Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory

Experiences and perceptions of conditional cash incentive provision and cessation among people with HIV for care engagement: A qualitative study

Background

Consistent engagement in HIV treatment is needed for healthy outcomes, yet substantial loss-to-follow up persists, leading to increased morbidity, mortality and onward transmission risk. Although conditional cash transfers (CCTs) address structural barriers, recent findings suggest that incentive effects are time-limited, with cessation resulting in HIV care engagement deterioration. We explored incentive experiences, perceptions, and effects after cessation to investigate potential mechanisms of this observation.

Methods

This qualitative study was nested within a larger trial, AdaPT-R (NCT02338739), focused on HIV care engagement in western Kenya. A subset of participants were purposively sampled from AdaPT-R participants: adults with HIV who had recently started ART, received CCTs for one year, completed one year of follow-up without missing a clinic visit, and were randomized to either continue or discontinue CCTs for one more year of follow-up. In-depth interviews were conducted by an experienced qualitative researcher using a semi-structed guide within a month of randomization. Interviews were conducted in the participants' preferred language (Dholuo, Kiswahili, English). Data on patient characteristics, randomization dates, and clinic visit dates to determine care lapses were extracted from the AdaPT-R database. A codebook was developed deductively based on the guide and inductively refined based on initial transcripts. Transcripts were coded using Dedoose software, and thematic saturation was identified.

Results

Of 38 participants, 15 (39%) continued receiving incentives, while 23 (61%) were discontinued from receiving incentives. Half were female (N = 19), median age was 30 years (range: 19-48), and about three-quarters were married or living with partners. Both groups expressed high intrinsic motivation to engage in care, prioritized clinic attendance regardless of CCTs and felt the incentives expanded their decision-making options. Despite high motivation, some participants reported that cessation of the CCTs affected their ability to access care, especially those with constrained financial situations. Participants also expressed concerns that incentives might foster dependency.

Conclusions

This study helps us better understand the durability of financial incentives for HIV care engagement, including when incentives end. Together with the quantitative findings in the parent AdaPT-R study, these results support the idea that careful consideration be exercised when implementing incentives for sustainable engagement effects.

Resilience and associated factors in orphaned and separated adolescents in Kenya: Understanding the relationship with care environment and HIV risks

Orphans are at higher risk of HIV infection and several important HIV risk factors than non-orphans; however, this may be due to a combination of related social, psychological, and economic factors, as well as care environment, rather than orphan status alone. Understanding these complex relationships may aid policy makers in supporting evidence-based, cost-effective programming for this vulnerable population. This longitudinal study uses a causal effect model to examine, through decomposition, the relationship between care environment and HIV risk factors in orphaned and separated adolescents and youths (OSAY) in Uasin Gishu County, Kenya; considering resilience, social, peer, or family support, volunteering, or having one's material needs met as potential mediators. We analysed survey responses from 1105 OSAY age 10-26 living in Charitable Children's Institutions (CCI) (orphanages) and family-based care settings (FBS). Follow-up time was 7-36 months. Care in CCIs (vs. FBS) was associated with a decreased likelihood of engaging in forced, exchange, and consensual sex. Excess relative risks (ERR) attributable to the indirect pathway, mediation, or interaction were not significant in any model. Care environment was not statistically associated with differences in substance use. Our findings support the direct, unmediated, association between institutional care and HIV risk factors.

Assessing behavioral economic biases among young adults who have increased likelihood of acquiring HIV: a mixed methods study in Baltimore, Maryland

BACKGROUND

Behavioral economic (BE) biases have been studied in the context of numerous health conditions, yet are understudied in the field of HIV prevention. This aim of this study was to quantify the prevalence of four common BE biases-present bias, information salience, overoptimism, and loss aversion-relating to condom use and HIV testing in economically-vulnerable young adults who had increased likelihood of acquiring HIV. We also qualitatively examined participants' perceptions of these biases.

METHODS

43 participants were enrolled in the study. Data were collected via interviews using a quantitative survey instrument embedded with qualitative questions to characterize responses. Interviews were transcribed and analyzed using descriptive statistics and deductive-inductive content analyses.

