Increasing HIV screening in a secondary hospital emergency department in Brazil: searching for opportunities

Patients seeking emergency care have higher HIV prevalence than the general population, but HIV testing is often not offered in these settings, constituting missed opportunities for HIV testing. Semi structured interviews were conducted withemergency department health workers in a secondary hospital in Brazil. Interviews were recorded, transcribed, and analyzed for themes related to barriers and facilitator to HIV testing in emergency departments (EDs) and strategies to implement HIV screening programs. Currently, most providers reported only offering HIV testing when suspecting that the health problem that motivated the patient to seek care could be HIV-related. Although some providers believed that EDs would not be appropriate to implement screening programs, acceptability of HIV screening programs in this setting was overall high, particularly among nurses. Barriers to increasing HIV testing in EDs included concerns about time, understaffing, and increased costs. The initial triage was identified as a leverage point to obtain consent for HIV screening. Advantages and limitations of HIV screening programs at initial triage, testing blood samples collected for other reasons, and for patients undergoing emergency surgical procedures are discussed. EDs in medium income countries constitute a potential scenario to implement HIV screening programs, and such programs may benefit from empowering nursing staff to that end.

Los pacientes que acuden a urgencias presentan una prevalencia del VIH superior a la de la población general, pero a menudo no se ofrecen pruebas del VIH en estos entornos, lo que constituye una pérdida de oportunidades para realizarlas. Se realizaronentrevistas semiestructuradas a trabajadores sanitarios del servicio de urgencias de un hospital secundario de Brasil. Las entrevistas fueron grabadas, transcritas y analizadas en busca de temas relacionados con las barreras y los facilitadores de las pruebas del VIH en los servicios de urgencias (SU) y las estrategias para implementar programas de cribado del VIH. En la actualidad, la mayoría de los proveedores informaron que sólo ofrecen la prueba del VIH cuando sospechan que el problema de salud que motivó al paciente a buscar atención podría estar relacionado con el VIH. Aunque algunos proveedores creían que los SUH no serían apropiados para implementar programas de cribado, la aceptación de los programas de cribado del VIH en este entorno era en general alta, especialmente entre las enfermeras. Los obstáculos para aumentar las pruebas del VIH en los SUH incluían la preocupación por el tiempo, la falta de personal y el aumento de los costes. El triaje inicial se identificó como un punto de apoyo para obtener el consentimiento para el cribado del VIH. Se discuten las ventajas y limitaciones de los programas de cribado del VIH en el triaje inicial, el análisis de muestras de sangre recogidas por otras razones, y para los pacientes sometidos a procedimientos quirúrgicos de emergencia. Los SUH de países de renta media constituyen un escenario potencial para implementar programas de cribado del VIH, y dichos programas pueden beneficiarse de la capacitación del personal de enfermería para tal fin.

Os pacientes que procuram atendimento de emergência têm maior prevalência de HIV do que a população em geral, mas o teste de HIV muitas vezes não é oferecido nesses ambientes, o que constitui oportunidades perdidas para o teste de HIV. Foram realizadas entrevistas semiestruturadas com profissionais de saúde do departamento de emergência em um hospital secundário no Brasil. As entrevistas foram gravadas, transcritas e analisadas quanto a temas relacionados a barreiras e facilitadores do teste de HIV em departamentos de emergência (EDs) e estratégias para implementar programas de triagem de HIV. Atualmente, a maioria dos provedores relatou que só oferece testes de HIV quando suspeita que o problema de saúde que motivou o paciente a procurar atendimento pode estar relacionado ao HIV. Embora alguns provedores acreditassem que os departamentos de emergência não seriam apropriados para implementar programas de triagem, a aceitabilidade dos programas de triagem de HIV nesse ambiente foi, em geral, alta, especialmente entre os enfermeiros. As barreiras para aumentar os testes de HIV nos DEs incluíam preocupações com o tempo, falta de pessoal e aumento dos custos. A triagem inicial foi identificada como um ponto de alavancagem para obter o consentimento para a triagem de HIV. São discutidas as vantagens e as limitações dos programas de triagem de HIV na triagem inicial, no teste de amostras de sangue coletadas por outros motivos e para pacientes submetidos a procedimentos cirúrgicos de emergência. As salas de emergência em países de renda média constituem um cenário em potencial para a implementação de programas de triagem de HIV, e esses programas podem se beneficiar da capacitação da equipe de enfermagem para esse fim.

