Social Network Organization, Structure, and Patterns of Influence Within a Community of Transgender Women in Lima, Peru: Implications for Biomedical HIV Prevention.

Understanding social network structures can contribute to the introduction of new HIV prevention strategies with socially marginalized populations like transgender women (TW). We conducted 20 semi-structured interviews and four focus groups (n = 32) with TW from selected social networks in Lima, Peru between May and July, 2015. Participants described layers of social influence from diverse actors in their social networks. The majority identified a close relative as their primary social support, with whom they confided secrets but avoided issues of transgender identity, sexuality, and sex work. Participants described close circles of TW friends with whom they shared information about gender identity, body modification, and sexual partners, but avoided issues like HIV. Community leadership included political leaders (who advocated for transgender rights) as well as social leaders (who introduced TW to hormone therapy, body modification, and commercial sex). Detailed analysis of TW social networks can contribute to implementation and acceptability of new HIV prevention technologies.

A missing perspective: injectable pre-exposure prophylaxis for people who inject drugs.

The efficacy of pre-exposure prophylaxis (PrEP) for HIV prevention has been established among people who inject drugs (PWID). HIV uninfected, at risk PWID, could likely benefit from long-acting injectable formulations of PrEP ("LAI-PrEP"); however, its acceptability in this population has not been previously documented. Thirty-three HIV-uninfected PWID in the U.S. Northeast completed an in-depth interview regarding perceived acceptability of LAI-PrEP. Coded data were synthesized using deductive thematic analysis. The majority of PWID interviewed believed LAI-PrEP would be acceptable. Participants perceived that receiving injections every two months would reduce barriers to daily oral PrEP adherence, including forgetting while "high" and safeguarding pills when homeless. A few participants expressed concerns regarding LAI-PrEP, including medical mistrust, a concern that injections could alter their "high" or be "triggering" for PWID. LAI-PrEP has the potential to reduce HIV among PWID; however, their perspectives are largely absent from research examining its efficacy, representing a missed opportunity.

Concordance in the reporting of intimate partner violence among male-male couples.

Intimate partner violence (IPV) among male couples is increasingly recognized as a public health concern. Research on IPV in opposite sex couples indicates frequent underreporting of IPV and high levels of discordance in reporting among dyads. Concordance studies inform refinement methods to measure the experience of IPV among dyads; however the lack of dyadic studies of male couples impedes our understanding of the extent to which IPV is differentially reported in male-male dyads. This study utilized baseline data from a randomized controlled trial of a behavioral intervention to optimize antiretroviral therapy (ART) adherence among 160 sero-discordant male couples in three US cities and provides the first analysis of concordance in reporting IPV among male couples. Low degrees of concordance in the reporting of IPV were identified among male dyads, with a greater proportion of men reporting violence perpetration than experiencing violence. The greater reporting of IPV perpetration may be linked to adherence to concepts of masculinity. The results underscore the unique experiences of IPV among male couples and the need to reexamine current IPV measurement and intervention strategies.

Perspectives on HIV pre-exposure prophylaxis (PrEP) utilization and related intervention needs among people who inject drugs.

BACKGROUND: Antiretroviral pre-exposure prophylaxis (PrEP) is clinically efficacious and recommended for HIV prevention among people who inject drugs (PWID), but uptake remains low and intervention needs are understudied. To inform the development of PrEP interventions for PWID, we conducted a qualitative study in the Northeastern USA, a region where recent clusters of new HIV infections have been attributed to injection drug use. METHODS: We conducted qualitative interviews with 33 HIV-uninfected PWID (hereafter, "participants") and 12 clinical and social service providers (professional "key informants") in Boston, MA, and Providence, RI, in 2017. Trained interviewers used semi-structured interviews to explore PrEP acceptability and perceived barriers to use. Thematic analysis of coded data identified multilevel barriers to PrEP use among PWID and related intervention strategies. RESULTS: Among PWID participants (n = 33, 55% male), interest in PrEP was high, but both participants and professional key informants (n = 12) described barriers to PrEP utilization that occurred at one or more socioecological levels. Individual-level barriers included low PrEP knowledge and limited HIV risk perception, concerns about PrEP side effects, and competing health priorities and needs due to drug use and dependence. Interpersonal-level barriers included negative experiences with healthcare providers and HIV-related stigma within social networks. Clinical barriers included poor infrastructure and capacity for PrEP delivery to PWID, and structural barriers related to homelessness, criminal justice system involvement, and lack of money or identification to get prescriptions. Participants and key informants provided some suggestions for strategies to address these multilevel barriers and better facilitate PrEP delivery to PWID. CONCLUSIONS: In addition to some of the facilitators of PrEP use identified by participants and key informants, we drew on our key findings and behavioral change theory to propose additional intervention targets. In particular, to help address the multilevel barriers to PrEP uptake and adherence, we discuss ways that interventions could target information, self-regulation and self-efficacy, social support, and environmental change. PrEP is clinically efficacious and has been recommended for PWID; thus, development and testing of strategies to improve PrEP delivery to this high-risk and socially marginalized population are needed.