RESULTS

56% of participants were present-biased, disproportionately discounting future rewards for smaller immediate rewards. 51% stated they were more likely to spend than save given financial need. Present-bias relating to condom use was lower with 28% reporting they would engage in condomless sex rather than wait one day to access condoms. Most participants (72%) were willing to wait for condom-supported sex given the risk. Only 35% knew someone living with HIV, but 67% knew someone who had taken an HIV test, and 74% said they often think about preventing HIV (e.g., high salience). Yet, 47% reported optimistically planning for condom use, HIV discussions with partners, or testing but failing to stick to their decision. Most (98%) were also averse (b = 9.4, SD  ±.9) to losing their HIV-negative status. Qualitative reasons for sub-optimal condom or testing choices were having already waited to find a sex partner, feeling awkward, having fear, or not remembering one's plan in the moment. Optimal decisions were attributed qualitatively to self-protective thoughts, establishing routine care, standing on one's own, and thinking of someone adversely impacted by HIV. 44% of participants preferred delayed monetary awards (e.g., future-biased), attributed qualitatively to fears of spending immediate money unwisely or needing time to plan.

CONCLUSION

Mixed methods BE assessments may be a valuable tool in understanding factors contributing to optimal and sub-optimal HIV prevention decisions. Future HIV prevention interventions may benefit from integrating savings products, loss framing, commitment contracts, cues, or incentives.

Condom Use Behaviors, Risk Perception, and Partner Communication Following Oral HIV Self-testing Among Adolescents and Young Adults in Kenya: A Cohort Study

HIV self-testing (HIVST) can improve testing completion among adolescents and young adults (AYA), although its influence on sexual behaviors is unclear. We evaluated whether HIVST was associated with changes in talking with sexual partners about HIVST, condom use, and HIV risk perception among AYA ages 15-24 years in a study of HIVST distribution through homes, pharmacies, and nightclubs in Nairobi, Kenya. All participants had negative HIVST results. Regression models were used to evaluate changes between pre-HIVST and 4 months post-HIVST. Overall, there was a significant increase in talking with sexual partners about HIVST. There was a significant reduction in number of condomless sex acts among AYA recruited through pharmacies and homes. Unexpectedly, among females, there was a significant decrease in consistent condom use with casual partners. HIVST services for AYA may benefit from including strategies to support condom use and partner communication about self-testing adapted to specific populations and partnerships.

Effectiveness of a mobile-based HIV prevention intervention for the rural and low-income population involving incentive policy to doctors in Liangshan, China: a randomized controlled trial protocol

Background

The HIV/AIDS epidemic is a concerning problem in many parts of the world, especially in rural and poor areas. Due to health service inequality and public stigma towards the disease, it is difficult to conduct face-to-face interventions. The widespread use of mobile phones and social media applications thus provide a feasible and acceptable approach for HIV prevention and education delivery in this population. The study aims to develop a generalizable, effective, acceptable, and convenient mobile-based information intervention model to improve HIV-related knowledge, attitudes, practices, and health outcomes in poverty-stricken areas in China and measure the impact of incentive policies on the work of village doctors in Liangshan, China.

Methods

A randomized controlled trial design is used to evaluate the effectiveness of an 18-month mobile-based HIV prevention intervention, collaborating with local village doctors and consisting of group-based knowledge dissemination and individualized communication on WeChat and the Chinese Version of TikTok in Liangshan, China. Each village is defined as a cluster managed by a village doctor with 20 adults possessing mobile phones randomly selected from different families as participants, totaling 200 villages. Clusters are randomized (1:1:1) to the Control without mobile-based knowledge dissemination, Intervention A with standardized compensation to the village doctors, or Intervention B with performance-based compensation to the village doctors. The intervention groups will receive biweekly messages containing HIV-related educational modules. Data will be collected at baseline and 6-, 12-, and 18-month periods for outcome measurements. The primary outcomes of the study are HIV-related knowledge improvement and the effectiveness of village doctor targeted incentive policies. The secondary outcomes include secondary knowledge transmission, behavioral changes, health outcomes, social factors, and study design’s acceptability and reproducibility. These outcomes will be explored via various qualitative and quantitative means.

Discussion

The findings will provide insights into the effectiveness, generalizability, and challenges of the mobile-based HIV prevention intervention for the population living in rural communities with low education levels and will guide the development of similar models in other low-income and culturally isolated regions.

Trial registration

ClinicalTrial.gov: NCT05015062; Registered on June 6, 2022.

