Providers' Attitudes and Experiences with Pre-Exposure Prophylaxis Implementation in a Population-Based Study in Kenya and Uganda.

Pre-exposure prophylaxis (PrEP) implementation is underway across sub-Saharan Africa. However, little is known about health care providers' experiences with PrEP provision in generalized epidemic settings, particularly outside of selected risk groups. In this study (NCT01864603), universal access to PrEP was offered to adolescents and adults at elevated risk during population-level HIV testing in rural Kenya and Uganda. Providers received training on PrEP prescribing and support from local senior clinicians. We conducted in-depth interviews with providers (n = 19) in four communities in Kenya and Uganda to explore the attitudes and experiences with implementation. Transcripts were coded and analyzed using interpretivist methods. Providers had heterogenous attitudes toward PrEP in its early implementation: some expressed enthusiasm, while others feared being blamed for "failures" (HIV seroconversions) if participants were nonadherent, or that offering PrEP would increase "immorality." Providers supported PrEP usage among HIV-serodifferent couples, whose mutual support for daily pill-taking facilitated harmony and protection from HIV. Providers reported challenges with counseling on "seasons of risk," and safely stopping and restarting PrEP. They felt uptake was hampered for women by difficulties negotiating with partners, and for youth by parental consent requirements. They believed PrEP continuation was hindered by transportation costs, stigma, pill burden, and side effects, and was facilitated by counseling, proactive management of side effects, and home/community-based provision. Providers are critical "implementation actors" in interventions to promote adoption of new technologies such as PrEP. Dedicated training and ongoing support for providers may facilitate successful scale-up.

An Intervention by and for Transgender Women Living With HIV: Study Protocol for a Two-Arm Randomized Controlled Trial Testing the Efficacy of "Healthy Divas" to Improve HIV Care Outcomes.

Introduction: Transgender women (assigned "male" at birth but who do not identify as male) are disproportionately impacted by HIV and experience unique barriers and facilitators to HIV care engagement. In formative work, we identified culturally specific and modifiable barriers to HIV treatment engagement among transgender women living with HIV (TWH), including prioritizing transition-related healthcare over HIV treatment, avoiding HIV care settings due to gender-related and HIV stigma, concerns about potential drug interactions with hormones, and inadequate social support. Grounded in the investigators' Models of Gender Affirmation and Health Care Empowerment, we developed the Healthy Divas intervention to optimize engagement in HIV care among TWH at risk for treatment failure and consequential morbidity, mortality, and onward transmission of HIV. Methods and Analysis: We conducted a 2-arm randomized controlled trial (RCT) of the intervention's efficacy in Los Angeles and San Francisco to improve engagement in care among TWH (N = 278). The primary outcome was virologic control indicated by undetectable HIV-1 level (undetectability = < 20 copies/mL), at baseline and follow-up assessment for 12 months at 3-month intervals. Ethics and Dissemination: This study was approved by University of California, San Francisco Institutional Review Board (15-17910) and Western Institutional Review Board (20181370). Participants provided informed consent before enrolment in the study. We are committed to collaboration with National Institutes of Health officials, other researchers, and health and social services communities for rapid dissemination of data and sharing of materials. The results will be published in peer-reviewed academic journals and scientific presentations. We will make our results available to researchers interested in transgender health to avoid unintentional duplication of research, as well as to others in health and social services communities, including HIV clinics, LGBT community-based organizations, and AIDS service organizations. Clinical Trial Registration: Clinicaltrials.gov, identifier NCT03081559.

Couples-based approach to HIV prevention for transgender women and their partners: study protocol for a randomised controlled trial testing the efficacy of the 'It Takes Two' intervention.