Alcohol use and HIV sexual risk among MSM in Chennai, India.

Men who have sex with men (MSM) in India are a core risk group for HIV. Heavy alcohol consumption is associated with increased sexual risk-taking behaviours in many cultures, in particular among MSM. However, no studies to date have explored alcohol use and HIV risk among MSM in India. MSM in Chennai, India (n = 210) completed an interviewer-administered behavioural and psychosocial assessment. Bivariate and multivariable logistic regression procedures examined behavioural and demographic associations with weekly alcohol consumption. Twenty-eight percent of the sample (n = 58) reported using alcohol at least weekly to the point of being buzzed/intoxicated, which was associated with older age, being married to a woman, being panthi (masculine appearing, predominantly insertive partners) versus kothi (feminine acting/appearing and predominantly receptive partners), weekly tobacco use, unprotected anal sex and unprotected vaginal sex in the three months prior to study enrollment (all P < 0.05). In a multivariable model, unprotected vaginal sex in the previous three months and being married to a women were unique variables associated with weekly alcohol use (all P < 0.01). Further investigation of alcohol use within the context of sexual risk taking is warranted among Indian MSM. Panthis and MSM who are married to women may be particularly likely to benefit from interventions to decrease alcohol intake and concurrent unsafe sex.

Study participation as a social group influencing sexual behaviours in an HIV-prevention trial for men who have sex with men.

Perceived group membership, perceptions about accompanying group norms and the degree to which a person identifies with a social group are predictive of a wide range of human behaviours. Behavioural clinical trials in general, and HIV-prevention intervention trials in particular, however, have not examined the degree to which individuals who join a large behavioural study (and hence, a group) may, in an unanticipated way, develop a sense of social identity related to the study, and how this identity or associated group norms may influence participants' behaviours and, potentially, study outcomes. Project EXPLORE was a large-scale behavioural intervention trial in six US cities to prevent HIV seroconversion among men who have sex with men (MSM) (EXPLORE Study Team, 2004). We previously found that participants (examined at one study site) were more likely to engage in high-risk sexual activities with other MSM who were EXPLORE participants than other partners. The present ancillary study (n=271) sought to examine the degree to which perceived group membership, group identity and group norms among EXPLORE study participants was associated with sexual behaviour with other EXPLORE participants, high-risk sexual behaviours with other EXPLORE participants and intentions to engage in high-risk sex with other EXPLORE participants. A principal components analysis of a 14-item scale assessing perceived group membership and norms regarding being part of EXPLORE yielded six principal components (PCs): PC1: perception that EXPLORE participants engage in safer sex; PC2: social comfort with EXPLORE participants; PC3: perceived group identity with EXPLORE; PC4: trust of other EXPLORE participants; PC5: perception that EXPLORE participants are cunning; and PC6: feeling detached from EXPLORE. Social comfort with other EXPLORE participants (OR = 1.24; p = 0.013) and trust of other EXPLORE participants (OR = 1.44; p=0.003) was significantly associated with a higher odds of having sex with another EXPLORE participant. Feeling detached from EXPLORE (OR = 0.56; p=0.020) was significantly associated with a lower odds of engaging in high-risk sexual behaviour with other EXPLORE participants. Regarding intentions to engage in high-risk sexual behaviour with other EXPLORE participants, social comfort with EXPLORE participants (OR = 1.39; p<0.001) and trust of other EXPLORE participants (OR = 1.30; p<0.027) were significantly associated with higher odds of this outcome and the perception that EXPLORE participants are cunning (OR = 0.66; p<0.004) and feeling detached from EXPLORE (OR = 0.68; p<0.007) were significantly associated with lower odds of this outcome. Final models controlled for potential confounders found to be statistically significant in the bivariate analyses. These findings suggest that large-scale studies such as EXPLORE may result in participant's perceptions about group membership, identity and norms, and that these perceptions can influence study outcomes.

Nonadherence to medical appointments is associated with increased plasma HIV RNA and decreased CD4 cell counts in a community-based HIV primary care clinic.

This study examined the association of appointment nonadherence to markers of disease severity using one year of demographic and health information on 995 individuals with HIV in primary care at an urban community health centre. At the latest visit, 106 of 946 valid cases (11.2%) had a CD4 less than or equal to 200, and 454 of 936 valid cases (48.5%) had detectable plasma HIV RNA (greater than 50 copies/ml). Using logistic regression, appointment nonadherence (number of missed appointments) was a significant predictor (p < .03) of having an AIDS-defining CD4 count over and above the effects of number of kept appointments (p < .0001), and whether or not the patient was taking HAART (p < .002). Appointment nonadherence was also a significant predictor (p < .05) of having a detectable viral load over and above the effects of number of kept appointments (p < .003), HAART (p < .0001) and age (p < .004). Looking only at individuals with a detectable viral load at the earliest visit, the only significant unique predictor of improvement to an undetectable viral load at the latest visit was being on HAART (p < .05). Looking at those only with an undetectable viral load at the earliest visit, the only predictor of declining to a detectable viral load was number of kept appointments (p < 003), and being on HAART (p < .05).