'I did not get this disease on the street; it was brought home as a gift': Gender, violence and HIV vulnerability among Cuban women

While gay, bisexual and other men who have sex with men are most affected by HIV in Cuba, infections among women have increased over time, but there has been little research to contextualise their vulnerability to HIV. The purpose of this study was to explore the role of gender and violence in shaping vulnerability to HIV among Cuban women. Qualitative in-depth interviews were conducted with women living with HIV at an outpatient HIV clinic in Havana. Narrative and thematic technique were used to systematically analyse the data. Participants described negotiating sexual relationships in a context where traditional gender norms merge with the paradox of increasing professional opportunities for women alongside growing economic precarity. Interconnected economic and emotional dependence along with violence influenced the acceptance of certain behaviours that heightened vulnerability to HIV, including inconsistent condom use and infidelity. Gender transformative approaches that recognise the complex interplay between gender norms, economic precarity and violence are needed to address women's vulnerability to HIV in the Cuban context. Such efforts can reinforce existing strategies to promote behaviourally focused prevention while creating an enabling environment for the integration and expansion of biomedical innovation in HIV prevention.

Prevalence and Predictive Factors of Hypertension Among People Living With HIV in Kebbi State, Nigeria: A Cross-sectional Study

ABSTRACT

The estimated number of people living with HIV (PLWH) globally in 2018 was 38 million, with sub-Saharan Africa accounting for 70%. Antiretroviral therapy has reduced morbidity among PLWH and has resulted in HIV now being considered a manageable chronic disease rather than a fatal one. The increase in the survival rate of PLWH has led to the emergence of chronic diseases, especially hypertension. The study aimed to assess the prevalence and predictive factors associated with hypertension among PLWH in Kebbi State, Nigeria. A descriptive cross-sectional study was adopted. The blood pressure of 301 PLWH was measured with an automated sphygmomanometer device. The median age of the respondents was 37 years. Females accounted for 61% of the respondents, and the majority were married (55.1%). The prevalence of hypertension was 17%. Older age, lack of exercise, and increasing weight were identified as the predictive factors of hypertension.

Understanding patterns of family support and its role on viral load suppression among youth living with HIV aged 15 to 24 years in southwestern Uganda

BACKGROUND

Active family support helps as a buffer against adverse life events associated with antiretroviral therapy (ART) uptake and adherence. There is limited data available to explain how family support shapes and affects individual healthcare choices, decisions, experiences, and health outcomes among youth living with HIV (YLWH). We aimed to describe family support patterns and its role in viral load suppression among YLWH at a rural hospital in southwestern Uganda.

METHODS

We performed a mixed-method cross-sectional study between March and September 2020, enrolling 88 eligible YLWH that received ART for at least 6 months. Our primary outcome of interest was viral load suppression, defined as a viral load detected of ≤500 copies/mL. Data analysis was performed using Statistical Package for Social Sciences version 20. Fifteen individuals were also purposively selected from the original sample and participated in an in-depth interview that was digitally recorded. Generated transcripts were coded and categories generated manually using the inductive content analytic approach. All participants provided written consent or guardian/parent assent (those <18 years) to participate in the study.

RESULTS

Forty-nine percent of YLWH were females, the median age was 21 (IQR: 16-22) years. About half of the participants (53%) stayed with a family member. A third (34%) of participants had not disclosed their status to any person they stayed with at home. Only 23% reported getting moderate to high family social support (Median score 2.3; IQR: 1.6-3.2). Seventy-eight percent of YLWH recorded viral load suppression. Viral load suppression was associated with one living with a parent, sibling, or spouse (AOR: 6.45; 95% CI: 1.16-16.13; P = .033), having a primary caretaker with a regular income (AOR: 1.57; 95% CI: 1.09-4.17; P = .014), and living or communicating with family at least twice a week (AOR: 4.2; 95% CI: 1.65-7.14; P = .003). Other significant factors included youth receiving moderate to high family support (AOR: 12.11; 95% CI: 2.06-17.09; P = .006) and those that perceived family support in the last 2 years as helpful (AOR: 1.98; 95% CI: 1.34-3.44; P = .001). HIV stigma (AOR: 0.10; 95% CI: 0.02-0.23; P = .007) and depression (AOR: 0.31; 95% CI: 0.06-0.52; P = .041) decreased viral load suppression. Qualitative data showed that dysfunctional family relationships, economic insecurity, physical separation, HIV- and disclosure-related stigma, past and ongoing family experiences with HIV/ART affected active family support. These factors fueled feelings of abandonment, helplessness, discrimination, and economic or emotional strife among YLWH.