High Interest in the Use of mHealth Platform for HIV Prevention among Men Who Have Sex with Men in Nepal.

Mobile technology growth in Nepal offers promising opportunities for using mobile health (mHealth) interventions to facilitate HIV prevention efforts. However, little is known about access and utilization of communication technology and their willingness to use mHealth for HIV prevention services in Nepal. We conducted a cross-sectional respondent-driven sampling survey of 250 MSM in Kathmandu Valley of Nepal from October to December 2022. We collected information on participant characteristics, HIV risk-related behaviors, ownership, or access to and frequency of use of communication technology (phones, tablets, laptops, and computers), and willingness to use mHealth to access HIV prevention services. Descriptive, bivariate, and multivariate linear regression analyses were performed. Almost all participants had smartphones with the internet (231/250, 92.4%) and accessed the internet daily (219/250, 87.6%) on the smartphone (236/250, 94.4%). The median score for willingness to use mHealth for HIV prevention was 10 (IQR: 3 to 17). Willingness to use mHealth was higher among those participants with a high school or above education (ß = 0.223, p = < 0.001), had experienced violence (ß = 0.231, p = 0.006), and had moderate to severe depressive symptoms (ß = 0.223, p = < 0.001). However, monthly income above NPR 20,000 (USD 150) (ß= -0.153, p = 0.008), disclosure of their sexual orientation to anyone (ß= -0.159, p = < 0.007), and worry about being negatively judged by health care workers (ß= -0.136, p = 0.023) were less willing to use mHealth strategies. The findings from this study suggest that there is a high willingness for utilizing mHealth interventions for HIV prevention in MSM population who are at higher risk of HIV acquisition.

Psychosocial and structural stressors and engagement in medical care among young sexual minority men across racial identities.

Psychosocial and structural stressors and low engagement in medical care likely contribute to the disproportionate burden of chronic disease among sexual minority men (SMM) across the life course. However, how these stressors impact engagement in medical care among young SMM (YSMM) across racial identities remains understudied. The association of psychosocial and structural stressors with forgoing care among YSMM across racial identities was examined using race-stratified adjusted logistic regression of cross-sectional data. Among 737 HIV-negative SMM aged 16-24 years, nearly all (93%) experienced discrimination in their daily lives. Non-Hispanic/Latinx Black participants reported significantly higher levels of discrimination, exposure to community violence, and food insecurity. Medical mistrust and mental health were not significantly different across racial groups. In the full sample model, education, food insecurity, and discrimination were associated with forgoing care. Among the non-Hispanic/Latinx White sample, medical mistrust and discrimination were associated with forgoing care. Among the non-Hispanic/Latinx Black sample, discrimination was associated with forgoing care. Among the Hispanic/Latinx sample, food insecurity was associated with forgoing care. Psychosocial and structural stressors were common in this YSMM cohort, and significantly different across racial/ethnic identities. Race-stratified analysis revealed differences in the association of stressors with forgoing care among YSMM across racial identities, not appreciated in the analysis limited to the total study population. Our findings may support efforts to address health inequity and improve engagement in medical care among SMM.

