Acceptability of a HIV self-testing program among people who use illicit drugs.

BACKGROUND: People who use illicit drugs (PWUD) remain at significantly elevated risk for HIV infection and continue to have very low testing rates. HIV self-testing (HIVST) has been shown to be acceptable among many high-risk populations, but less is known about PWUD. METHODS: From May-June 2021, a HIVST program was implemented at a syringe services program (SSP) in Louisville, Kentucky. PWUD were given the option to privately self-test at the SSP or take the test home and follow-up with study staff. Primary outcomes were acceptability, ease of use, usability, reasons for self-testing, testing location, frequency of future testing, and preference for future testing location. RESULTS: Among 230 study participants, 77% reported high acceptability (i.e., the HIVST kits made them feel much more able to keep track of their HIV status compared to standard testing methods). Virtually all (97.4%) reported the test kits were very easy to use. Problems while using the HIVST kits were rare (range 1.3-3.0%). The most common reasons for testing were a desire to know their status (85.2%), the test was free (37%), and the short duration for results (30.9%). Testing primarily occurred onsite (87.8%). The majority (83%) reported they would use the HIVST kits at least every six months if made available through the health department and would prefer to test at home (71.7%). Multivariate analyses found that awareness of and intention to use pre-exposure prophylaxis (PrEP) were significantly associated with high acceptability and testing onsite. CONCLUSION: Study participants found HIVST to be acceptable and very easy to use. The multivariate findings suggest HIVST interventions should be packaged with PrEP interventions and harm reduction programs.

How does qualitative data collection modality affect disclosure of sensitive information and participant experience? Findings from a quasi-experimental study.

Focus groups (FGs) and individual interviews (IDIs) can be conducted in-person or in several different online contexts. We conducted a quasi-experimental study and assessed sharing of sensitive or dissenting information and participant comfort in FGs and IDIs across four modalities: (1) in-person, (2) online video-based, (3) online chat-based (synchronous), and (4) online email/message board-based (asynchronous). Participants were systematically assigned to one of the four modalities and randomized to one of 24 FGs or 48 IDIs (N = 171). The study topic was medical risk during pregnancy. All participants also completed a survey on their perceptions of the data collection process. We found no significant difference in the frequency of disclosure of sensitive information by modality. Text-based FGs (chat and message board) were more likely to contain dissenting opinions than visually-based FGs (in-person and video). Participants also reported feeling less rapport and personal comfort in sharing information in the FG video modality than other modalities. These findings provide initial data that can guide researchers in choosing among data collection modalities to maximize participant engagement and comfort.

A simple method to assess and report thematic saturation in qualitative research.

Data saturation is the most commonly employed concept for estimating sample sizes in qualitative research. Over the past 20 years, scholars using both empirical research and mathematical/statistical models have made significant contributions to the question: How many qualitative interviews are enough? This body of work has advanced the evidence base for sample size estimation in qualitative inquiry during the design phase of a study, prior to data collection, but it does not provide qualitative researchers with a simple and reliable way to determine the adequacy of sample sizes during and/or after data collection. Using the principle of saturation as a foundation, we describe and validate a simple-to-apply method for assessing and reporting on saturation in the context of inductive thematic analyses. Following a review of the empirical research on data saturation and sample size estimation in qualitative research, we propose an alternative way to evaluate saturation that overcomes the shortcomings and challenges associated with existing methods identified in our review. Our approach includes three primary elements in its calculation and assessment: Base Size, Run Length, and New Information Threshold. We additionally propose a more flexible approach to reporting saturation. To validate our method, we use a bootstrapping technique on three existing thematically coded qualitative datasets generated from in-depth interviews. Results from this analysis indicate the method we propose to assess and report on saturation is feasible and congruent with findings from earlier studies.

Beyond the Individual: Social and Cultural Influences on the Health-Seeking Behaviors of African American Men.

Morbidity and mortality rates are alarmingly high among African American men and are influenced by the health-seeking behaviors of this population. This study examined data from 40 focus groups with African American men in Durham, North Carolina, to better understand social and cultural influences on health-seeking behaviors. Data were analyzed using inductive thematic analysis. Three broad types of social/cultural influence on motivation to seek health care services were identified: family, culture and upbringing, and peers. Study findings confirm the importance of social relationships in influencing African American men's health-seeking behaviors and offer characterization of the nature of influence across different types of relationships, according to the direct support or indirect messages they provide. Future programs can draw on these data to inform efforts to include family and peers as well as utilize existing cultural gender norms to the advantage of health promotion for African American men.

