Human immunodeficiency virus prevention outcomes associated with arts-based sexual health workshop participation among Northern and Indigenous adolescents in the Northwest Territories, Canada

BACKGROUND

Contextually tailored, arts-based HIV prevention strategies hold potential to advance adolescent sexual health and wellbeing. We examined HIV prevention outcomes associated with arts-based sexual health workshop participation with Northern and Indigenous adolescents in the Northwest Territories (NWT), Canada.

METHODS

An Indigenous community-based youth agency delivered arts-based workshops in school settings to adolescents aged 13-18 in 24 NWT communities. Pre and post-test surveys included socio-demographic characteristics, sexually infections (STI) knowledge, HIV/STI risk perception, sexual relationship equity, condom use self-efficacy, and safer sex efficacy (SSE). Latent change score models were conducted to assess pre-post differences and factors associated with these differences.

RESULTS

Among participants (n = 344; mean age 14.3 years, SD: 1.3; Indigenous: 79%) most (66%) had previously attended this workshop. Latent change score models revealed a significant and large effect size for increased STI knowledge (β = 2.10, SE = 0.48, p < .001) and significant and small effect sizes for increased HIV/STI risk perception (β = 0.24, SE = 0.06, p < .001) and SSE (β = 0.16, SE = 0.07, p = .02). The largest increases across several outcomes occurred with first time workshop participants; yet previous workshop participants continued to report increases in HIV/STI risk perception and SSE.

CONCLUSION

Arts-based HIV prevention approaches show promise in advancing STI knowledge, risk perception, and SSE with Northern and Indigenous youth.

Esengo ya Bosembo ("Joy of Equity"): Development of an Advocacy Video to Reduce Stigma and to Promote Sexual and Reproductive Health and Rights of Women Sex Professionals in Pointe-Noire, Congo Republic

Sex workers experience elevated risks of sexual and gender-based violence (SGBV) from intimate partners, clients, and community members that harms health and human rights. While SGBV contributes to poorer sexual and reproductive health (SRH) outcomes among sex workers, including elevated human immunodeficiency virus (HIV) vulnerabilities, stigma targeting sex workers reduces SRH service access and uptake. The Congo Republic is an exemplar context to address stigma toward sex workers. Sex workers' HIV prevalence (8.1%) in Congo Republic is double the national prevalence, yet research indicates that nearly one-fifth (17.2%) of sex workers in Congo Republic avoid health care because of stigma and discrimination. This Resources, Frameworks, & Perspectives article describes the process of developing Esengo ya Bosembo ("Joy of Equity"), a culturally tailored advocacy video that aims to reduce health care and community stigma toward women sex professionals (e.g., sex workers) in Pointe-Noire, Congo Republic. This knowledge translation product stems from a participatory mapping intervention with sex professionals in Pointe-Noire that revealed the need for sensitization tools and activities to reduce sex work stigma among health care providers and community members. The video incorporates three overarching key messages: (1) sex professionals are human beings with equal rights to dignity, protection, and health services; (2) elevated risks of SGBV and stigma targeting sex workers reduce SRH service access and uptake; and (3) participatory mapping is a potential way to empower sex professionals to share their experiences and recommendations for change. This article details how health promotion practitioners and sex professionals may use the video to advocate for change.

Sexual and reproductive health among forcibly displaced persons in urban environments in low and middle-income countries: scoping review findings

BACKGROUND

Most forcibly displaced persons are hosted in low- and middle-income countries (LMIC). There is a growing urbanization of forcibly displaced persons, whereby most refugees and nearly half of internally displaced persons live in urban areas. This scoping review assesses the sexual and reproductive health (SRH) needs, outcomes, and priorities among forcibly displaced persons living in urban LMIC.

METHODS

Following The Joanna Briggs Institute scoping review methodology we searched eight databases for literature published between 1998 and 2023 on SRH needs among urban refugees in LMIC. SHR was operationalized as any dimension of sexual health (comprehensive sexuality education [CSE]; sexual and gender based violence [GBV]; HIV and STI prevention and control; sexual function and psychosexual counseling) and/or reproductive health (antental, intrapartum, and postnatal care; contraception; fertility care; safe abortion care). Searches included peer-reviewed and grey literature studies across quantitative, qualitative, or mixed-methods designs.