Who prefers what? Correlates of preferences for next-generation HIV prevention products among a national U.S. sample of young men who have sex with men.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) has been available for young people for over a decade, yet only ∼15% of young people in the United States with indications for PrEP have a prescription for it. Next-generation PrEP modalities may address some of the challenges of daily oral PrEP. However, preferences for these products are unknown. METHODS: From October 2020 to June 2021, we conducted an online survey of 737 cisgender, young men who have sex with men (age 15-24 years) without HIV across the United States who reported same-sex attraction or consensual sex with another man in the past 6 months. Participants completed a conjoint experiment comparing daily oral pills, event-driven oral pills, event-driven rectal douches, intramuscular injections, intravenous broadly neutralizing antibody (bnAb) infusions and subcutaneous implants. Participants ranked the products from most to least preferred. Exploded logit models examined the association between ranked preferences of PrEP modalities and socio-demographic and behavioural characteristics. RESULTS: Participants' mean age was 21 years (SD = 2.3), and 56% identified as White. Nineteen percent were currently taking daily oral PrEP, and another 9% had previously taken it. Participants prioritized efficacy, absence of side effects and costs in the conjoint analyses. Daily oral PrEP had the highest preference ranking, followed by event-driven oral (OR = 0.89, p = 0.058), injectable (OR = 0.83, p = 0.005), implant (OR = 0.48, p < 0.0001), bnAb infusions (OR = 0.38, p < 0.0001) and rectal douches (OR = 0.24, p < 0.0001). There were differences in PrEP preferences across age, insurance status, sexual behaviour, PrEP use history, HIV and sexually transmitted infection (STI) testing history, and STI diagnoses (omnibus tests: p < 0.05). Participants also provided reasons for selecting their top product choice: ease of use for those who chose daily oral (99%) and daily event-driven (98.5%); feel more protected against HIV for those who chose injectable (95.4%) and implants (100%); not worrying about forgetting to take it for those who chose bnAbs (93.8%); and being able to stop taking it when they want for those who chose rectal douche (90.9%). CONCLUSIONS: Next-generation modalities were less likely to be preferred over daily oral PrEP, with differences in the magnitude by socio-demographic and behavioural characteristics. Given the low uptake of daily oral PrEP, end-users' preferences for and concerns about PrEP products must be understood to ensure high acceptability and penetration.

Positive patient-provider relationships among transgender and nonbinary individuals in New York City.

Background: Transgender and nonbinary (TGNB) individuals have diverse health needs and may face disproportionate barriers to healthcare, including developing positive patient-provider relationships. While there is mounting evidence of gender-based stigma and discrimination in healthcare, little is known about how TGNB individuals develop positive patient-provider relationships. Aims: To examine TGNB individuals' interactions with healthcare providers and identify main characteristics of positive patient-providers relationships. Methods: We conducted semi-structured interviews with a purposive sample of 13 TGNB individuals in New York, NY. Interviews were transcribed verbatim and analyzed inductively for themes related to characteristics of positive and trusting relationships with healthcare providers. Results: Participants' mean age was 30 years (IQR = 13 years) and most participants were nonwhite (n = 12, 92%). Receiving peer referrals to specific clinics or providers helped many participants find providers perceived to be competent and created initial grounds for positive patient-provider relationships. Providers with whom participants had positive relationships commonly managed primary care and gender-affirming care and relied on a network of interdisciplinary providers for other specialized care. Providers who were positively evaluated were perceived to possess in-depth clinical knowledge on the issues they were responsible for managing, including gender-affirming interventions, particularly for TGNB patients who perceived themselves to be knowledgeable about TGNB-specific care. Provider and staff cultural competence and a TGNB-affirming clinic environment were also important, particularly early in the patient-provider relationship, and if combined with TGNB clinical competence. Discussion: Provider-focused training and education programs should combine components of TGNB clinical and cultural competence to facilitate development of positive relationships between TGNB patients and providers, thereby improving the health and wellbeing of TGNB people.

PrEPare for Work: A Pilot Randomized Controlled Trial of an Intervention to Optimize HIV PrEP Outcomes Among Male Sex Workers.

HIV pre-exposure prophylaxis (PrEP) use is limited among male sex workers, who are at exceptionally high-risk for HIV infection. We developed a theory-informed, two-pronged intervention ("PrEPare-for-Work") to optimize PrEP initiation and adherence among male sex workers, which was preliminarily evaluated in a two-stage pilot randomized controlled trial of 110 male sex workers in the US Northeast. Individuals randomized to the Stage 1 PrEPare-for-Work Case Management arm were three times as likely as those in the standard of care (SOC) arm to initiate PrEP (RR = 2.95, 95% CI = 1.57-5.57). Participants who initiated PrEP and were randomized to the Stage 2 PrEPare-for-Work Adherence Counseling arm had higher rates of prevention-effective adherence (measured via tenofovir in hair) compared to those in the SOC arm (RR = 1.7, 95% CI 0.64-4.77; 55.6% vs. 28.6%, respectively); though not statistically significant. Given the need and the promise of this pilot RCT, further efficacy testing is warranted and should be prioritized.

