant. Mistrust, which has arisen as a response to centuries of systemic racism, mediated the association between combined Black/Latino race/ethnicity and lower screening likelihood. We recommend patient-level (e.g., peer navigation) and provider interventions to integrate HCV screening and treatment into HIV care.
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http://dx.doi.org/10.1353/hpu.2021.0077DOI Listing
September 2021

Inter-Group and Intraminority-Group Discrimination Experiences and the Coping Responses of Latino Sexual Minority Men Living With HIV.

Ann LGBTQ Public Popul Health 2021 ;2(1):1-21

Department of Psychology, University of Massachusetts, Boston, MA, USA.

Discrimination negatively impacts the health of HIV-positive Latino sexual minority men (LSMM+). A growing literature on LSMM+ chronicles associations based on multiple devalued identities and mental health symptoms, HIV medication nonadherence, and sexual behaviors with the potential to transmit HIV. To gain additional insights on identity-based discrimination-as well as the associated coping responses-we conducted 30 qualitative interviews with LSMM+.Participantswereprobedregardingrecentdiscriminationevents(context,details,perpetrator, type) based on their intersecting identities (Latinx ethnicity, residency status, sexual minority orientation, HIV-positive serostatus) and their coping responses. We transcribed and translated the interviews and conducted a content analysis. Participants reported inter-group (i.e., between majority and minority group members) and intraminority-group (i.e., within minority group members) experiences as common. Participants described their intraminority-group experiences with discrimination based on being a Latinx sexual minority person in their families and home communities. Participants reported a range of coping responses to discrimination experiences. However, participants reported only functional (and no dysfunctional) coping strategies, and they endorsed using similar strategies in response to inter-group and intraminority-group discrimination. Coping strategies included strategic avoidance, social support, self-advocacy, and external attribution. Additional coping strategies (spirituality and positive reframing) emerged more strongly in response to inter-group experiences with discrimination. Our results underscore the need to address both inter-group and intraminority-group discrimination experiences. Future interventions can focus on strengthening the effective coping skills that LSMM+ currently employ as potential levers to address LSMM+ health disparities.
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http://dx.doi.org/10.1891/lgbtq-2020-0028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130892PMC
January 2021

Medical Mistrust and Stigma Associated with COVID-19 Among People Living with HIV in South Africa.

AIDS Behav 2021 May 17. Epub 2021 May 17.

Division of Infectious Diseases, Massachusetts General Hospital, Boston, USA.

We evaluated COVID-19 stigma and medical mistrust among people living with HIV in South Africa. We conducted telephone interviews with participants in a prospective study of a decentralized antiretroviral therapy program. Scales assessing medical mistrust, conspiracy beliefs, anticipated and internalized stigma, and stereotypes specific to COVID-19 were adapted primarily from the HIV literature, with higher scores indicating more stigma or mistrust. Among 303 participants, the median stigma summary score was 4 [interquartile range (IQR) 0-8; possible range 0-24] and 6 (IQR 2-9) for mistrust (possible range 0-28). A substantial proportion of participants agreed or strongly agreed with at least one item assessing stigma (54%) or mistrust (43%). Higher COVID-19 stigma was associated with female gender and antecedent HIV stigma, and lower stigma with reporting television as a source of information on COVID-19. Further efforts should focus on effects of stigma and mistrust on protective health behaviors and vaccine hesitancy.
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http://dx.doi.org/10.1007/s10461-021-03307-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8127851PMC
May 2021

Examination of Mediators and Moderators to Understand How and in What Context Game Changers Increases HIV Prevention Advocacy Among Persons Living With HIV in Uganda.

Int J Behav Med 2021 Mar 31. Epub 2021 Mar 31.

Makerere University School of Public Health, Kampala, Uganda.

Background: Our randomized controlled trial (RCT) of the group-based Game Changers intervention demonstrated effects on the primary goal of increased HIV-protective behaviors among social network members (alters), via the mechanism of increased participant engagement in HIV prevention advocacy with alters. We sought to understand how and in what context the intervention has its effects by examining specific mediators and moderators of the intervention's effect on increased prevention advocacy.

Methods: The RCT was conducted with 98 adult PLWH in Uganda. Intervention content targeted internalized HIV stigma, HIV disclosure, positive living behaviors, and self-efficacy for advocacy; these constructs were examined as intervention mediators (at the 5-month follow-up) of advocacy effects reported at the 8-month follow-up. Baseline sample characteristics were explored as moderators.

Results: Internalized HIV stigma and HIV disclosure mediated intervention effects on prevention advocacy, but not antiretroviral adherence or self-efficacy for advocacy. Moderators of the intervention effect included several network characteristics (trust in, support from, stigma from, and connectedness among network members), but not respondent socio-demographics or HIV disease characteristics. The intervention was associated with greater prevention advocacy when trust in, support from, and connectedness among alters were high, and stigma from alters was low.

Conclusions: These findings highlight the importance of helping PLWH cope with self-stigma and gain comfort with disclosure, as well as the potential influence of network support, trustworthiness, connectedness, and stigmatization on engagement in prevention advocacy.
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http://dx.doi.org/10.1007/s12529-021-09983-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8481355PMC
March 2021

HIV Risk-Related Behaviors and Willingness to Use Pre-Exposure Prophylaxis Among Black Americans with an Arrest History.

J Racial Ethn Health Disparities 2021 Feb 5. Epub 2021 Feb 5.

Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Objective: Black individuals in the USA are arrested and incarcerated at a significantly higher rate than White individuals, and incarceration is associated with increased HIV vulnerability. Pre-exposure prophylaxis (PrEP) reduces the risk for HIV transmission, but little is known about the relationship between HIV risk behavior and willingness to use PrEP among Black individuals with an arrest history.

Method: A total of 868 individuals completed a nationally representative survey and provided baseline data on sexual risk. Participants were grouped as those with a history of arrest (N = 226) and those with no history of arrest (N=619) based on self-reported arrest history. Our study examined HIV risk behaviors associated with willingness to use PrEP between those with arrest history and those without arrest history.

Results: Participants with an arrest history were more likely to have a lifetime history of anal sex (p<0.0001) and sexually transmitted diseases (p=0.0007). A history of multiple sexual partners in the past 3 months was associated with PrEP willingness in individuals with an arrest history [aPR 2.61 (1.77, 3.85), p<0.0001], adjusting for other covariates in the model.

Conclusions: Differences in risk behavior and willingness to use PrEP exist by arrest history. Understanding these risk behaviors are necessary to increase access to PrEP. PrEP uptake and adherence interventions, when recommended and made available for individuals at substantive risk of HIV infection at the time of arrest and during incarceration, are essential to reducing the spread of HIV in correctional facilities and in communities to which they return.
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http://dx.doi.org/10.1007/s40615-021-00980-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370684PMC
February 2021

Multilevel Barriers to HIV PrEP Uptake and Adherence Among Black and Hispanic/Latinx Transgender Women in Southern California.

AIDS Behav 2021 Jul 29;25(7):2301-2315. Epub 2021 Jan 29.

AntiViral Research Center, San Diego School of Medicine, University of California, San Diego, CA, USA.

Black and Hispanic/Latinx transgender women in the United States (U.S.) are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) reduces risk of HIV infection but PrEP uptake remains low among Black and Hispanic/Latinx transgender women. Between July 2018 and August 2019, we conducted individual interviews with 30 Black and Hispanic/Latinx transgender women who were prescribed PrEP through a PrEP demonstration project and 10 healthcare providers who provide PrEP services to transgender women in Los Angeles and San Diego, California. The interviews assessed general attitudes, experiences, and beliefs about PrEP as well as individual-, interpersonal-, community-, and structural-level barriers to PrEP uptake and adherence. PrEP adherence was assessed by collecting quantitative intracellular tenofovir-diphosphate (TFV-DP) levels in retrospect on batched, banked dried blood spot (DBS) samples. We utilized qualitative content analysis to identify themes from the interviews. Findings indicated the presence of individual-level barriers including cost concerns, mental health issues, substance use, and concerns about PrEP side effects including hormone interaction. Interpersonal-level barriers included the influence of intimate/romantic partners and the impact of patient-provider communication. Community-level barriers consisted of experiencing stigma and negative community opinions about PrEP use as well as having negative experiences in healthcare settings. Structural-level barriers included unreliable transportation, employment, and housing insecurity. Interventions aiming to increase PrEP uptake and adherence among Black and Hispanic/Latinx transgender women in the U.S. should employ a multilevel approach to addressing the needs of transgender women, especially the structural barriers that have greatly limited the use of PrEP.
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http://dx.doi.org/10.1007/s10461-021-03159-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7845787PMC
July 2021

Disclosure, Stigma, and Social Support among Young People Receiving Treatment for Substance Use Disorders and their Caregivers: A Qualitative Analysis.

Int J Ment Health Addict 2019 Dec 7;17(6):1535-1549. Epub 2018 May 7.

Harvard Medical School, 25 Shattuck Street, Boston, MA 02115.

Relational processes (i.e., disclosure, stigma, social support) experienced by youth with substance use disorders (SUDs) and their caregivers may act as barriers to, or facilitators of, recovery but are understudied. Single-session qualitative semi-structured interviews were conducted with 19 patients and 15 caregivers recruited by clinicians from a SUD program. There was variability in disclosure experiences, including how many people knew about patients' SUD diagnosis and treatment, whether patients or caregivers primarily disclosed to others, and feelings about others knowing about one's or one's child's SUD treatment. After disclosing, patients and caregivers experienced stigmatizing (e.g., social rejection) and supportive (e.g., understanding, advice) reactions from others. Disclosures may have important implications for relationship and recovery-related outcomes. Moreover, some child-caregiver pairs have significant disagreements regarding disclosure of SUD treatment. Addressing relational processes within treatment by encouraging patients and caregivers to share the disclosure decision-making process may support the recovery of youth with SUDs.
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http://dx.doi.org/10.1007/s11469-018-9930-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731618PMC
December 2019

Pilot Randomized Controlled Trial of an Intervention to Improve Coping with Intersectional Stigma and Medication Adherence Among HIV-Positive Latinx Sexual Minority Men.

AIDS Behav 2021 Jun 24;25(6):1647-1660. Epub 2020 Nov 24.

University of Massachusetts Boston, Boston, MA, USA.