FINDINGS

The review included 92 studies spanning 100 countries: 55 peer-reviewed publications and 37 grey literature reports. Most peer-reviewed articles (n = 38) discussed sexual health domains including: GBV (n = 23); HIV/STI (n = 19); and CSE (n = 12). Over one-third (n = 20) discussed reproductive health, including: antenatal, intrapartum and postnatal care (n = 13); contraception (n = 13); fertility (n = 1); and safe abortion (n = 1). Eight included both reproductive and sexual health. Most grey literature (n = 29) examined GBV vulnerabilities. Themes across studies revealed social-ecological barriers to realizing optimal SRH and accessing SRH services, including factors spanning structural (e.g., livelihood loss), health institution (e.g., lack of health insurance), community (e.g., reduced social support), interpersonal (e.g., gender inequitable relationships), and intrapersonal (e.g., low literacy) levels.

CONCLUSIONS

This review identified displacement processes, resource insecurities, and multiple forms of stigma as factors contributing to poor SRH outcomes, as well as producing SRH access barriers for forcibly displaced individuals in urban LMIC. Findings have implications for mobilizing innovative approaches such as self-care strategies for SRH (e.g., HIV self-testing) to address these gaps. Regions such as Africa, Latin America, and the Caribbean are underrepresented in research in this review. Our findings can guide SRH providers, policymakers, and researchers to develop programming to address the diverse SRH needs of urban forcibly displaced persons in LMIC. Most forcibly displaced individuals live in low- and middle-income countries (LMICs), with a significant number residing in urban areas. This scoping review examines the sexual and reproductive health (SRH) outcomes of forcibly displaced individuals in urban LMICs. We searched eight databases for relevant literature published between 1998 and 2023. Inclusion criteria encompassed peer-reviewed articles and grey literature. SRH was defined to include various dimensions of sexual health (comprehensive sexuality education; sexual and gender-based violence; HIV/ STI prevention; sexual function, and psychosexual counseling) and reproductive health (antenatal, intrapartum, and postnatal care; contraception; fertility care; and safe abortion care). We included 90 documents (53 peer-reviewed articles, 37 grey literature reports) spanning 100 countries. Most peer-reviewed articles addressed sexual health and approximately one-third centered reproductive health. The grey literature primarily explored sexual and gender-based violence vulnerabilities. Identified SRH barriers encompassed challenges across structural (livelihood loss), health institution (lack of insurance), community (reduced social support), interpersonal (gender inequities), and individual (low literacy) levels. Findings underscore gaps in addressing SRH needs among urban refugees in LMICs specifically regarding sexual function, fertility care, and safe abortion, as well as regional knowledge gaps regarding urban refugees in Africa, Latin America, and the Caribbean. Self-care strategies for SRH (e.g., HIV self-testing, long-acting self-injectable contraception, abortion self-management) hold significant promise to address SRH barriers experienced by urban refugees and warrant further exploration with this population. Urgent research efforts are necessary to bridge these knowledge gaps and develop tailored interventions aimed at supporting urban refugees in LMICs.

Experiences and resultant care gaps among women with HIV in Canada: concept mapping the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) findings

OBJECTIVES

The community-based, longitudinal, Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) explored the experiences of women with HIV in Canada over the past decade. CHIWOS' high-impact publications document significant gaps in the provision of healthcare to women with HIV. We used concept mapping to analyse and present a summary of CHIWOS findings on women's experiences navigating these gaps.

DESIGN

Concept mapping procedures were performed in two steps between June 2019 and March 2021. First, two reviewers (AY and PM) independently reviewed CHIWOS manuscripts and conference abstracts written before 1 August 2019 to identify main themes and generate individual concept maps. Next, the preliminary results were presented to national experts, including women with HIV, to consolidate findings into visuals summarising the experiences and care gaps of women with HIV in CHIWOS.

SETTING

British Columbia, Ontario and Quebec, Canada.

PARTICIPANTS

A total of 18 individual CHIWOS team members participated in this study including six lead investigators of CHIWOS and 12 community researchers.

RESULTS

Overall, a total of 60 peer-reviewed manuscripts and conference abstracts met the inclusion criteria. Using concept mapping, themes were generated and structured through online meetings. In total, six composite concept maps were co-developed: quality of life, HIV care, psychosocial and mental health, sexual health, reproductive health, and trans women's health. Two summary diagrams were created encompassing the concept map themes, one for all women and one specific to trans women with HIV. Through our analysis, resilience, social support, positive healthy actions and women-centred HIV care were highlighted as strengths leading to well-being for women with HIV.

CONCLUSIONS

Concept mapping resulted in a composite summary of 60 peer-reviewed CHIWOS publications. This activity allows for priority setting to optimise care and well-being for women with HIV.