Evaluating the impact of integrated development: are we asking the right questions? A systematic review.

Background: Emerging global transformations - including a new Sustainable Development Agenda - are revealing increasingly interrelated goals and challenges, poised to be addressed by similarly integrated, multi-faceted solutions. Research to date has focused on determining the effectiveness of these approaches, yet a key question remains: are synergistic effects produced by integrating two or more sectors?  We systematically reviewed impact evaluations on integrated development interventions to assess whether synergistic, amplified impacts are being measured and evaluated. Methods: The International Initiative for Impact Evaluation's (3ie) Impact Evaluation Repository comprised our sampling frame (n = 4,339). Following PRISMA guidelines, we employed a three-stage screening and review process. Results: We identified 601 journal articles that evaluated integrated interventions. Seventy percent used a randomized design to assess impact with regard to whether the intervention achieved its desired outcomes. Only 26 of these evaluations, however, used a full factorial design to statistically detect any synergistic effects produced by integrating sectors. Of those, seven showed synergistic effects. Conclusions: To date, evaluations of integrated development approaches have demonstrated positive impacts in numerous contexts, but gaps remain with regard to documenting whether integrated programming produces synergistic, amplified outcomes. Research on these program models needs to extend beyond impact only, and more explicitly examine and measure the synergies and efficiencies associated with linking two or more sectors. Doing so will be critical for identifying effective integrated development strategies that will help achieve the multi-sector SDG agenda.

Beyond the Page: A Process Review of Using Ethnodrama to Disseminate Research Findings.

Public health researchers are charged with communicating study findings to appropriate audiences. Dissemination activities typically target the academic research community. However, as participatory research grows, researchers are increasingly exploring innovative dissemination techniques to reach broader audiences, particularly research participants and their communities. One technique is ethnodrama/ethnotheatre, a written or live performance based on study findings. Though used effectively in social change programs, dramas are seldom used to distribute research findings exclusively. Therefore, little information is available about planning and implementing an ethnodrama for this purpose. We present a case study describing the process of planning and implementing an ethnodrama in the context of the Durham Focus Group Study, which explored men's health-seeking behaviors and experiences with health and healthcare services in Durham, North Carolina. Here, we highlight lessons learned throughout the production of the ethnodrama, and how we addressed challenges associated with transforming research data into educational entertainment. Additionally, we provide discussion of audience feedback, which indicated that our ethnodrama evoked an urgency to change health behaviors among lay persons (67%) and delivery of health services among those identifying as providers (84%), pointing to the success of the performance in both entertaining and educating the audience.

When and why women might suspend PrEP use according to perceived seasons of risk: implications for PrEP-specific risk-reduction counselling.

Oral pre-exposure prophylaxis (PrEP) using the antiretroviral drug emtricitabine/tenofovir disoproxil fumarate (Truvada) has been shown to dramatically reduce the risk of HIV acquisition for women at higher risk of infection if taken daily. Understanding when and why women would intentionally stop using an efficacious oral PrEP drug within the context of their 'normal' daily lives is essential for delivering effective PrEP risk-reduction counselling. As part of a larger study, we conducted 60 qualitative interviews with women at higher risk of HIV in Bondo, Kenya, and Pretoria, South Africa. Participants charted their sexual contacts over the previous six months, indicated whether they would have taken PrEP if available and discussed whether and why they would have suspended PrEP use. Nearly all participants said they would have used PrEP in the previous six months; half indicated they would have suspended PrEP use at some point. Participants' reasons for an extended break from PrEP were related to partnership dynamics (e.g., perceived low risk of a stable partner) and phases of life (e.g., trying to conceive). Life events (e.g., holidays and travel) could prompt shorter breaks in PrEP use. These circumstances may or may not correspond to actual contexts of lower risk, highlighting the importance of tailored PrEP risk-reduction counselling.

On the road again: concurrency and condom use among Uganda truck drivers.