We developed and pilot-tested an eight-session community-based cognitive behavior therapy group intervention to improve coping with intersectional stigma, address medical mistrust, and improve antiretroviral treatment adherence. Seventy-six HIV-positive Latinx sexual minority men (SMM; 38 intervention, 38 wait-list control) completed surveys at baseline, and 4- and 7-months post-baseline. Adherence was electronically monitored. Intention-to-treat, repeated-measures regressions showed improved adherence in the intervention vs. control group from baseline to follow-up [electronically monitored: b (95% CI) 9.24 (- 0.55, 19.03), p = 0.06; self-reported: b (95% CI) 4.50 (0.70, 8.30), p = .02]. Intervention participants showed marginally decreased negative religious coping beliefs in response to stigma [b (95% CI) = - 0.18 (- 0.37, 0.01), p = .06], and significantly lower medical mistrust [b (95% CI) = - 0.47 (- 0.84, - 0.09), p = .02]. Our intervention holds promise for improving HIV outcomes by empowering Latinx SMM to leverage innate resilience resources when faced with stigma.ClinicalTrials.gov ID (TRN): NCT03432819, 01/31/2018.
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http://dx.doi.org/10.1007/s10461-020-03081-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084890PMC
June 2021

COVID-19 Related Medical Mistrust, Health Impacts, and Potential Vaccine Hesitancy Among Black Americans Living With HIV.

J Acquir Immune Defic Syndr 2021 02;86(2):200-207

Community-Based Research, APLA Health & Wellness; and.

Background: Medical mistrust, a result of systemic racism, is prevalent among Black Americans and may play a role in COVID-19 inequities. In a convenience sample of HIV-positive Black Americans, we examined associations of COVID-19-related medical mistrust with COVID-19 vaccine and COVID-19 treatment hesitancy and negative impacts of COVID-19 on antiretroviral therapy (ART) adherence.

Methods: Participants were 101 HIV-positive Black Americans (age: M = 50.3 years; SD = 11.5; 86% cisgender men; 77% sexual minority) enrolled in a randomized controlled trial of a community-based ART adherence intervention in Los Angeles County, CA. From May to July 2020, participants completed telephone interviews on negative COVID-19 impacts, general COVID-19 mistrust (eg, about the government withholding information), COVID-19 vaccine and treatment hesitancy, and trust in COVID-19 information sources. Adherence was monitored electronically with the Medication Event Monitoring System.

Results: Nearly all participants (97%) endorsed at least one general COVID-19 mistrust belief, and more than half endorsed at least one COVID-19 vaccine or treatment hesitancy belief. Social service and health care providers were the most trusted sources. Greater COVID-19 mistrust was related to greater vaccine and treatment hesitancy [b (SE) = 0.85 (0.14), P < 0.0001 and b (SE) = 0.88 (0.14), P < 0.0001, respectively]. Participants experiencing more negative COVID-19 impacts showed lower ART adherence, assessed among a subset of 49 participants [b (SE) = -5.19 (2.08), P = 0.02].

Discussion: To prevent widening health inequities, health care providers should engage with communities to tailor strategies to overcome mistrust and deliver evidence-based information, to encourage COVID-19 vaccine and treatment uptake.
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http://dx.doi.org/10.1097/QAI.0000000000002570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808278PMC
February 2021

Changing contextual factors from baseline to 9-months post-HIV diagnosis predict 5-year mortality in Durban, South Africa.

AIDS Care 2020 Nov 2:1-8. Epub 2020 Nov 2.

Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.

Changes in an individual's contextual factors following HIV diagnosis may influence long-term outcomes. We evaluated how changes to contextual factors between HIV diagnosis and 9-month follow-up predict 5-year mortality among HIV-infected individuals in Durban, South Africa enrolled in the Sizanani Trial (NCT01188941). We used random survival forests to identify 9-month variables and changes from baseline predictive of time to mortality. We incorporated these into a Cox proportional hazards model including age, sex, and starting ART by 9 months , 9-month social support and competing needs, and changes in mental health between baseline and 9 months. Among 1,154 participants with South African ID numbers, 900 (78%) had baseline and 9-month data available of whom 109 (12%) died after 9-month follow-up. Those who reported less social support at 9 months had a 16% higher risk of mortality. Participants who went without basic needs or healthcare at 9 months had a 2.6 times higher hazard of death compared to participants who did not. Low social support and competing needs at 9-month follow-up substantially increase long-term mortality risk. Reassessing contextual factors during follow-up and targeting interventions to increase social support and affordability of care may reduce long-term mortality for HIV-infected individuals in South Africa.
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http://dx.doi.org/10.1080/09540121.2020.1837338DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088454PMC
November 2020

The Treatment Ambassador Program: A Highly Acceptable and Feasible Community-Based Peer Intervention for South Africans Living with HIV Who Delay or Discontinue Antiretroviral Therapy.

AIDS Behav 2021 Apr 30;25(4):1129-1143. Epub 2020 Oct 30.

Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA.

We conducted a novel pilot randomized controlled trial of the Treatment Ambassador Program (TAP), an 8-session, peer-based, behavioral intervention for people with HIV (PWH) in South Africa not on antiretroviral therapy (ART). PWH (43 intervention, 41 controls) completed baseline, 3- and 6-month assessments. TAP was highly feasible (90% completion), with peer counselors demonstrating good intervention fidelity. Post-intervention interviews showed high acceptability of TAP and counselors, who supported autonomy, assisted with clinical navigation, and provided psychosocial support. Intention-to-treat analyses indicated increased ART initiation by 3 months in the intervention vs. control arm (12.2% [5/41] vs. 2.3% [1/43], Fisher exact p-value = 0.105; Cohen's h = 0.41). Among those previously on ART (off for > 6 months), 33.3% initiated ART by 3 months in the intervention vs. 14.3% in the control arm (Cohen's h = 0.45). Results suggest that TAP was highly acceptable and feasible among PWH not on ART.
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http://dx.doi.org/10.1007/s10461-020-03063-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7979476PMC
April 2021

Identifying and predicting longitudinal trajectories of care for people newly diagnosed with HIV in South Africa.