RESUMEN: El uso de la profilaxis prexposición (PrEP) para prevenir la adquisición del VIH es limitado entre trabajadores sexuales masculinos, que están en muy alto riesgo de contraerlo. Desarrollamos una intervención de dos partes basada en la teoría para optimizar el inicio y la observancia del tratamiento de la PrEP entre trabajadores sexuales masculinos, que se evaluó preliminarmente en un ensayo piloto controlado y aleatorizado (ECA) de dos fases de 110 trabajadores sexuales masculinos en el noreste de Estados Unidos. Las personas aleatorizadas al grupo de intervención (la primera fase de nuestro programa "PrEPare for Work" ­ la atención individualizada) eran tres veces más probable que las aleatorizadas al grupo control (la norma de atención) a iniciar la PrEP (RR = 2.95, 95% IC = 1.57­5.57). Los participantes que iniciaron la PrEP y se aleatorizaron al grupo de intervención (la segunda fase de "PrEPare for Work" ­ la terapia para aumentar la adherencia al tratamiento) tenían tasas más altas de adherencia al tratamiento (medido por tenofovir en el cabello) que los aleatorizados al grupo control (RR = 1.7, 95% IC 0.64­4.77; 55.6% vs. 28.6%, respectivamente); aunque la diferencia no fue estadísticamente significativa. En vista de la necesidad y el potencial de este ECA piloto, más pruebas de eficacia son necesarias y deben ser priorizadas.

The need for a health equity framework in next-generation pre-exposure prophylaxis implementation.

Pre-exposure prophylaxis (PrEP) is highly effective for prevention of HIV transmission and plays an important role in efforts to end the HIV epidemic within the next decade. However, disparities in access to PrEP might be fuelling disparities in the burden of HIV in the USA. The advent of next-generation PrEP formulations that do not involve daily regimens (eg, long-acting cabotegravir) holds potential to facilitate medication adherence, but if the roll-out of these formulations does not consider disparities in access, HIV disparities might be further widened. On the basis of US epidemiological data and informed by the Theory of Fundamental Causes of Health Disparities, we propose an equity-promoting framework to guide the implementation of daily oral and next-generation PrEP. Multilevel efforts to bolster equity in PrEP care include generating demand for next-generation PrEP formulations among marginalised groups, expanding the availability of health services providing oral and next-generation PrEP, and addressing structural and financial barriers to HIV prevention care. The aim of these strategies is to realise the potential of next-generation PrEP to provide people at high risk with effective options to prevent HIV acquisition, thereby helping to reduce both overall HIV transmission and health disparities in the USA.

Readiness to Provide Oral and Injectable PrEP for Sexual and Gender Minority Youth Among Healthcare Providers and Clinics in the U.S. Northeast.

PURPOSE: To examine readiness to provide oral and injectable pre-exposure prophylaxis (PrEP) for sexual and gender minority youth (SGMY) and to explore decision-making for HIV prevention strategies (e.g., condom use, daily and event-driven oral PrEP, and injectable PrEP) among healthcare providers. METHODS: Between February and April 2022, we recruited 31 prescribing providers (M.Ds, D.Os, P.As, and N.Ps) practicing in primary care and specialized clinics in the U.S. Northeast for focus groups or individual interviews. Focus groups and interview transcripts were analyzed using thematic analysis. RESULTS: Most providers specialized in Pediatrics (42%) or Adolescent Medicine (23%) and 58% had previously prescribed PrEP. Main barriers to PrEP readiness were low PrEP knowledge, limited time for visits, and competing clinical priorities. Organizational factors such as routine HIV/STI testing, PrEP-specific electronic health records templates, and specialized staff (e.g., PrEP navigators) promoted PrEP readiness. Providers held positive attitudes toward injectable PrEP to promote adherence among SGMY, yet barriers to implementation of this modality were identified (e.g., patient anxiety about needles, additional staffing needs). Providers described event-driven oral PrEP as an option for SGMY with episodic HIV risk. Assurances of conditional confidentiality, including preventing disclosure of sensitive information through insurance forms, and shared decision-making facilitated conversations about HIV prevention with SGMY. DISCUSSION: Future PrEP implementation efforts for SGMY should consider combined efforts targeting provider knowledge about PrEP modalities (e.g., decision aids) and clinic organizational factors (e.g., routine HIV/STI testing, resources to assist providers and patients in navigating the multiple steps between prescription and adherence to PrEP).