INTRODUCTION: HIV transmission and acquisition risk among transgender women is particularly high in the context of primary partnerships. This project extends a previous pilot couples-focused HIV intervention programme, which was shown to be feasible, acceptable and promising in reducing sexual risk behaviour among transgender women and their partners. This randomised controlled trial (RCT) tests the efficacy of this culturally sensitive HIV prevention programme for HIV-serodiscordant and HIV-negative seroconcordant transgender women and their partners. METHODS AND ANALYSIS: To finalise the protocol for trial, we used qualitative methods to hone eligibility criteria, refine the intervention and control manuals, and name and brand the intervention ('It Takes Two'). The RCT investigates the effects of the It Takes Two intervention on Composite Risk for HIV (CR-HIV) among 100 couples. CR-HIV is a binary indicator of couple HIV risk using validated measures of sexual behaviour, pre-exposure prophylaxis use among HIV-negative participants and viral suppression among participants living with HIV. Using a two-arm RCT, we will examine intervention effects on CR-HIV at 12-month follow-up comparing transgender women and their partners randomised to the intervention versus control (HIV prevention information only). ETHICS AND DISSEMINATION: This study has been reviewed and approved by the University of California, San Francisco (19-28624) and the University of Michigan (HUM00147690) Institutional Review Boards. Participants provide informed consent before taking part of the study activities. Results will be published in peer-reviewed journals and presented at scientific conferences. We will make our results available to the community of researchers and general public interested in transgender health to avoid unintentional duplication of research, as well as to others in the health and social services community, including LGBT community-based organisations, AIDS service organisations and other transgender-serving organisations. The full de-identified dataset and codebook will be shared at the University of Michigan Digital Repository. TRIAL REGISTRATION NUMBER: NCT04067661.

Pilot Results from the First HIV/AIDS Intervention Among Transgender Women in the Middle East: Gender Affirmation and Social Support from Within Trans Communities in Beirut, Lebanon.

Transgender women are 49 times more likely to become HIV positive than all adults worldwide. Data were unavailable for trans women's sexual and mental health in the Middle East and North Africa until 2015-2016, when HIV prevalence (10%) and suicide attempt (46%) rates were established in Lebanon. Because of the lack of evidence-based interventions for this marginalized group, the purpose of this study was to pilot test an adapted intervention, "Baynetna," to assess preliminary impact on mental and sexual health. Using the gender affirmative model and community connectedness and social cohesion constructs, we pilot tested Baynetna among sixteen trans women, who attended 6 weekly 3-h trans-facilitated group-delivered sessions in Beirut with post-test assessments at 1, 3, and 6 months. Each participant acted as her own control; we used paired t-tests to assess changes at follow-up to evaluate potential differences in outcomes. Positive directionality in intervention impact on gender affirmation satisfaction, community connectedness, and social cohesion was demonstrated. An increase in HIV testing proportion between 6 months before and after enrollment was achieved. Higher social cohesion was associated with less suicidal thoughts (p = .05). There was a significant (p = .019) relationship between more community connectedness and lower depression scores. War event exposure was associated with higher anxiety (p = .02; p = .004). Those who reported never having had a sexually transmitted infection had higher gender affirmation satisfaction scores (7.5, 95% confidence interval: 1.4-13.6) (p = .019). Increases in community connectedness, social cohesion, and gender affirmation satisfaction scores confirm Baynetna's proposed mechanisms of impact. Proportional HIV testing increases demonstrate prevention objectives' progress. The significant results contribute to confidence in Baynetna's mechanisms of action and support the hypothesis that the Gender Affirmation model is applicable to the Lebanese context. We have shown for the first time that the adapted intervention, and its constructs, are applicable in this context outside the United States.

Characterizing the relationship between incarceration and structural risks among female sex workers in Iran: findings of a nationwide biobehavioral surveillance survey.

PURPOSE: Given the adverse impacts of enforcement-based approaches toward sex work on female sex workers' (FSWs') health, safety, and well-being, we explored the prevalence and correlates of recent incarceration among FSWs in Iran. METHODS: From January to August 2015, we recruited FSWs from 21 harm reduction facilities and 152 FSWs from street venues in 13 major cities across Iran. Correlates of recent (i.e., last year) incarceration were assessed through an exploratory multivariable logistic regression model. RESULTS: A total of 90 of 1326 (6.8%) FSWs reported a recent incarceration; primary reasons for incarceration were drug-related (n = 48/90; 52.9%). Having a recent incarceration was significantly and positively associated with history of illicit drug use/injection (adjusted odds ratio [aOR] = 3.22, 95% confidence interval [CI]: 1.67, 6.19), rape in last year (aOR = 2.67, 95% CI: 1.65, 4.31), unstable housing (aOR = 2.28, 95% CI: 1.16, 4.91), and working in brothels (aOR = 2.22, 95% CI: 1.18, 4.16). CONCLUSIONS: In sum, recent incarceration was significantly associated with history of drug use and sociostructural vulnerabilities. Taken together, these data suggest the potential health impacts of the integration of programs to mitigate substance use, sexual violence, and living conditions into comprehensive services for FSWs in Iran.