PLoS One 2020 21;15(9):e0238975. Epub 2020 Sep 21.

Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America.

Background: Predicting long-term care trajectories at the time of HIV diagnosis may allow targeted interventions. Our objective was to uncover distinct CD4-based trajectories and determine baseline demographic, clinical, and contextual factors associated with trajectory membership.

Methods: We used data from the Sizanani trial (NCT01188941), in which adults were enrolled prior to HIV testing in Durban, South Africa from August 2010-January 2013. We ascertained CD4 counts from the National Health Laboratory Service over 5y follow-up. We used group-based statistical modeling to identify groups with similar CD4 count trajectories and Bayesian information criteria to determine distinct CD4 trajectories. We evaluated baseline factors that predict membership in specific trajectories using multinomial logistic regression. We examined calendar year of participant enrollment, age, gender, cohabitation, TB positivity, self-identified barriers to care, and ART initiation within 3 months of diagnosis.

Results: 688 participants had longitudinal data available. Group-based trajectory modeling identified four distinct trajectories: one with consistently low CD4 counts (21%), one with low CD4 counts that increased over time (22%), one with moderate CD4 counts that remained stable (41%), and one with high CD4 counts that increased over time (16%). Those with higher CD4 counts at diagnosis were younger, less likely to have TB, and less likely to identify barriers to care. Those in the least favorable trajectory (consistently low CD4 count) were least likely to start ART within 3 months.

Conclusions: One-fifth of people newly-diagnosed with HIV presented with low CD4 counts that failed to rise over time. Less than 40% were in a trajectory characterized by increasing CD4 counts. Patients in more favorable trajectories were younger, less likely to have TB, and less likely to report barriers to healthcare. Better understanding barriers to early care engagement and ART initiation will be necessary to improve long-term clinical outcomes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238975PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505419PMC
October 2020

Feasibility and acceptability of a pilot, peer-led HIV self-testing intervention in a hyperendemic fishing community in rural Uganda.

PLoS One 2020 7;15(8):e0236141. Epub 2020 Aug 7.

Yale School of Public Health, New Haven, CT, United States of America.

Background: Novel interventions are needed to reach young people and adult men with HIV services given the low HIV testing rates in these population sub-groups. We assessed the feasibility and acceptability of a peer-led oral HIV self-testing (HIVST) intervention in Kasensero, a hyperendemic fishing community (HIV prevalence: 37-41%) in Rakai, Uganda.

Methods: This study was conducted among young people (15-24 years) and adult men (25+ years) between May and August 2019. The study entailed distribution of HIVST kits by trained "peer-leaders," who were selected from existing social networks and trained in HIVST distribution processes. Peer-leaders received up to 10 kits to distribute to eligible social network members (i.e. aged 15-24 years if young people or 25+ years if adult man, not tested in the past 3 months, and HIV-negative or of unknown HIV status at enrolment). The intervention was evaluated against the feasibility benchmark of 70% of peer-leaders distributing up to 70% of the kits that they received; and the acceptability benchmark of >80% of the respondents self-testing for HIV.

Results: Of 298 enrolled into the study at baseline, 56.4% (n = 168) were young people (15-24 years) and 43.6% (n = 130) were adult males (25+ years). Peer-leaders received 298 kits and distributed 296 (99.3%) kits to their social network members. Of the 282 interviewed at follow-up, 98.2% (n = 277) reported that they used the HIVST kits. HIV prevalence was 7.4% (n = 21). Of the 57.1% (n = 12) first-time HIV-positives, 100% sought confirmatory HIV testing and nine of the ten (90%) respondents who were confirmed as HIV-positive were linked to HIV care within 1 week of HIV diagnosis.

Conclusion: Our findings show that a social network-based, peer-led HIVST intervention in a hyperendemic fishing community is highly feasible and acceptable, and achieves high linkage to HIV care among newly diagnosed HIV-positive individuals.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236141PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413506PMC
October 2020

Acceptability of oral HIV self-testing among female sex workers in Gaborone, Botswana.

PLoS One 2020 27;15(7):e0236052. Epub 2020 Jul 27.

Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.

Background: HIV prevalence among female sex workers (FSW) in sub-Saharan Africa is much higher than in the general population. HIV self-testing (HIVST) may be useful for increasing testing rates in FSW.

Methods: We conducted semi-structured in-depth interviews among FSW, nurses and lay counsellors providing services to FSWs in Botswana. We aimed to gain understanding of perceived acceptability, anticipated barriers, and preferred approaches to HIVST among FSW. Interviews were audio-recorded, transcribed and translated. Transcripts were reviewed and coded independently by two investigators; high inter-coder agreement was achieved (Kappa = 0.80).

Results: We interviewed five care providers whose average age was 40 years (SD = 2,64, range = 37-43); three nurses and two counsellors. Thirty FSW were interviewed, with mean age 34 years (range = 20-52). Most (27; 90%) FSW expressed great interest in using HIVST kits. Facilitators of HIVST were: awareness of own risky sexual behaviours, desire to stay healthy, and perceived autonomy over one's healthcare decisions. Perceived advantages of HIVST included convenience, privacy, and perception of decreased stigma. Identified barriers to HIVST included lack of knowledge about the HIVST kit, fear of testing due to anticipated stigma, mistrust of the test's accuracy, doubt of self-competency to perform HIVST, and concerns about not linking to care. Assisting someone to test was noted as good for providing emotional support, but there were concerns about confidentiality breaches. Providers expressed concerns over low literacy among FSWs which could affect comprehension of testing instructions, and competency to perform testing and interpret results. Participants' recommendations for implementation of HIVST included: ensuring wide dissemination of information on HIVST, engaging peers in information-sharing and education, making test kits accessible in FSW-friendly centres, and having clear instructions for linkage to healthcare and support.