CONCLUSION

Our data showed that living with a family member, having a primary caretaker with a regular income, living or communicating with family members regularly, and reporting good family support were associated with viral load suppression among YLWH in rural southwestern Uganda. Experiencing depression due to HIV and or disclosure-related stigma was associated with increased viral load. All YLWH desire ongoing emotional, physical, and financial support from immediate family to thrive and take medications daily and timely. Future interventions should explore contextual community approaches that encourage acceptance, disclosure, and resource mobilization for YLWH who rely on family support to use ART appropriately.

The built environment and perceived HIV risk among young women living in the peri-urban slum of Kibra, Nairobi, Kenya

This study reports on the lived experiences of young women living in a peri-urban slum in Kenya and its impact on perceived HIV risk and prevention needs. Guided by the theory of gender and power and postcolonial theory, 73 women 15-24 years of age participated in individual and focus group interviews. Results revealed that the built environment inside and outside the home such as inadequate physical space and lack of security impacted perceived HIV risk. To have meaningful and sustainable change, HIV prevention efforts must address social structures that impact daily lived experiences of young women.

Food Choice With Economic Scarcity and Time Abundance: A Qualitative Study

Consumers with low income in the United States have higher vulnerability to unhealthy diets compared with the general population. Although some literature speculates that scarcity is an explanation for this disparity, empirical evidence is lacking. We conducted a qualitative study of food choice to explore whether scarcity-related phenomena, such as tunneling and bandwidth tax, may contribute to unhealthy dietary choices. We used participant-driven photo elicitation (n = 18) to investigate the food choice behaviors of individuals living in the greater Boston area who met the federal guidelines for poverty. Participants took photos at the point of food acquisition for 1 month, after which we interviewed them using a semistructured interview guide with the photos as prompts. Thematic coding was used for analysis. Respondents had relative time abundance. Two major themes emerged: participants used a set of strategies to stretch their budgets, and they highly prioritized cost and preference when making food choices. The extreme focus on obtaining food at low cost, which required time and effort, was suggestive of tunneling. We found no evidence of the bandwidth tax. Our findings raise the hypothesis of scarcity as a continuum: when individuals experience multiple resource constraints, they experience scarcity; whereas people with very limited finances and relative time abundance may instead be in a prescarcity condition, with a hyperfocus on a scarce resource that could lead to tunneling as constraints increase. Additional studies are needed to understand whether and how tunneling and bandwidth tax emerge, independently or together, as people face different levels and types of scarcity.

Framing Contraceptive Use Motivations Among Adolescents and Young Adults Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda

Introduction: The use of contraceptives among adolescents and young adults is one of the most cost-effective strategies to address many sexual and reproductive health (SRH) challenges, including unintended pregnancies, early marriages, and sexually transmitted infections. Despite a high burden of SRH challenges, uptake and unmet needs of modern contraceptives remain low in Uganda, especially among adolescents and young adults in informal settlement settings. This study aimed to explore the motivations of adolescents and young people to use modern contraceptives (or not). Methods: We analysed qualitative data from eight focus group discussions with 88 adolescents and young people aged 18-24 years residing in informal settlements of urban communities in Kira Municipality of Wakiso district, Uganda. Results: Motivations for use (or not) of modern contraceptives were framed by two interrelated constructs, sources of information on contraception and the unacceptable use of contraceptives among adolescents widespread in the community. These two, in turn, formed the scope of knowledge upon which adolescents and young people based their decision on whether or not to access and use modern contraceptives. Conclusion: To be more effective, sexual and reproductive health programs and interventions that aim to motivate the use of modern contraceptives among adolescents and young people in informal settings should be more comprehensive and focused on alleviating individual, health systems, social, religious factors that reinforce negative health-seeking behaviours towards contraceptive use. In addition, there is a need to support adolescents and young people with socio-economic empowering strategies that equip them with sufficient resources to choose contraceptives of their choice.

Qualitative Analysis of Community Support to Methadone Access in Kenya

BACKGROUND

Methadone, as part of Medically Assisted Therapy (MAT) for treatment of opioid dependence and supporting HIV prevention and treatment, has been recently introduced in Kenya. Few low income settings have implemented methadone, so there is little evidence to guide ongoing scale-up across the region. We specifically consider the role of community level access barriers and support.

OBJECTIVES

To inform ongoing MAT implementation we implemented a qualitative study to understand access barriers and enablers at a community level.

METHODS

We conducted 30 semi-structured interviews with people who use drugs accessing MAT, supplemented by interviews with 2 stakeholders, linked to participant observation in a community drop in center within one urban area in Kenya. We used thematic analysis.