Feasibility and Acceptability of a Behavioral Group Support Intervention Among Transgender Women: A Sexual and Mental Health Mixed-Methods Pilot Study in Beirut, Lebanon.

Transgender women are among the most at risk of populations for HIV infection and transmission globally. Feasible and acceptable intervention strategies that are culturally and contextually appropriate are urgently needed to address the burden of disease worldwide. The first study to address the unique health needs of transgender women in the Middle East and North Africa, this mixed-methods pilot (N = 16) demonstrated high levels of feasibility and acceptability among adult transgender women in Lebanon as measured quantitatively and qualitatively in the domains of: time allotment, venue, group dynamics, facilitation, content, and retention. The intervention, adapted from an existing trans-facilitated group support intervention, addresses the sexual and mental health of transgender women with mixed HIV status. Next steps should include scale-up, randomization, and testing to determine larger-scale feasibility, acceptability, and efficacy for mitigating sexual and mental health risk and promoting community connectedness and social cohesion.

The Elephants in the Room: Sex, HIV, and LGBT Populations in MENA. Intersectionality in Lebanon Comment on "Improving the Quality and Quantity of HIV Data in the Middle East and North Africa: Key Challenges and Ways Forward".

In response to this insightful editorial, we wish to provide commentary that seeks to highlight recent successes and illuminate the often unspoken hurdles at the intersections of culture, politics, and taboo. We focus on sexual transmission and draw examples from Lebanon, where the pursuit of data in quality and quantity is teaching us lessons about the way forward and where we are experiencing many of the challenges referenced in the editorial such as discrepancies between national statistics and rates derived via research as well as the impact of protracted political conflict and displacement. Two important points were raised in the editorial about HIV in Middle East and North Africa (MENA) that we would like to expand further: (1) The epidemic is largely driven by drug-related and sexual behavior among key populations; and (2) Several key populations continue to be criminalized and excluded from surveillance programs.

Suicide risk factors among trans feminine individuals in Lebanon.

Transgender women are disproportionately affected by high rates of depression and suicide attempts. It is therefore important to identify factors that influence suicidal risk, particularly in the Middle East where little research has examined the mental health of transgender women. We examined risk factors associated with suicide attempts among 54 trans feminine individuals in Beirut, Lebanon. Data were collected using interviewer-administered questionnaires and analyzed using bivariate statistics. Twenty-five (46%) participants reported having ever attempted suicide. Among them, only one participant received some kind of counseling in response to the attempted suicide. Low general social support, low social integration, and low support from peers were significantly associated with a history of attempted suicide, as were being more open about transgender identity in public and any hormone use (past or current). These findings suggest that progression in gender transition can have unintended consequences related to mental health and suicide risk, while social support systems can mitigate the impact of mental health problems. Some of these findings mirror other contexts around the globe and can inform mental health services for trans feminine individuals in Lebanon, the greater Middle East region, and other international settings.

HIV prevalence and demographic determinants of condomless receptive anal intercourse among trans feminine individuals in Beirut, Lebanon.