Conclusion: HIVST shows high acceptability among FSWs in Gaborone Botswana, with providers expressing some concerns. Implementation should be peer-driven with healthcare provider oversight.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236052PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384658PMC
September 2020

A Pilot Test of Game Changers, a Social Network Intervention to Empower People with HIV to be Prevention Advocates in Uganda.

AIDS Behav 2020 Sep;24(9):2490-2508

Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.

We conducted a pilot randomized controlled trial of Game Changers, a 6-session group intervention that empowers people with HIV to be HIV prevention advocates in their social networks. Ninety-nine people with HIV (51 intervention, 48 wait-list control) and 58 of their social network members (alters) completed baseline and 5- and 8-month post-baseline assessments. Results indicated high acceptability, demonstrated by participants' and facilitators' positive attitudes qualitatively and favorable ratings of intervention sessions quantitatively, and high feasibility (76% attended all intervention sessions). Intention-to-treat analyses indicated significantly increased HIV prevention advocacy among HIV-positive participants and alters [b (SE) = 0.4 (0.2), p = .017; b (SE) = 0.4 (0.2), p = .035]; reduced internalized HIV stigma [b (SE) =  - 0.3 (0.1), p = .012], increased HIV-serostatus disclosure [b (SE) = 0.1 (0.1), p = .051], and increased social network density among HIV-positive participants [b (SE) = 0.1 (0.03), p = .004]; and marginally reduced condomless sex among alters [OR (95% CI) = 0.3 (0.1-1.2), p = .08]. Positioning people with HIV as central to prevention has the potential to reduce stigma and improve prevention outcomes throughout social networks.
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http://dx.doi.org/10.1007/s10461-020-02806-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415589PMC
September 2020

Area-level HIV risk and socioeconomic factors associated with willingness to use PrEP among Black people in the U.S. South.

Ann Epidemiol 2020 02 30;42:33-41. Epub 2019 Nov 30.

Harvard Medical School, Boston, MA; Brigham and Women's Hospital, Boston, MA.

Purpose: In the United States (U.S.), southern states have the highest HIV incidence. Uptake of pre-exposure prophylaxis (PrEP) has been slow among Black people, particularly in the South. We know little about how area-level HIV risk influences one's willingness to use PrEP.

Methods: 169 Black participants across 142 ZIP codes in the South completed the 2016 National Survey on HIV in the Black Community. We performed log-binomial regression to estimate the prevalence risk associated with residing in the upper 25th percentile of increases in new HIV diagnosis (2014-2015) within ZIP code and an individual's willingness to use PrEP, adjusting for individual and area-level covariates.

Results: Participants were 68% female, mean age of 36 years, and 24% willing to use PrEP. Among the ZIP codes, 23% were within Atlanta, GA. The median increase in new HIV diagnoses was 25 per 100,000 population from 2014 to 2015 (IQR, 14-49). Participants living in ZIP codes within the upper 25th (compared-to-lower 75th) percentile of new HIV diagnoses were more willing to use PrEP (adjusted prevalence ratio (aPR) = 2.02, 95% CI = 1.06-3.86, P = .03). Area-level socioeconomic factors attenuated that association (aPR = 1.63, 95% CI = 0.78-3.39, P = .19).

Conclusions: Area-level factors may influence PrEP uptake among Black people in the South.
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http://dx.doi.org/10.1016/j.annepidem.2019.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7056502PMC
February 2020

A Pilot Cognitive Behavior Therapy Group Intervention to Address Coping with Discrimination Among HIV-Positive Latino Immigrant Sexual Minority Men.

Ann LGBTQ Public Popul Health 2020 ;1(1):6-26

University of Massachusetts Boston, Boston, MA.

Discrimination is thought to be a key driver of health disparities that affect people with multiple intersecting devalued identities, such as HIV-positive Latino sexual minority men (SMM). Ineffective coping with the stress of discrimination (e.g., rumination, substance use) may lead to worse long-term mental and physical health. Within the context of a community partnership, we developed a nine-session, community-based, cognitive behavior therapy group intervention to address coping with discrimination among HIV-positive Latino immigrant SMM. In Study 1, we assessed anticipated intervention acceptability via semi-structured interviews with 28 HIV-positive Latino SMM and ten social service providers and administrators; we used interview data to develop the manualized intervention. In Study 2, we assessed acceptability, feasibility, and preliminary effects in a pre-post, non-randomized intervention evaluation with two intervention groups of HIV-positive Latino SMM (n = 30, average age = 48.5, SD = 10.3). In semi-structured interviews, key stakeholders were enthusiastic about the proposed intervention. In the non-randomized evaluation, feasibility was evidenced by moderate levels of intervention attendance (five sessions on average); reasons for missed sessions (e.g., illness, scheduling conflict with work) were unrelated to the intervention. Linear regressions showed preliminary effects for decreased negative emotional coping responses to discrimination pre-to-post intervention (i.e., feeling less anger, sadness, powerlessness, helplessness, and shame on two subscales; b () = -0.23 (0.10), = .03; b () = -0.25 (0.11), = .03). Our intervention holds promise for reducing disparities by empowering Latino SMM to leverage innate resilience resources to improve their health in the face of discrimination.
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http://dx.doi.org/10.1891/lgbtq.2019-0003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8336475PMC
January 2020

Trajectories of HIV-related internalized stigma and disclosure concerns among ART initiators and non-initiators in South Africa.