RESULTS

We developed five themes to express experiences of factors enabling and disabling MAT access and how community support can address these: 1) time, travel and economic hardship; 2) managing methadone and contingencies of life, 3) peer support among MAT clients as treatment ambassadors, 4) family relations, and 5)outreach project contributions. Crosscutting themes address managing socioeconomic constraints and gender inequities.

CONCLUSIONS

People who use drugs experience and manage socio-economic constraints and gender inequities in accessing MAT with the support of local communities. We discuss how these access barriers could be addressed through strengthening the participation of networks of people who use drugs in drug treatment and supporting community projects working with people who use drugs. We also explore potential for how socio-economic constraints could be managed within an integrated health and social care response.

Towards a better understanding of factors affecting smoking uptake among Saudi male adolescents: A qualitative study

INTRODUCTION

An increased smoking uptake by Saudi male adolescents and a lack of data about its determinants emphasize the need for a better understanding of factors leading to the onset of smoking and identifying ways to prevent it. The aim of this qualitative study is to explore adolescents' views on smoking and their opinions about a smoking prevention program.

METHODS

A total of 103 school-going adolescents, aged 12-16 years, were purposely selected from grades seven, eight and nine from nine schools in Taif in Saudi Arabia. They were interviewed in 11 focus group discussions; five groups were held for smokers and six for non-smokers. An interview scheme was developed based on the I-Change Model, a model used for understanding smoking onset and prevention. We used QDA Lite version 2:0 software for data analysis.

RESULTS

Most of the participants agreed on the importance of social influences as determining factors to start smoking. The presence of smoking friend(s) and family member(s), especially the father, were mentioned. Factors such as having extra pocket money, absence of alternatives, showing off, to be seen as western, to be seen as an adult and the good taste of cigarettes were also mentioned as beliefs associated with smoking. Adolescents indicated to have low confidence not to smoke under peer pressure, suggesting self-efficacy problems. Intentions to smoke were also often mentioned. Almost all participants agreed that an interactive approach is optimal for an effective smoking prevention program.

CONCLUSIONS

Determinants of smoking seem to be very similar to those outlined by previous studies. A smoking prevention program for Saudi adolescents should address how to cope with social pressure to smoke, the advantages connected with smoking, and how to increase self-efficacy. Information should be presented in an interactive rather than static way.

Poverty, gender and reproductive justice. A qualitative study among adolescent girls in Western Uganda

Low socio-economic status has been consistently identified as a primary risk factor for sexual and reproductive health violations affecting young women. This study shows how poverty interacts with gender power relations to impact upon adolescent girls' sexual and reproductive lives in Western Uganda. Qualitative research with 147 participants was undertaken. This comprised 59 in-depth interviews and 11 focus group discussions with groups of 12-14 year-old young women, teachers and parents. Data were analysed manually using open and axial coding, and conclusions were generated inductively. Findings reveal that young women are restricted in exercising their sexual and reproductive rights not only by poverty and unequal gender relations, but also by corruption and poor service provision. In contrast to interventions using liberal rights-based approaches, we advocate the use of a 'marketplace of options' since access to sexual and reproductive health services is very limited for poor girls and not evenly distributed. Moreover, while poverty and unequal gender relations render girls vulnerable to sexual coercion and violence, the criminal justice system is often weak, leaving victims powerless. Investment in appropriate resources and inclusive and affordable access to justice is essential to advance young women's sexual and reproductive health.

Slums, Space, and State of Health-A Link between Settlement Morphology and Health Data

Approximately 1 billion slum dwellers worldwide are exposed to increased health risks due to their spatial environment. Recent studies have therefore called for the spatial environment to be introduced as a separate dimension in medical studies. Hence, this study investigates how and on which spatial scale relationships between the settlement morphology and the health status of the inhabitants can be identified. To this end, we summarize the current literature on the identification of slums from a geographical perspective and review the current literature on slums and health of the last five years (376 studies) focusing on the considered scales in the studies. We show that the majority of medical studies are restricted to certain geographical regions. It is desirable that the number of studies be adapted to the number of the respective population. On the basis of these studies, we develop a framework to investigate the relationship between space and health. Finally, we apply our methodology to investigate the relationship between the prevalence of slums and different health metrics using data of the global burden of diseases for different prefectures in Brazil on a subnational level.