Long-distance truck drivers have been shown to be a critical population in the spread of HIV in Africa. In 2009, surveys with 385 Ugandan long-distance truck drivers measured concurrency point prevalence with two methods; it ranged from 37.4% (calendar-method) to 50.1% (direct question). The majority (84%) of relationships reported were long-term resulting in a long duration of overlap (average of 58 months) across concurrent partnerships. Only 7% of these men reported using any condoms with their spouses during the past month. Among all non-spousal relationships, duration of relationship was the factor most strongly associated with engaging in unprotected sex in the past month in a multivariable analyses controlling for partner and relationship characteristics. Innovative intervention programs for these men and their partners are needed that address the realities of truck drivers' lifestyles.

Motivations for Reducing Other HIV Risk-Reduction Practices if Taking Pre-Exposure Prophylaxis: Findings from a Qualitative Study Among Women in Kenya and South Africa.

Findings from a survey conducted among women at high risk for HIV in Bondo, Kenya, and Pretoria, South Africa, demonstrated that a substantial proportion would be inclined to reduce their use of other HIV risk-reduction practices if they were taking pre-exposure prophylaxis (PrEP). To explore the motivations for their anticipated behavior change, we conducted qualitative interviews with 60 women whose survey responses suggested they would be more likely to reduce condom use or have sex with a new partner if they were taking PrEP compared to if they were not taking PrEP. Three interrelated themes were identified: (1) "PrEP protects"--PrEP was perceived as an effective HIV prevention method that replaced the need for condoms; (2) condoms were a source of conflict in relationships, and PrEP would provide an opportunity to resolve or avoid this conflict; and (3) having sex without a condom or having sex with a new partner was necessary for receiving material goods and financial assistance--PrEP would provide reassurance in these situations. Many believed that PrEP alone would be a sufficient HIV risk-reduction strategy. These findings suggest that participants' HIV risk-reduction intentions, if they were to use PrEP, were based predominately on their understanding of the high efficacy of PrEP and their experiences with the limitations of condoms. Enhanced counseling is needed to promote informed decision making and to ensure overall sexual health for women using PrEP for HIV prevention, particularly with respect to the prevention of pregnancy and other sexually transmitted infections when PrEP is used alone.

Preparing for the Rollout of Pre-Exposure Prophylaxis (PrEP): A Vignette Survey to Identify Intended Sexual Behaviors among Women in Kenya and South Africa if Using PrEP.

INTRODUCTION: Several clinical trials have demonstrated the efficacy of pre-exposure prophylaxis (PrEP) in reducing HIV risk. One concern with introducing PrEP is whether users will engage in riskier sexual behaviors. METHODS: We assessed the effect that PrEP may have on sexual risk behaviors by administering a survey to 799 women in Bondo, Kenya, and Pretoria, South Africa. Participants were asked about their sexual behavior intentions twice--once as if they were taking PrEP and once as if they were not taking PrEP--within four risk situations (vignettes). They responded using a 5-point ordinal scale. We used a series of linear mixed effects models with an unstructured residual covariance matrix to estimate the between- and within-subject differences in the mean likelihood of engaging in risky sexual behavior across the PrEP and non-PrEP contexts. We also calculated the total percentage of participants who reported a greater likelihood of engaging in risky sexual behavior if taking PrEP than if not taking PrEP, by vignette. RESULTS: We found statistically significant differences in the mean likelihood of engaging in risky sexual behavior with the between-subject comparison (-0.17, p < 0.01) and with the within-subject comparison (-0.31, p < 0.001). Depending on the vignette, 27% to 40% of participants reported a greater likelihood of engaging in risky sexual behavior if taking PrEP than if not taking PrEP. CONCLUSIONS: Our findings indicate that modest increases in risky sexual behavior could occur with PrEP. Although responses from the majority of participants suggest they would not be more likely to engage in risky sexual behavior if they took PrEP, a substantial proportion might. Programs rolling out PrEP should be prepared to assist similar women in making informed choices about reducing their risk of HIV and about their sexual health beyond HIV prevention.

The role of relationship types on condom use among urban men with concurrent partners in Ghana and Tanzania.