Stigma Health 2019 Nov 28;4(4):433-441. Epub 2019 Jan 28.

Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.

Background: HIV-related stigma among people living with HIV (PLHIV) is associated with worse health outcomes. We used longitudinal data from a multi-site cohort in South Africa to assess changes over time in stigma after HIV diagnosis and determine whether antiretroviral therapy (ART) initiation is associated with stigma reduction.

Methods: We administered the Internalized AIDS-Related Stigma Scale (IARSS, a six-item dichotomous scale questionnaire) at baseline, three months, and six months to newly diagnosed ART-eligible participants between 2014-2015. A confirmatory factor analysis indicated that the IARSS contained a four-item internalized stigma factor (α=0.80) and a two-item disclosure concerns factor (α=0.75). We fitted multiple logistic regression models specifying internalized stigma/disclosure concerns at six months as the outcome and ART initiation as the predictor of interest.

Results: Of the 500 participants (187 men and 313 women) enrolled, 308 (62%) initiated ART. Internalized stigma declined among people entering care (mean score, 1.0 to 0.7, p<0.01); however, disclosure concerns remained unchanged (percentage endorsing either disclosure concern item, 78% to 77%, p=0.23). These findings were similar between ART initiators and non-initiators. We estimated a statistically significant positive association between ART initiation and disclosure concerns at six months (OR=1.88; 95% CI, 1.20-2.94) but not between ART initiation and internalized stigma at six months (OR=1.15; 95% CI, 0.75-1.78).

Conclusions: Among ART-eligible South African PLHIV entering into HIV care, internalized stigma modestly declined over time but disclosure concerns persisted. PLHIV who initiated ART were more likely to have persistent disclosure concerns over time as compared with those who did not start ART.
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http://dx.doi.org/10.1037/sah0000159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884335PMC
November 2019

High consumption of energy-dense nutrient-poor foods among low-income groups in the Mississippi Delta and Alabama.

Public Health Nutr 2020 04 30;23(6):1067-1075. Epub 2019 Sep 30.

RAND Corporation, 1776 Main Street, Santa Monica, CA90407, USA.

Objective: To assess the consumption of sugar-sweetened beverages (SSB) and other energy-dense nutrient-poor (EDNP) foods in two Southern low-income communities targeted by the Balance Calories Initiative, a campaign by the top-three American beverage companies intended to reduce the consumption of sugary beverages by 20 % over 10 years.

Design: We conducted self-administered intercept surveys in front of food retail outlets between August and November 2016. We recruited adults with children <18 years living at home and adolescents aged 10-17 years with parental consent.

Setting: Retail food outlets in Mississippi and Alabama, USA.

Participants: Adults (n 11 311) and adolescents (n 3460).

Results: The percentage of high SSB consumers (≥4 servings/d) was 40·9 % among adult males, 32·3 % among adult females, 43·0 % among adolescent males and 34·4 % among adolescent females (male - female difference, P < 0·0001). In aggregate, respondents also reported consuming a mean of 3 servings of salty snacks, cookies and/or candy in the past 24 h, with adolescent males reporting 4 servings.

Conclusions: SSB should be a primary target of future interventions to improve dietary intake, but EDNP foods likely contribute as many daily kilojoules as SSB among this population. Future campaigns should aim to limit the consumption of all EDNP foods.
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http://dx.doi.org/10.1017/S1368980019002817DOI Listing
April 2020

Assessing rates and contextual predictors of 5-year mortality among HIV-infected and HIV-uninfected individuals following HIV testing in Durban, South Africa.

BMC Infect Dis 2019 Aug 28;19(1):751. Epub 2019 Aug 28.

Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.

Background: Little is known about contextual factors that predict long-term mortality following HIV testing in resource-limited settings. We evaluated the impact of contextual factors on 5-year mortality among HIV-infected and HIV-uninfected individuals in Durban, South Africa.

Methods: We used data from the Sizanani trial (NCT01188941) in which adults (≥18y) were enrolled prior to HIV testing at 4 outpatient sites. We ascertained vital status via the South African National Population Register. We used random survival forests to identify the most influential predictors of time to death and incorporated these into a Cox model that included age, gender, HIV status, CD4 count, healthcare usage, health facility type, mental health, and self-identified barriers to care (i.e., service delivery, financial, logistical, structural and perceived health).

Results: Among 4816 participants, 39% were HIV-infected. Median age was 31y and 49% were female. 380 of 2508 with survival information (15%) died during median follow-up of 5.8y. For both HIV-infected and HIV-uninfected participants, each additional barrier domain increased the HR of dying by 11% (HR 1.11, 95% CI 1.05-1.18). Every 10-point increase in mental health score decreased the HR by 7% (HR 0.93, 95% CI 0.89-0.97). The hazard ratio (HR) for death of HIV-infected versus HIV-uninfected varied by age: HR of 6.59 (95% CI: 4.79-9.06) at age 20 dropping to a HR of 1.13 (95% CI: 0.86-1.48) at age 60.