The changing modes of human immunodeficiency virus transmission and spatial variations among women in a minority prefecture in southwest China: An exploratory study

Liangshan Yi Autonomous Prefecture in Southwest China has a high human immunodeficiency virus (HIV) prevalence rate. This study examined the changing modes of HIV transmission among women with new HIV infections and explored the spatial heterogeneities in the factors associated with heterosexual transmission in this minority region.The data consisting of women with new HIV infections from 2011 to 2014 were collected from multiple sources. New infections were identified by BED capture enzyme immunoassay. The Bayesian hierarchical model was used to estimate the proportion of women with new HIV infections via heterosexual transmission across all townships in the Prefecture. A geographically weighted regression (GWR) model was utilized to investigate spatial variations in the sociodemographic characteristics associated with the changing modes of HIV transmission.An analytical sample of 927 women with new HIV infections was constructed and utilized to investigate the changing mode of HIV transmission. The rate of heterosexual transmission among women with new HIV infections in 2011 was below 20%. However, by 2014 this rate dramatically increased to nearly 80%. Among sociodemographic characteristics, GWR results revealed significant ethnic differences in heterosexual HIV transmission between Yi women and women in other ethnic groups, with Yi women demonstrating a lower risk of infection through heterosexual transmission. However, such ethnic differences were observed only in 30% of the townships in the Prefecture. Moreover, having a primary education decreased the odds of heterosexual transmission, which was observed in about 56% of the townships. Also, being involved in occupations other than agriculture or animal husbandry and being single or married decreased the odds of HIV infection through heterosexual contact among women, which did not significantly vary across the Prefecture.Heterosexual transmission was the predominant mode of HIV transmission among women in the Prefecture, and this transformation was clearly marked by a fast-growing trend and a spatial diffusion pattern. Spatial variations also existed in sociodemographic factors that were associated with the changing modes of HIV transmission.

Microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices in economically-vulnerable African-American young adults (EMERGE): protocol for a feasibility randomized clinical trial

Background

Economic vulnerability, such as homelessness and unemployment, contributes to the HIV risk among racial minorities in the U.S., who are disproportionately infected. Yet, few economic-strengthening interventions have been adapted for HIV prevention in economically-vulnerable African-American young adults. Engaging Microenterprise for Resource Generation and Health Empowerment (EMERGE) is a feasibility randomized clinical trial of an HIV prevention microenterprise intervention with integrated text messages (“nudges”) that are informed by behavioral economic principles. The trial aims to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors.

Methods/design

In total, 40 young adults who are African-American, aged 18–24, live in Baltimore City, have experienced at least one episode of homelessness in the last 12 months, are unemployed or underemployed (fewer than 10 h per week), are not enrolled in school, own a cell phone with text messaging, and report at least one episode of unprotected or unsafe sex in the prior 12 months will be recruited from two community-based organizations providing residential supportive services to urban youth. Participants will undergo a 3-week run-in period and thereafter be randomly assigned to one of two groups with active interventions for 20 weeks. The first group (“comparison”) will receive text messages with information on job openings. The second group (“experimental”) will receive text messages with information on job openings plus information on HIV prevention and business educational sessions, a mentored apprenticeship, and a start-up grant, and business and HIV prevention text messages based on principles from behavioral economics. The two primary outcomes relate to the feasibility of conducting a larger trial. Secondary outcomes relate to employment, sexual risk behaviors, and HIV preventive practices. All participants will be assessed using an in-person questionnaire at pre-intervention (prior to randomization) and at 3 weeks post-intervention. To obtain repeated, longitudinal measures, participants will be assessed weekly using text message surveys from pre-intervention up to 3 weeks post-intervention.

Discussion

This study will be one of the first U.S.-based feasibility randomized clinical trials of an HIV prevention microenterprise intervention for economically-vulnerable African-American young adults. The findings will inform whether and how to conduct a larger efficacy trial for HIV risk reduction in this population.

Trial registration

ClinicalTrials.gov, NCT03766165. Registered on 4 December 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3529-7) contains supplementary material, which is available to authorized users.