Preferences Across Pre-Exposure Prophylaxis Modalities Among Young Men Who Have Sex with Men in the United States: A Latent Class Analysis Study.

Access to daily oral pre-exposure prophylaxis (PrEP) is suboptimal among young cisgender men who have sex with men (YMSM) in the United States. Next-generation modalities that do not involve daily oral regimens may mitigate some of the barriers to PrEP use. We identified latent classes of YMSM based on health care decision-making patterns and examined associations between latent classes and access to health care and PrEP modality preferences (i.e., daily and event-driven oral, rectal douches, broadly neutralizing antibodies, subcutaneous implants, and an injectable). Between October 2020 and June 2021, we administered an online survey to 737 YMSM. Latent class analysis (LCA) identified groups of YMSM based on communication with providers, stigma and mistrust in health care, and autonomy in sexual health decisions. Logistic regression examined associations between class membership and health care access, and exploded logit regression examined associations between class membership and ranked PrEP modality preferences. LCA identified three classes: shared decision-making (high communication with providers and high autonomy); provider-led decision-making (high communication and low autonomy); and patient-driven decision-making (low communication and high autonomy). Shared decision-making was associated with higher access to health care in comparison with the other classes. Across all classes, YMSM preferred daily oral PrEP over all next-generation PrEP modalities. Preferences for daily oral PrEP over next-generation PrEP modalities were particularly marked among the patient-driven decision-making class. Shared decision-making is associated with access to health care and HIV prevention and higher acceptability of next-generation PrEP modalities, and should be considered as part of future interventions to promote use of daily oral and next-generation PrEP.

Next Generation Pre-Exposure Prophylaxis for Young Men who have Sex with Men: Lessons from System and Provider-level barriers to oral PrEP.

Next generation pre-exposure prophylaxis (PrEP) modalities that do not require daily regimens may address some of the barriers to daily oral PrEP among young men who have sex with men (YMSM). We conducted online semi-structured interviews with 30 YMSM to examine experiences and preferences related to HIV prevention care that may inform implementation of next generation PrEP. Barriers to PrEP care included initiating conversations about sexuality with providers; confidentiality concerns regarding disclosure of sexual practices and PrEP use to family; gaps in access to healthcare; and limited availability of affordable health services. Future implementation of next generation PrEP may benefit from providers addressing confidentiality concerns when discussing PrEP with YMSM; PrEP programs accounting for discontinuities in healthcare access among YMSM while strengthening access to affordable services; and collaborations between generalist providers and specialized clinics and providers to address providers' education needs, which may increase as next generation PrEP becomes available. We have linked affiliation 9 to author name "Katie B. Biello". Please check and confirm. Okay!

RESUMEN: Las modalidades de próxima generación de la profilaxis pre-exposición (PrEP) que no requieren un régimen diario pueden disminuir las barreras de tomar la PrEP oral diariamente por hombres jóvenes que tienen sexo con hombres (YMSM). Llevamos a cabo entrevistas semiestructuradas en línea con 30 YMSM para entender sus experiencias y preferencias relacionadas con el cuidado de la prevención del VIH que puedan informar la implementación de la próxima generación de la PrEP. Las barreras al cuidado de la PrEP incluyeron tender conversaciones sobre la sexualidad con proveedores médicos; las preocupaciones de confidencialidad al divulgar información sobre las relaciones sexuales y el uso de la PrEP con la familia; las brechas en el acceso al cuidado médico; y la disponibilidad limitada de servicios de salud accesibles. La futura implementación de la próxima generación de la PrEP se puede beneficiar de proveedores que hablan sobre las preocupaciones de confidencialidad al discutir la PrEP con YMSM; los programas de la PrEP que tienen en cuenta las discontinuidades en el acceso de salud por YMSM mientras que fortalezcan acceso a servicios accesibles; y las colaboraciones entre proveedores de atención primaria y proveedores especializados para entender las necesidades educativas de proveedores, que puedan aumentar cuando la próxima generación esté disponible.