Multiple concurrent partnerships are hypothesized to be important drivers of HIV transmission. Despite the demonstrated importance of relationship type (i.e., wife, girlfriend, casual partner, sex worker) on condom use, research on concurrency has not examined how different combinations of relationship types might affect condom use. We address this gap, using survey data from a sample of men from Ghana (GH: n = 807) and Tanzania (TZ: n = 800) who have at least three sexual partners in the past three months. We found that approximately two-thirds of men's reported relationships were classified as a girlfriend. Men were more likely to use a condom with a girlfriend if their other partner was a wife compared to if their other partner was a sex worker (GH: OR 3.10, 95% CI, 1.40, 6.86; TZ: OR 2.34, 95% CI 1.35, 4.06). These findings underscore the importance of considering relationship type when designing HIV prevention strategies in these settings.

Assessment of the psychometric properties of HIV knowledge items across five countries.

HIV knowledge is commonly measured in HIV prevention research and program evaluations, but rigorous measurement standards are not always applied. Using item response theory methods, we examined the psychometric functioning of five commonly used HIV knowledge questions in five countries with varying HIV prevalence. We evaluated the internal consistency and measurement invariance of the items. The items performed poorly in all samples and the scale as a whole did not perform equally across samples. We conclude that current ways of measuring HIV knowledge are not adequate and recommend new items be developed, tested, and validated using psychometric methods.

Changes in couples' communication as a result of a male-involvement family planning intervention.

Research suggests that spousal communication and male involvement in decision making can positively influence family-planning use and continuation. However, few existing studies explore the dynamics of this communication and how they factor into family-planning decision making. Building upon a recent evaluation of a theory-based male-involvement intervention in Malawi, this study aimed to fill this gap by examining the role of communication in the intervention's success, through semi-structured in-depth interviews with male participants and female partners of study participants. Results support the idea that communication is an integral component of successful interventions to increase male involvement in family planning. Participants reported improvements in spousal communication, increased frequency of communication, and an increase in shared decision making as a result of the study, which directly contributed to their family-planning use. This effect was often mediated through increased knowledge or reduced male opposition to family planning. Further analysis of communication and decision-making dynamics revealed shifts in gendered communication norms, leading to improvements in spousal relationships in addition to contraceptive uptake. This study shows that interventions can and should encourage spousal communication and shared decision making, and it provides an effective model for involving men in family-planning use.

Encouraging contraceptive uptake by motivating men to communicate about family planning: the Malawi Male Motivator project.

OBJECTIVES: We examined the effect of a peer-delivered educational intervention, the Malawi Male Motivator intervention, on couples' contraceptive uptake. We based the intervention design on the information-motivation-behavioral skills (IMB) model. METHODS: In 2008 we recruited 400 men from Malawi's Mangochi province who reported not using any method of contraception. We randomized them into an intervention arm and a control arm, and administered surveys on contraceptive use at baseline and after the intervention. We also conducted in-depth interviews with a subset of intervention participants. RESULTS: After the intervention, contraceptive use increased significantly within both arms (P < .01), and this increase was significantly greater in the intervention arm than it was in the control arm (P < .01). Quantitative and qualitative data indicated that increased ease and frequency of communication within couples were the only significant predictors of uptake (P < .01). CONCLUSIONS: Our findings indicate that men facilitated contraceptive use for their partners. Although the IMB model does not fully explain our findings, our results show that the intervention's content and its training in communication skills are essential mechanisms for successfully enabling men to help couples use a contraceptive.

Acceptability of PrEP for HIV prevention among women at high risk for HIV.

OBJECTIVE: To assess the acceptability of a daily pill for prevention of HIV acquisition among 400 Ghanaian women in the oral tenofovir disoproxil fumarate (TDF) clinical trial. METHODS: Structured questionnaires were conducted with women enrolled in the trial at enrollment and at each of the 12 monthly follow-up visits. Growth curve analysis was used to examine adherence patterns over time. Qualitative interviews were carried out with a subsample of the clinical trial population, and thematic analysis was applied to these data. RESULTS: Overall, acceptability of the pill was good. Adherence remained > 82% throughout the 12-month trial. Consistent access to the pill and study assignment were both associated with adherence. Most reported problems diminished over time as women became accustomed to the pill and developed strategies to incorporate pill taking into their daily routines. CONCLUSIONS: If daily preexposure prophylaxis (PrEP) for HIV is found to be efficacious and has as few physical side effects as TDF, acceptability of this method among women in the study population may not be problematic. However, future studies must develop better acceptability measures, in order to more fully address the relationship among adherence, safety, and effectiveness.

Changes in sexual risk behavior among participants in a PrEP HIV prevention trial.