Conclusions: Independent of serostatus, more self-identified barrier domains and poorer mental health increased mortality risk. Additionally, the impact of HIV on mortality was most pronounced in younger persons. These factors may be used to identify high-risk individuals requiring intensive follow up, regardless of serostatus.

Trial Registration: Clinical Trials.gov Identifier NCT01188941. Registered 26 August 2010.
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http://dx.doi.org/10.1186/s12879-019-4373-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712739PMC
August 2019

Understanding the role of resilience resources, antiretroviral therapy initiation, and HIV-1 RNA suppression among people living with HIV in South Africa: a prospective cohort study.

AIDS 2019 06;33 Suppl 1:S71-S79

Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, USA.

Objective: Failure to initiate antiretroviral therapy (ART) and achieve virologic suppression are significant barriers to the United Nations 90-90-90 goals. Identifying resilience resources, or modifiable strength-based factors, among people living with HIV is critical for successful HIV treatment and prevention.

Design: Prospective cohort study.

Methods: From July 2014 to July 2015, 500 adults presenting for voluntary counseling and HIV testing who were diagnosed with HIV and were ART-eligible in South Africa (Soweto and Gugulethu) were enrolled and surveyed. Logistic regression models assessed resilience-related predictors of ART initiation within 6 months of voluntary counseling and HIV testing for HIV, and HIV-1 plasma RNA suppression within 9 months, adjusting for sociodemographic factors.

Results: Within 6 months, 62% initiated ART, and within 9 months, 25% had evidence of an undetectable HIV-1 plasma RNA (<50 copies/ml). Participants who initiated ART relied less on social support from friends [adjusted odds ratio (aOR) 0.94, 95% confidence interval (CI): 0.89-0.99], coped using self-distraction (aOR 1.05, 95% CI: 1.00-1.10) and avoided coping through substance use (aOR 0.79, 95% CI: 0.65-0.97), as compared with participants who did not initiate ART. Those who achieved plasma RNA suppression relied more on social support from a significant other/partner (aOR 1.04, 95% CI: 1.02-1.07), used positive religious coping (aOR 1.03, 95% CI: 1.00-1.07), and were less likely to engage in denial coping (aOR 0.84, 95% CI: 0.77-0.92), compared with those who initiated ART but did not achieve plasma RNA suppression.

Conclusion: Interventions optimizing resilience resources and decreasing maladaptive coping strategies (e.g., substance use, denial) may present a feasible approach to maximizing ART-based HIV treatment strategies among South African people living with HIV.
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http://dx.doi.org/10.1097/QAD.0000000000002175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712569PMC
June 2019

HIV-Related Medical Mistrust, HIV Testing, and HIV Risk in the National Survey on HIV in the Black Community.

Behav Med 2019 Apr-Jun;45(2):134-142

e Department of Medicine, Brigham and Women's Hospital.

Black Americans are greatly affected by HIV disparities and exhibit high levels of medical mistrust, including HIV conspiracy beliefs, a form of mistrust around HIV's origin and treatment. A 2002-2003 national survey of Black Americans found that 48% believed that "HIV is a manmade virus." However, the extent to which such beliefs remain widespread is unknown. Moreover, HIV conspiracy beliefs have been associated with greater HIV risk, but have also been associated with a higher testing likelihood-and no research to date has attempted to explain these seemingly contradictory findings. We obtained updated data on prevalence and correlates of HIV conspiracy beliefs from the US National Survey on HIV in the Black Community, a nationally representative e-mail survey of 868 Black individuals aged 18-50 years (February-April 2016). Substantial percentages agreed that HIV is man-made (31%) and that the government is withholding a cure for HIV (40%). HIV conspiracy beliefs and HIV risk were both significantly associated with a higher HIV testing likelihood. The association between HIV conspiracy beliefs and HIV testing was significantly mediated by individual-level HIV risk (73% of total effect), but not by area-level socioeconomic position (an ecological determinant of higher HIV prevalence). Mistrust remains high among Black Americans, but the association of mistrust with prevention behaviors is complex. People who do not trust the public health system may also be at greater risk-and thus, more likely to get tested, potentially due to greater access to community-based testing venues that engage higher risk populations.
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http://dx.doi.org/10.1080/08964289.2019.1585324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6783255PMC
February 2020

Age matters: differences in correlates of self-reported HIV antiretroviral treatment adherence between older and younger Black men who have sex with men living with HIV.

AIDS Care 2019 08 9;31(8):965-972. Epub 2019 May 9.

d Department of Psychiatry and Behavioral Sciences , Keck School of Medicine of the University of Southern California , Los Angeles , USA.

Black men who have sex with men (BMSM) show lower levels of adherence to antiretroviral therapy (ART) for HIV medications than other racial/ethnic groups in the U.S. Yet, little is known about age differences in factors that predict ART adherence among BMSM. We combined data from two surveys of HIV-positive BMSM, resulting in 209 participants (130 aged 18-50 years; 79 aged 50 years or older). Multivariate linear regressions examined associations between baseline characteristics and adherence to HIV medications as well as interactions of baseline characteristics with age. The associations between trust in healthcare and doctor satisfaction ratings with higher adherence were stronger for older vs younger men ( < .05); the association between problem drinking and lower adherence was stronger among younger men ( < .05). Future research should examine how interventions may address these age-specific factors to improve ART adherence among BMSM living with HIV.
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http://dx.doi.org/10.1080/09540121.2019.1612020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628933PMC
August 2019

A qualitative exploration of parents', youths' and food establishment managers' perceptions of beverage industry self-regulation for obesity prevention.