Cash Transfers, Young Women's Economic Well-Being, and HIV Risk: Evidence from HPTN 068

Despite the large interest in economic interventions to reduce HIV risk, little research has been done to show whether there are economic gains of these interventions for younger women and what intermediary role economic resources play in changing participants' sexual behavior. This paper contributes to this gap by examining the impacts of a conditional cash transfer (CCT) for young women in South Africa on young women's economic resources and the extent to which they play a role in young women's health and behavior. We used data from HIV Prevention Trials Network 068 study, which provided transfers to young women (in addition to their parents) conditional on the young woman attending at least 80% of school days in the previous month. We found that the CCT increased young women's economic wellbeing in terms of having savings, spending money, being unindebted, and food secure. We also investigated heterogeneous effects of the program by household economic status at baseline because the program was not specifically poverty targeted and found that the results were driven by young women from the poorest families. From these results, we examined heterogeneity by baseline poverty for other outcomes related to HIV risk including sexual behavior and psychosocial well-being. We found psychosocial well-being benefits in young women from the poorest families and that economic wellbeing gains explained much these impacts.

Screening for HIV and linkage to care in adolescents: insights from a systematic review of recent interventions in high- versus low- and middle-income settings

Introduction

Compared to adults, adolescents and young adults have a higher incidence of HIV infection, yet lower rates of HIV testing. Few evidence-based interventions effectively diagnose new HIV infections among adolescents while successfully providing linkage to care.

Methods

We conducted a systematic review of recent interventions to increase HIV testing among adolescents and young adults using data retrieved from PubMed and Google Scholar, and using abstracts presented at the International AIDS Society conferences and Conference on Retroviruses and Opportunistic Infections published between January 1, 2015, and April 28, 2018.

Results

We identified 36 interventions (N=14 in high- income countries and N=22 in low- and middle-income countries) that were published in the literature (N=28) or presented at conferences (N=8). Interventions were categorized as behavioral/educational, alternate venue/self-testing, youth-friendly services, technology/mobile health, incentives, or peer-based/community-based interventions. The studies consisted of randomized controlled trials (RCTs), prospective and retrospective observational studies, and quasi-experimental/pre-post evaluations with variable sample sizes. Study designs, populations, and settings varied. All categories showed some degree of acceptability, yet not all interventions were effective in increasing HIV testing. Effectiveness was seen in more than one RCT involving technology/mobile health (2/3 RCTs) and alternative venue/self-testing (3/3 RCTs) interventions, and only in one RCT each for behavioral interventions, community interventions, and incentives. There were no effective RCTs for adolescent-friendly services. Data were limited on the number of new infections identified and on the methods to increase linkage to care after diagnosis.

Conclusion

Future studies should include combinations of proven methods for engaging adolescents in HIV testing, while ensuring effective methods of linkage to care.

"How am I going to live?": exploring barriers to ART adherence among adolescents and young adults living with HIV in Uganda

Background

Studies from sub-Saharan Africa (SSA) document how barriers to ART adherence present additional complications among adolescents and young adults living with HIV. We qualitatively explored barriers to ART adherence in Uganda among individuals age 14–24 to understand the unique challenges faced by this age group.

Methods

We conducted focus group (FG) discussions with Community Advisory Board members (n = 1), health care providers (n = 2), and male and female groups of adolescents age 14–17 (n = 2) and youth age 18–24 (n = 2) in Kampala, Uganda. FGs were transcribed verbatim and translated from Luganda into English. Two investigators independently reviewed all transcripts, developed a detailed codebook, achieved a pooled Cohen’s Kappa of 0.79 and 0.80, and used a directed content analysis to identify key themes.

Results

Four barriers to ART adherence emerged: 1) poverty limited adolescents’ ability to buy food and undercut efforts to become economically independent in their transition from adolescence to adulthood; 2) school attendance limited their privacy, further disrupting ART adherence; 3) family support was unreliable, and youth often struggled with a constant change in guardianship because they had lost their biological parents to HIV. In contrast peer influence, especially among HIV-positive youth, was strong and created an important network to support ART adherence; 4) the burden of taking multiple medications daily frustrated youth, often leading to so-called ‘drug holidays.’ Adolescent and youth-specific issues around disclosure emerged across three of the four barriers.

Conclusions

To be effective, programs and policies to improve ART adherence among youth in Uganda must address the special challenges that adolescents and young adults confront in achieving optimal adherence. For example, training on budgeting and savings practices could help promote their transition to financial independence. School staff could develop strategies to help students take their medications consistently and confidentially. While challenging to extend the range of services provided by HIV clinics, successful efforts will require engaging the family, peers, and larger community of health and educational providers to support adolescents and young adults living with HIV to live longer and healthier lives.

Trial registration

ClinicalTrials.gov Identifier: NCT02514356. Registered August 3, 2015.