BACKGROUND: One of the concerns raised regarding the introduction of any new HIV-prevention measure, such as PrEP, is the potential for risk disinhibition or sexual risk compensation. The oral tenofovir HIV prevention trial has been the subject of international discussion in this regard. METHODS: This article maps the changes in sexual risk behavior among women participating in the oral tenofovir HIV prevention trial in Ghana. Content-driven, thematic analysis was carried out on qualitative data obtained from in-depth interviews with study participants. Growth curve analysis was the primary method used to document trends over time in self-reported sexual behavior collected monthly. RESULTS: Overall, the study found that sexual risk behavior did not increase during the trial. Number of sexual partners and rate of unprotected sex acts decreased across the 12-month period of study enrollment. Certain subgroups of women, however, exhibited different growth curves. Data indicate that the HIV prevention counseling associated with the trial was effective. CONCLUSIONS: Counseling during the trial was effective. Different types of counseling and messaging may be needed for different subgroups within a population. These findings also have implications for required sample sizes for future HIV prevention trials where seroconversion is the main outcome.

Changes in sexual behavior during a safety and feasibility trial of a microbicide/diaphragm combination: an integrated qualitative and quantitative analysis.

If proven effective, vaginal microbicides and diaphragms will likely be part of a larger HIV prevention model that includes condoms and other prevention strategies. It is, therefore, important to understand how introducing new prevention methods may affect overall patterns of sexual risk behavior. Data presented were collected as part of a safety and feasibility study of ACIDFORM gel with a diaphragm among 120 women in South Africa. Interviews were administered at enrollment and months 1, 3, 5, and 6 of the trial. Focus groups were conducted at trial exit. Frequency of sex increased significantly after enrollment. This increase appears to be owing to perceived protection from HIV and greater sexual pleasure afforded by the gel. Male condom use was high overall but increased significantly from enrollment. Data suggest this is because of increased partner involvement, increased negotiating power afforded by study participation, and provision of free condoms perceived to be of high quality.

Factors affecting vasectomy acceptability in Tanzania.

CONTEXT: Calls for increased inclusion of men in matters of reproductive health emphasize the need for research into vasectomy acceptability and decision making. Vasectomy is a safe, simple and effective method of contraception, but is underused worldwide. METHODS: Focus group discussions and in-depth interviews were conducted with potential and actual sterilization clients and their partners in the Kigoma Region of Tanzania. Content analysis was used to search for emergent themes related to vasectomy decision making. RESULTS: Six themes emerged as overarching factors contributing to the vasectomy decision-making process: economics, spousal influence, religion, provider reputation and availability, uncertainty about the future, and poor vasectomy knowledge and understanding. There was substantial communication between partners regarding the vasectomy decision, and wives had a strong influence on the outcome; however, men and women agreed that husbands would resist vasectomy if wives initially raised the topic. Vasectomy acceptance is limited by the scarcity of skilled vasectomy providers and by the fact that men and women hold many of the same misunderstandings about vasectomy, including a fear of decreased sexual performance as a result of the procedure. CONCLUSIONS: Spousal discussions are important in the decision to get a vasectomy, but these discussions should be initiated by the male partner. Programs need to educate men about contraceptive options, including vasectomies. Detailed, culturally relevant knowledge of the barriers and facilitators individuals experience during their decision- making process will enable vasectomy promotion programs to more successfully target appropriate populations.

Talking about sex in Botswana: social desirability bias and possible implications for HIV-prevention research.

Evaluations of the safety, effectiveness, and feasibility of HIV prevention interventions rely on self-reported sexual behaviour data. The accuracy of such data has sometimes been questioned. The absence of a so-called objective measure of sexual behaviour complicates this. Social desirability bias (SDB) is a key factor affecting the accuracy of self-reports. Individual, semi-structured interviews focusing on possible causes of and solutions to SDB were conducted with 30 Batswana women such as those who might enrol in planned vaginal microbicide trials. Respondents pointed to shame and the fear of public talk about them as key factors contributing to inaccurate self-reports, and they stressed the importance of privacy and confidentiality. Interviewer characteristics such as age, gender and personality were often viewed as likely to affect their candour. Alternative interviewing techniques such as audio computer-assisted self-interviewing (ACASI) were appealing to some for the potential to reduce embarrassment; others were sceptical. The possible implications for HIV-prevention research are presented.