INTRODUCTION: Growing evidence suggests increased HIV incidence in the Middle East and North Africa among "key populations." To date, epidemiological data have not accurately included and measured HIV prevalence and risk among trans feminine individuals in the region. Through the lens of the Gender Affirmation Framework, we assessed demographic correlates of risk behaviour and the prevalence of HIV among trans feminine individuals in Lebanon. METHODS: Long-chain referral sampling was used to recruit 53 participants for completion of a behavioural survey and optional free rapid HIV tests. Data were collected using interviewer-administered questionnaires. A multivariable logistic regression model was used to identify demographic determinants of HIV risk behaviour. RESULTS: Fifty-seven percent of participants reported condomless receptive anal intercourse (CRAI) with male partner(s) in the last three months, 40% of whom reported not knowing the HIV status of the partner(s). Of the participants tested for HIV as part of the study or via self-report, four (10%) were HIV positive; 13 declined HIV testing. Forty percent of the sample had no prior history of HIV testing. A history of trauma such as sexual abuse/assault was reported by almost half of the participants (49%). Sixty-eight percent reported experiencing physical violence and 32% police arrest, because of gender identity or presentation. A staggering 98% reported having experienced gender identity or gender presentation-related discrimination. Sixty-six percent of the sample reported current sex work; sex work was correlated with CRAI but was not significant in multivariate analysis. In regression analysis, "openness"/"outness" about transgender identity at work or school was significantly associated with CRAI. Surprisingly, a history of sexual abuse/assault was negatively correlated with CRAI, suggesting the need for further inquiry. CONCLUSIONS: The results of this study provide implications for how to address sexual health among trans feminine individuals in Lebanon and the greater Middle East and North Africa region.

The role of the illusion in the construction of erotic desire: narratives from heterosexual men who have occasional sex with transgender women.

Little is known about men's sexual desire for and erotic attraction to male-to-female transgender women. To better understand how erotic desire is constructed, this study examined the narratives of a sample of heterosexual men who had had an occasional sexual encounter with a transgender woman. Open-ended qualitative interviews were conducted with 16 heterosexual men who reported at least one sexual encounter with a transgender woman in the previous 12 months. Using principles of Grounded Theory, three themes emerged: (1) the erotic desire that transpired from a transgender woman's construction of her femininity, (2) the sexual act that dictated the specific navigation of a transgender woman's penis and (3) the sexual dissonance that resulted from being a heterosexually identified man having sex with a partner who had a penis. These themes reflected how the participants defined and negotiated their sexual encounters, both psychologically through their understanding of sex with a transgender woman with a penis, and physically through the navigation of specific sex acts. The role of the 'illusion' was central to the meaning and construction of erotic desire. These narratives provided another framework for continuing discourse on the complexity of erotic desire.

In the name of brevity: The problem with binary HIV risk categories.

According to the 'Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations' there are five groups of people at elevated risk of HIV, including 'transgender women or transgender men who have receptive anal sex with men'. Although cost effectiveness strategies and best practice lessons recommend targeting specific populations for HIV prevention, existing risk categories lack specificity, and may in fact cause further confusion. Existing categories of risk often perpetuate notions of gender and sexuality that can erroneously exclude, alienate, and stigmatise those who are at the highest risk and thus should be prioritised. We review the troubled history of the MSM category and the problematic conflation of trans feminine individuals and MSM in much of the existing HIV literature, and how this practice has stymied progress in slowing the HIV epidemic in the most at-risk groups, including those who do not fit neatly into binary notions of gender and sex. We draw from examples in the field, specifically among trans feminine people in Beirut and San Francisco, to illustrate the lived experiences of individuals whose identities may not fit into Euro-Atlantic constructs of HIV prevention categories.

Living Day by Day: The Meaning of Living With HIV/AIDS Among Women in Lebanon.

We examined the meaning of living with HIV/AIDS among women in Lebanon. Ten women living with HIV/AIDS (WLWHA) described their experiences via semistructured in-depth interviews. They navigated a process of HIV diagnosis acceptance that incorporated six overlapping elements: receiving the news, accessing care, starting treatment, navigating disclosure decisions, negotiating stigma, and maintaining stability. Through these elements, we provide a framework for understanding three major themes that were constructed during data analysis: Stand by my side: Decisions of disclosure; Being "sick" and feeling "normal": Interacting with self, others, and society; and Living day by day: focusing on the present. We contribute to the existing literature by providing a theoretical framework for understanding the process of diagnosis and sero-status acceptance among WLWHA. This was the first study of its kind to examine the meaning of living with HIV/AIDS among women in a Middle Eastern country.