Determinants of HIV testing and receipt of test results among adolescent girls in Nigeria: the role of assets and decision-making

Purpose Many adolescent girls in Nigeria do not test for HIV despite being at high risk. While the influence of psychosocial factors on HIV testing has been examined, there is less evidence regarding the impact of assets and control of assets on HIV testing. This study investigated the protective effects of specific adolescent girls' assets on decision-making regarding HIV testing. Methods Cross-sectional data from the 2013 Nigeria Demographic and Health Survey was analyzed. The main outcome variables were self-reports of having been tested for HIV and knowledge of a place that offers HIV testing. Binary logistic regression was used with employment, education, wealth index, home ownership, land ownership and decision making as potential predictors. Demographic characteristics were controlled in the analysis. Results Age [odds ratio (OR = 1.49)], employment (OR = 3.38), education (OR = 3.16), wealth index (OR = 1.33) and decision making (OR = 3.16) were positively associated with HIV testing. Age (OR = 1.20), employment (OR = 1.33), education (OR = 1.38), wealth (OR = 1.64), land ownership (OR = 1.42), and decision making (OR = 1.26) were positively associated with knowledge of an HIV testing location. Conclusion Our findings suggest that assets play an important role with HIV testing decisions for adolescent girls. Further research to elucidate the specific asset-based needs of adolescent girls will be needed to enhance decisions surrounding uptake of HIV testing and receipt of test results in Nigeria.

Factors associated with HIV infection among Yi minority residents in Liangshan Prefecture, Sichuan Province: A path analysis

We aimed to evaluate HIV prevalence among residents of Liangshan Prefecture through HIV sentinel surveillance (HSS) data over the period from 2010 to 2016, and investigate risk factors for HIV infection in this population and interactions among them.Two sites (Dechang and Ningnan counties) with majority-Han populations, and 1 site (Butuo) with a majority-Yi population were selected. We used questionnaires to investigate residents' demographic and behavioral characteristics from 2010 to 2016, and performed HIV testing. Multivariate logistic regression and path analysis were undertaken to investigate the interactions and mediating effects among significant risk factors for HIV infection.A total of 5403 community residents in the Yi area and 10,897 community residents in the Han areas were enrolled. HIV prevalence in the Yi area was consistently high, ranging from 9.46% (63/666, 2011) to 2.88% (23/798, 2012) over the period from 2010 to 2016. HIV prevalence in the Han areas ranged from 0.15% (2/1333, 2010) to 0.44% (7/1604, 2011) over the same period. Multivariate logistic regression showed that unprotected casual sexual behavior, male gender, illiteracy, drug use, and injection drug use were positively associated with HIV infection risk in the Yi area. Path analysis of the risk factors revealed that casual sexual behavior (0.051) and injection drug use (0.161) were directly associated with HIV infection. However, marital status (0.004), ethnicity (0.017), education level (-0.004), HIV/AIDS-related prevention knowledge (-0.012), and drug use (0.11) had an indirect influence on HIV infection through casual sexual behavior and injection drug use.The prevalence of HIV is high among residents of majority-Yi areas, and injection drug use and casual sexual behavior are risk factors for infection.

Pre-exposure prophylaxis for HIV prevention in women: current perspectives

There are ~900,000 new HIV infections among women every year, representing nearly half of all new HIV infections globally. In the US, nearly one-fifth of all new HIV infections occur among women, and women from racial and ethnic minority communities experience disproportionately high rates of new HIV infections. Thus, there is a need to develop and implement effective HIV prevention strategies for women in the US and internationally, with a specific need to advance strategies in minority communities. Previous studies have demonstrated that oral HIV pre-exposure prophylaxis (PrEP), the use of antiretroviral medications by HIV-uninfected persons to prevent HIV acquisition, can reduce HIV incidence among women who are adherent to PrEP. However, to date, awareness and uptake of PrEP among women have been very limited, suggesting a need for innovative strategies to increase the knowledge of and access to PrEP among women in diverse settings. This narrative review summarizes the efficacy and safety data of PrEP in women, discusses considerations related to medication adherence for women who use PrEP, and highlights behavioral, social, and structural barriers to maximize the effectiveness of PrEP in women. It also reviews novel modalities for PrEP in women which are being developed and tested, including topical formulations and long-acting injectable agents that may offer advantages as compared to oral PrEP and proposes a community-oriented, social networking framework to increase awareness of PrEP among women. If women are provided with access to PrEP and support to overcome social and structural barriers to adhere to PrEP, this prevention strategy holds great promise to impact the HIV epidemic among women in the US and globally.