Public Health Nutr 2019 04 13;22(5):805-813. Epub 2019 Feb 13.

RAND Corporation,1776 Main Street,PO Box 2138,Santa Monica,CA,90407-2138,USA.

Objective: We aimed to explore the range of stakeholders' perceptions of the Balance Calories Initiative (BCI), under which the American Beverage Association pledged to decrease per capita US consumption of beverage energy by 20 % by 2025.

Design: Semi-structured cross-sectional interviews were conducted in 2017.

Setting: Participants were recruited from communities targeted by the BCI (Montgomery, AL; North Mississippi Delta, MS; Eastern Los Angeles, CA).ParticipantsA total of thirty-three parents and thirty-eight youths aged 10-17 years were recruited through youth-serving organizations, street intercept and snowball sampling; sixteen store/restaurant managers were recruited at businesses. Participants were asked about their awareness of the BCI. Parents and youths were asked to 'think aloud' as they viewed BCI messages (e.g. 'Balance What You Eat, Drink, and Do') and managers were asked about beverage marketing.

Results: Twelve parents and twenty-four youths had seen BCI messages; only four managers were aware of the BCI. Many parents and youths showed some misunderstanding of BCI messages (e.g. that they should drink more sugar-sweetened beverages (SSB) or they needed to equalize healthy and unhealthy beverage intake). Only one manager had communicated with beverage companies about the BCI.

Conclusions: We found mixed comprehension and low awareness of BCI messages in communities targeted by the American Beverage Association for reduced SSB consumption. Industry self-regulation attempts to reduce SSB consumption may have limited effectiveness if stakeholder input is not addressed. Public health practitioners should be aware of the need to address youths' and parents' misunderstandings about SSB consumption, especially in BCI-targeted communities.
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http://dx.doi.org/10.1017/S1368980018003865DOI Listing
April 2019

HIV fatalism and engagement in transactional sex among Ugandan fisherfolk living with HIV.

SAHARA J 2019 12;16(1):1-9

f Department of Disease Control and Environmental Health , Makerere University , Kampala , Uganda.

HIV fatalism, or the belief that HIV acquisition and mortality is out of one's control, is thought to contribute to HIV risk in fishing populations in East Africa. The objective of this cross-sectional study was to investigate the association between fatalism and sexual risk behaviours (unprotected sex, engagement in transactional sex), beyond the influence of other known HIV risk factors (e.g. food insecurity, mobility), and identify demographic, psychosocial, and structural correlates of HIV fatalism. Ninety-one men and women living in fishing villages on two islands in Lake Victoria, Uganda completed an interviewer-administered questionnaire after testing HIV-positive during home or community-based HIV testing between May and July 2015. Multivariate logistic regression was used to test the association between HIV fatalism and transactional sex and multivariate linear regression was used to identify demographic, psychosocial, and structural correlates of HIV fatalism. HIV fatalism was significantly associated with a greater likelihood of transactional sex (AOR = 3.07, 95% CI = 1.02-9.23, p = 0.04), and structural barriers to HIV care (e.g. distance to clinic) were significantly associated with HIV fatalism (β = 0.26, SE = 0.12, p = 0.04). Our findings highlight HIV fatalism as a contributor to transactional sex in Ugandan fishing communities, and as a product of broader social and contextual factors, suggesting the potential need for structural HIV interventions in this setting.
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http://dx.doi.org/10.1080/17290376.2019.1572533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366790PMC
December 2019

Spatial Access and Willingness to Use Pre-Exposure Prophylaxis Among Black/African American Individuals in the United States: Cross-Sectional Survey.

JMIR Public Health Surveill 2019 Feb 4;5(1):e12405. Epub 2019 Feb 4.

Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States.

Background: Uptake of pre-exposure prophylaxis (PrEP) among black individuals in the United States is low and may be associated with the limited availability of clinics where PrEP is prescribed.

Objective: We aimed to determine the association between spatial access to clinics where PrEP is prescribed and willingness to use PrEP.

Methods: We identified locations of clinics where PrEP is prescribed from AIDSVu.org and calculated the density of PrEP clinics per 10,000 residents according to the ZIP code. Individual-level data were obtained from the 2016 National Survey on HIV in the Black Community. We used multilevel modelling to estimate the association between willingness to use PrEP and clinic density among participants with individual-level (HIV risk, age, gender, education, income, insurance, doctor visit, census region, urban/rural residence) and ZIP code-level (%poverty, %unemployed, %uninsured, %black population, and density of health care facilities) variables.

Results: All participants identified as black/African American. Of the 787 participants, 45% were men and 23% were found to be at high risk based on the self-reported behavioral characteristics. The mean age of the participants was 34 years (SD 9), 54% of participants resided in the South, and 26% were willing to use PrEP. More than one-third (38%) of the sample had to drive more than 1 hour to access a PrEP provider. Participants living in areas with higher PrEP clinic density were significantly more willing to use PrEP (one SD higher density of PrEP clinics per 10,000 population was associated with 16% higher willingness [adjusted prevalence ratio=1.16, 95% CI: 1.03-1.31]).

Conclusions: Willingness to use PrEP was associated with spatial availability of clinics where providers prescribe PrEP in this nationally representative sample of black African Americans.
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http://dx.doi.org/10.2196/12405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6378549PMC
February 2019
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