An Exploratory Study of HIV Risk Behaviors and Testing among Male Sex Workers in Beirut, Lebanon.

Male sex workers (MSW) are a particularly high-risk subset of men who have sex with men in Lebanon and report higher numbers of sex partners and lower rates of condom use. The purpose was to explore the factors influencing sexual risk behaviors and HIV testing among MSW. Qualitative interviews were conducted with 16 MSW living in Beirut and working in bathhouses (hammam) or as escorts; content analysis identified emergent themes. Escorts reported more consistent condom use with clients and HIV testing than hammam MSW, with influential factors including HIV risk knowledge and perceived risk susceptibility, job security, and internalized stigma and related feelings of self-worth and fatalism regarding health and HIV risk. In contrast, both groups of MSW typically opted not to condoms with nonclient sex partners, in an effort to differentiate sex for work versus pleasure. The uptake of HIV testing was limited by concerns about the confidentiality of the test results and fear of repercussions of a positive test result for their health and employment. The respondents described an insular existence within the sex work culture, in part to limit exposure to stigma, which has implications for access to support as well as the influence of peer norms regarding sexual risk behavior and health seeking behaviors such as HIV testing. Further research is needed to tailor prevention and HIV testing efforts to reflect the distinct sexual health "cultures" that distinguish these two populations of MSW in Lebanon.

Disclosure of Male Sexual Partnering and HIV Serostatus Among a Sample of Heterosexually Identified Men Who Have Sex With Men and Women.

This study employed qualitative methods to understand better the disclosure practices of men with their male and female sexual partners. Open-ended, in-depth, semi-structured interviews were conducted with 21 heterosexually identified men who reported at least one sexual encounter with a male in the previous year but not more than one sexual encounter with a male per month. Fifty-eight percent of the participants were HIV infected. Most HIV-infected participants reported disclosure of their HIV serostatus to their female sexual partners but did not disclose that they engaged in occasional sexual encounters with a male partner. Disclosure of HIV serostatus to male sexual partners was minimal and inconsistent.

Forms of Safety and Their Impact on Health: An Exploration of HIV/AIDS-Related Risk and Resilience Among Trans Women in Lebanon.

Using minority stress theory, the authors investigated risk behaviors of transgender women (trans women) in Lebanon. Using semistructured interviews, the authors explored six areas: relationships with family and friends; openness about gender and sexuality; experiences with stigma; sexual behavior; attitudes and behaviors regarding HIV testing; and perceived HIV-related norms among transgender peers. Participants voiced the importance of different forms of safety: social/emotional, physical, sexual, and financial. Strategies for obtaining safety were negotiated differently depending on social, behavioral, and structural factors in the environment. In this article, we provide study findings from the perspectives of trans women, their exposure to stigma, and the necessary navigation of environments characterized by transphobia.

Sexual stigma, psychological well-being and social engagement among men who have sex with men in Beirut, Lebanon.

This qualitative study sought to explore sexual identity development among men who have sex with men in Beirut, Lebanon; the stigma experienced by these men; and how their psychological well-being and social engagement are shaped by how they cope with this stigma. Semi-structured interviews were conducted with 31 men who have sex with men and content analysis was used to identify emergent themes. While many men reported feeling very comfortable with their sexual orientation and had disclosed their sexual orientation to family, most men struggled at least somewhat with their sexuality, often because of perceived stigma from others and internal religious conflict about the immorality of homosexuality. Most participants described experiencing verbal harassment or ridicule or being treated as different or lesser than in social relationships with friends or family. Mechanisms for coping with stigma included social avoidance (trying to pass as heterosexual and limiting interaction with men who have sex with men to the internet) or withdrawal from relationships in an attempt to limit exposure to stigma. Findings suggest that effective coping with both internal and external sexual stigma is central to the psychological well-being and social engagement of men who have sex with men in Beirut, much as has been found in Western gay communities.

A qualitative exploration of sexual risk and HIV testing behaviors among men who have sex with men in Beirut, Lebanon.