Prospective relationships between stigma, mental health, and resilience in a multi-city cohort of transgender and nonbinary individuals in the United States, 2016-2019.

PURPOSE: Gender-based stigma is a fundamental cause of mental health disparities among transgender and non-binary (TGNB) individuals, while resilience factors may be protective. We examined prospective relationships between gender-based enacted stigma, psychological distress, and resilience factors among TGNB individuals. METHODS: Between 2016 and 2017, we enrolled 330 TGNB individuals in three metropolitan areas in the U.S. in a prospective cohort study focused on gender identity development, risk, and resilience across the lifespan. Using multilevel regression, we examined prospective associations between enacted gender-based stigma and psychological distress (measured by the Global Severity Index/BSI-18), and examined transgender pride and social support as moderators, adjusting for age, sex assigned at birth, race/ethnicity, education, and income. RESULTS: Our sample was diverse in age (M = 34.4, range 16-87) and race/ethnicity (56.4% non-White). Over 2 years of follow-up, there was a decrease in reported gender-based stigma (b = - 0.61, p < 0.001) and transgender pride (b = - 0.14, p = 0.003), increase in social support (b = 0.21, p < 0.001), and no change in psychological distress. In adjusted analyses, gender-based stigma was positively associated with psychological distress (b = 1.10, p < 0.001) and social support was negatively associated with psychological distress (b = - 2.60, p < 0.001). Transgender pride moderated the relationship between stigma and psychological distress (p < 0.01), such that the association was stronger for lower levels of transgender pride. CONCLUSIONS: Our study provides longitudinal evidence for the deleterious role of gender-based stigma among TGNB individuals. Future interventions should consider fostering transgender pride and social support to promote mental health and mitigate negative effects of gender-based stigma.

PrEParing for NextGen: Cognitive Interviews to Improve Next Generation PrEP Modality Descriptions for Young Men Who have Sex with Men.

Next generation PrEP formulations may circumvent factors that impede daily oral pre-exposure prophylaxis (PrEP) use among young men who have sex with men (YMSM). We conducted video-based cognitive interviews with 20 YMSM (age 16-24) recruited in the US Northeast to assess participants' attitudes and comprehension of written descriptions of next generation PrEP modalities. Participants were predominately racial/ethnic minorities and half used daily oral PrEP. We identified four main areas for improvement of descriptions: defining scientific terms and balancing medical jargon and casual language; referencing more established products to contextualize PrEP formulations (e.g., hormonal implants); ensuring clarity and reducing redundancy; and including imagery (e.g., rectal douche applicator). The refined descriptions serve as exemplar text that may be used in future studies examining YMSM's preferences across next generation PrEP modalities. Accurate descriptions of next generation PrEP products strengthen measurement accuracy and can help roll-out products that become approved for clinical use.