Men who have sex with men (MSM) may account for most new HIV infections in Lebanon, yet little is known about the factors that influence sexual risk behavior and HIV testing in this population. Qualitative interviews were conducted with 31 MSM living in Beirut, and content analysis was used to identify emergent themes. Mean age of the participants was 28.4 years, and all identified as either gay (77%) or bisexual (23%). Half reported not using condoms consistently and one quarter had not been HIV-tested. Many described not using condoms with a regular partner in the context of a meaningful relationship, mutual HIV testing, and a desire to not use condoms, suggesting that trust, commitment and intimacy play a role in condom use decisions. Condoms were more likely to be used with casual partners, partners believed to be HIV-positive, and with partners met online where men found it easier to candidly discuss HIV risk. Fear of infection motivated many to get HIV tested and use condoms, but such affect also led some to avoid HIV testing in fear of disease and social stigma if found to be infected. Respondents who were very comfortable with their sexual orientation and who had disclosed their sexuality to family and parents tended to be more likely to use condoms consistently and be tested for HIV. These findings indicate that similar factors influence the condom use and HIV testing of MSM in Beirut as those observed in studies elsewhere of MSM; hence, prevention efforts in Lebanon can likely benefit from lessons learned and interventions developed in other regions, particularly for younger, gay-identified men. Further research is needed to determine how prevention efforts may need to be tailored to address the needs of men who are less integrated into or do not identify with the gay community.

Condom use attitudes and HIV risk among American MSM seeking partners for unprotected sex via the internet.

This chapter examines attitudes toward condom use in a national random sample of 332 MSM who use the Internet to seek men with whom they can engage in unprotected sex. Data collection was conducted via telephone interviews between January 2008 and May 2009. The following three research questions were addressed: 1) How do these men feel about using condoms, both ideologically and personally? 2) How do condom use attitudes relate to actual HIV risk behavior practices? 3) What factors underlie men's attitudes toward condom use? The findings indicated that men held weakly-positive attitudes toward condom use overall, but were noticeably more negative in their attitudes regarding the personal use of condoms. Condom use attitudes were related consistently and inversely to involvement in HIV risk practices. In both multivariate and structural equation analyses, men's condom-related attitudes were the single strongest factor associated with their involvement in risky sex. A number of factors were found to be correlated with more favorable attitudes toward condom use. These were: caring about potential sex partners' HIV serostatus, experiencing fewer drug-related problems, having a lower level of educational attainment, not preferring to have "wild" or "uninhibited" sex, higher self-esteem, being African American, and not perceiving great accuracy in the information that sex partners supply verbally about their HIV serostatus.

Sexual risk behaviors and acceptability of HIV pre-exposure prophylaxis among HIV-negative gay and bisexual men in serodiscordant relationships: a mixed methods study.

The objective of this mixed methods study was to examine current sexual risk behaviors, acceptability and potential adoption of pre-exposure prophylaxis (PrEP) for HIV prevention, and sexual behavior intentions with PrEP adoption among HIV-negative gay and bisexual men (GBM) in HIV serodiscordant relationships. A multiracial/ethnic sample of 25 HIV-negative GBM in serodiscordant relationships completed a qualitative interview and a brief interviewer-administered survey. A modified grounded theory approach was used to identify key themes relating to acceptability and future adoption of PrEP. Participants reported engaging in sexual risk behaviors that place them at risk for HIV infection. Participants also reported a high level of acceptability for PrEP and willingness to adopt PrEP for HIV prevention. Qualitative themes explaining future PrEP adoption included: (1) the opportunity to engage in sex using a noncondom HIV prevention method, (2) protection from HIV infection, and (3) less anxiety when engaging in sex with an HIV-positive partner. Associated with the future adoption of PrEP, a majority (64%) of participants indicated the likelihood for an increase in sexual risk behaviors and a majority (60%) of participants also indicated the likelihood for a decrease or abandonment of condom use, both of which are in contrast to the findings from the large iPrEx study. These findings suggest that the use of PrEP by HIV-negative GBM in serodiscordant relationships carries with it the potential for risk compensation. The findings suggest that PrEP only be offered as part of a comprehensive HIV prevention strategy that includes ongoing risk reduction counseling in the delivery of PrEP to help moderate risk compensation.