RESUMEN: Las formulaciones de próxima generación para la profilaxis pre-exposición (PrEP) pueden eludir los factores que impiden el uso diario del PrEP oral en hombres jóvenes que tienen relaciones sexuales con hombres (YMSM). Realizamos entrevistas cognitivas usando videoconferencia con 20 YMSM (de 16 a 24 años) reclutados del noreste de los Estados Unidos con el fin de evaluar sus actitudes y su comprensión de las definiciones desarrolladas para describir las modalidades de PrEP de próxima generación. Los participantes eran predominantemente minorías raciales/étnicas y la mitad usaba PrEP oral diariamente. Identificamos cuatro áreas principales para mejorar las descripciones: definir términos científicos y equilibrar la jerga médica y el lenguaje casual; hacer referencia a productos más establecidos para contextualizar las formulaciones de PrEP (por ejemplo, implantes hormonales); garantizar la claridad y reducir la redundancia; e incluir imágenes (por ejemplo, aplicador de duchas rectales). Las descripciones refinadas sirven como texto ejemplar y pueden usarse en estudios futuros que examinen las preferencias de modalidades de PrEP de próxima generación entre YMSM. Las descripciones precisas de los productos PrEP de próxima generación fortalecen la precisión de la medición y pueden ayudar a implementar productos que se aprueben para uso clínico.

Violence and Victimization in Interactions Between Male Sex Workers and Male Clients in Mombasa, Kenya.

Male sex workers (MSWs) and male clients (MCMs) who engage their services face increased vulnerability to violence in Kenya, where same-sex practices and sex work are criminalized. However, little is known about how violence might arise in negotiations between MSWs and MCMs. This study explored the types of victimization experienced by MSWs and MCMs, the contexts in which these experiences occurred, and the responses to violence among these groups. We conducted in-depth interviews with 25 MSWs and 11 MCMs recruited at bars and clubs identified by peer sex worker educators as "hotspots" for sex work in Mombasa, Kenya. Violence against MSWs frequently included physical or sexual assault and theft, whereas MCMs' experiences of victimization usually involved theft, extortion, or other forms of economic violence. Explicitly negotiating the price for the sexual exchange before having sex helped avoid conflict and violence. For many participants, guesthouses that were tolerant of same-sex encounters were perceived as safer places for engaging in sex work. MSWs and MCMs rarely reported incidents of violence to the police due to fear of discrimination and arrests by law enforcement agents. Some MSWs fought back against violence enacted by clients or tapped into peer networks to obtain information about potentially violent clients as a strategy for averting conflicts and violence. Our study contributes to the limited literature examining the perspectives of MSWs and MCMs with respect to violence and victimization, showing that both groups are vulnerable to violence and in need of interventions to mitigate violence and protect their health. Future interventions should consider including existing peer networks of MSWs in efforts to prevent violence in the context of sex work. Moreover, decriminalizing same-sex practices and sex work in Kenya may inhibit violence against MSWs and MCMs and provide individuals with safer spaces for engaging in sex work.

Solidarity, support and competition among communities of female and male sex workers in Mombasa, Kenya.

Female and male sex workers are at elevated risk for HIV infection, psychological distress and other adverse health outcomes. It is therefore important to understand how sex workers' social relationships with one another might inform psychosocial support services for this population. We conducted semi-structured interviews to examine the formation and nature of social networks of 25 female and 25 male sex workers recruited from bars and clubs in Mombasa, Kenya. Relationships between and among female and male participants were often formed based on a mutual understanding of the challenging nature of sex work. Both groups described their relationships in terms of friendship and brotherhood/sisterhood and highlighted the following benefits of sex worker social networks: economic benefits, access to information about HIV/STIs and protection, and support against violence from clients and law enforcement agents. Social networks were often threatened by competition for clients and hence could result in conflict. However, sex workers explained that their sense of solidarity and reliance on one another for health, protection and economic well-being helped minimise conflict. The social networks of sex workers could therefore be used to leverage or optimise access to HIV prevention and care.

Health Service- and Provider-Level Factors Influencing Engagement in HIV Pre-Exposure Prophylaxis Care Among Male Sex Workers.

Multilevel barriers to pre-exposure prophylaxis (PrEP) care among male sex workers (MSW) include aspects of interactions with health services and providers. We examined relationships between health service- and provider-level factors and PrEP care among MSW. Between 2017 and 2019, we enrolled 111 MSW in the Northeast United States who were not on PrEP, but expressed interest in potentially using PrEP, in a behavioral intervention to promote PrEP uptake and adherence. Using baseline data, we examined whether having a primary care provider, past year frequency of medical visits, comfort discussing sexual practices with providers, and transportation difficulties to accessing general health care were associated with PrEP use self-efficacy, anticipated barriers to PrEP uptake, adherence, and retention (linear regression), and intention to initiate PrEP (logistic regression). Models adjusted for age, race/ethnicity, sexual identity, education, and income. Participants' mean age was 34.2 [standard deviation (SD) = 8.5], and 47% were non-White. Three-quarters (76%) intended to initiate PrEP within the next month. Comfort discussing sexual practices with providers was associated with PrEP use self-efficacy (b = 0.41, p = 0.008). Comfort discussing sexual practices with providers was negatively associated with anticipated barriers to PrEP uptake (b = -0.29, p = 0.006). Transportation difficulties to accessing general health care were associated with barriers to PrEP uptake (b = 0.30, p = 0.007) and barriers to PrEP adherence and retention (b = 0.57, p < 0.001). No health service- and provider-level characteristics were associated with intention to initiate PrEP. PrEP programs targeting MSW may benefit from interventions to foster communication between MSW and providers about sexual practices and should consider structural barriers to accessing care, including lack of access to transportation.

"You need money to get high, and that's the easiest and fastest way:" A typology of sex work and health behaviours among people who inject drugs.

BACKGROUND: In the United States, the criminalization and stigmatization of drug use and sex work contribute to infectious disease transmission and healthcare disengagement. People who inject drugs (PWID) and engage in sex work experience exacerbated HIV risk. In the context of the ongoing HIV and overdose epidemics little research describes why PWID engage in sex work and its relative HIV risk. To inform intervention needs, we aimed to create a typology of sex work among PWID with a focus on HIV risk and healthcare utilization behaviours. METHODS: We drew from in-depth interviews conducted across Massachusetts and Rhode Island from 2016-2019. Participants were ≥18 years old and self-reported past-month injection drug use and HIV-negative status. Using data from individuals reporting sex work experience (n=33/78), we utilized the framework method to develop a typology of perspectives on sex work engagement and attributes pertaining to HIV risk and healthcare utilization behaviours. RESULTS: We uncovered varying perspectives on sex work and associated HIV risks and prevention needs. A typology included three groups who viewed their sex work engagement as a (1) consistent job, (2) income supplement, or (3) survival method to abate withdrawal symptoms. The first group described more consistent sexual and injection behaviours to mitigate HIV risk than the second group. The third group appeared particularly vulnerable to HIV, describing inconsistent condom use and frequent sharing of injection equipment, low healthcare utilization, and limited disclosure of sex work and injection drug use to healthcare providers. CONCLUSION: Findings highlight distinct perspectives on sex work among PWID involved in it and corresponding perceptions of HIV risk and healthcare utilization behaviours. Understanding the nuances in sex work engagement among PWID can inform interventions to prevent infectious disease transmission, including efforts to further connect this marginalized population to harm reduction, health, and low barrier opioid treatment services.

COVID-19 Vaccine Acceptance among an Online Sample of Sexual and Gender Minority Men and Transgender Women.

Sexual and gender minority (SGM) populations are particularly vulnerable to poor COVID-19 outcomes and are more likely to experience stigma and medical mistrust that may impact COVID-19 vaccine acceptance. This study examined the prevalence of COVID testing and diagnosis and assessed COVID-19 vaccine acceptance among a large sample of SGM. Participants were recruited as part of an online cross-sectional study focused on an HIV biomedical prevention technology willingness in the United States at increased risk for HIV sero-conversion. Multivariate linear analysis was conducted to examine COVID-19 vaccine acceptance. The study sample included 1350 predominately gay (61.6%), Black (57.9%), cis-gender (95.7%) males with a mean age of 32.9 years. Medical mistrust and social concern regarding COVID-19 vaccine stigma were significantly associated with decreased COVID-19 vaccine acceptance, and altruism was significantly associated with increased vaccine acceptance. Black participants were significantly less likely to accept a COVID-19 vaccine, and Asian participants were significantly more likely to accept a vaccine, compared to White peers. As the planning of COVID-19 vaccine rollout efforts is conceptualized and designed, these data may inform equitable implementation strategies and prevent worsening health inequities among SGM populations.