Intersectional Stigma, Fear of Negative Evaluation, Depression, and ART Adherence Among Women Living with HIV Who Engage in Substance Use: A Latent Class Serial Mediation Analysis

Women Living with HIV (WLHIV) who use substances face stigma related to HIV and substance use (SU). The relationship between the intersection of these stigmas and adherence to antiretroviral therapy (ART), as well as the underlying mechanisms, remains poorly understood. This study aimed to examine the association between intersectional HIV and SU stigma and ART adherence, while also exploring the potential role of depression and fear of negative evaluation (FNE) by other people in explaining this association. We analyzed data from 409 WLHIV collected between April 2016 and April 2017, Using Multidimensional Latent Class Item Response Theory analysis. We identified five subgroups (i.e., latent classes [C]) of WLHIV with different combinations of experienced SU and HIV stigma levels: (C1) low HIV and SU stigma; (C2) moderate SU stigma; (C3) higher HIV and lower SU stigma; (C4) moderate HIV and high SU stigma; and (C5) high HIV and moderate SU stigma. Medication adherence differed significantly among these classes. Women in the class with moderate HIV and high SU stigma had lower adherence than other classes. A serial mediation analysis suggested that FNE and depression symptoms are mechanisms that contribute to explaining the differences in ART adherence among WLHIV who experience different combinations of intersectional HIV and SU stigma. We suggest that FNE is a key intervention target to attenuate the effect of intersectional stigma on depression symptoms and ART adherence, and ultimately improve health outcomes among WLHIV.

Self-care interventions for women's health and well-being

The human right to health is universal and non-exclusionary, supporting health in full, and for all. Despite advances in health systems globally, 3.6 billion people lack access to essential health services. Women and girls are disadvantaged when it comes to benefiting from quality health services, owing to social norms, unequal power in relationships, lack of consideration beyond their reproductive roles and poverty. Self-care interventions, including medicines and diagnostics, which offer an additional option to facility-based care, can improve the autonomy and agency of women in managing their own health. However, tackling challenges such as stigma is essential to avoid scenarios in which self-care interventions provide more choice for those who already benefit from access to quality healthcare, and leave behind those with the greatest need. This Perspective explores the opportunities that self-care interventions offer to advance the health and well-being of women with an approach grounded in human rights, gender equality and equity.

Associations between water insecurity and mental health outcomes among lesbian, gay, bisexual, transgender and queer persons in Bangkok, Thailand and Mumbai, India: Cross-sectional survey findings

Background

Water insecurity disproportionally affects socially marginalized populations and may harm mental health. Lesbian, gay, bisexual, transgender and queer (LGBTQ) persons are at the nexus of social marginalization and mental health disparities; however, they are understudied in water insecurity research. Yet LGBTQ persons likely have distinct water needs. We explored associations between water insecurity and mental health outcomes among LGBTQ adults in Mumbai, India and Bangkok, Thailand.

Methods

This cross-sectional survey with a sample of LGBTQ adults in Mumbai and Bangkok assessed associations between water insecurity and mental health outcomes, including anxiety symptoms, depression symptoms, loneliness, alcohol misuse, COVID-19 stress and resilience. We conducted multivariable logistic and linear regression analyses to examine associations between water insecurity and mental health outcomes.

Results

Water insecurity prevalence was 28.9% in Mumbai and 18.6% in Bangkok samples. In adjusted analyses, in both sites, water insecurity was associated with higher likelihood of depression symptoms, anxiety symptoms, COVID-19 stress, alcohol misuse and loneliness. In Mumbai, water insecurity was also associated with reduced resilience.

Conclusion

Water insecurity was common among LGBTQ participants in Bangkok and Mumbai and associated with poorer well-being. Findings signal the importance of assessing water security as a stressor harmful to LGBTQ mental health.

Exploring ecosocial contexts of alcohol use and misuse during the COVID-19 pandemic among urban refugee youth in Kampala, Uganda: Multi-method findings

Urban refugees may be disproportionately affected by socio-environmental stressors that shape alcohol use, and this may have been exacerbated by additional stressors in the COVID-19 pandemic. This multi-method study aimed to understand experiences of, and contextual factors associated with, alcohol use during the pandemic among urban refugee youth in Kampala, Uganda. We conducted a cross-sectional survey (n = 335), in-depth individual interviews (IDI) (n = 24), and focus groups (n = 4) with urban refugee youth in Kampala. We also conducted key informant interviews (n = 15) with a range of stakeholders in Kampala. We conducted multivariable logistic regression analyses with survey data to examine socio-demographic and ecosocial (structural, community, interpersonal) factors associated with ever using alcohol and alcohol misuse. We applied thematic analyses across qualitative data to explore lived experiences, and perceived impacts, of alcohol use. Among survey participants (n = 335, mean age= 20.8, standard deviation: 3.01), half of men and one-fifth of women reported ever using alcohol. Among those reporting any alcohol use, half (n = 66, 51.2 %) can be classified as alcohol misuse. In multivariable analyses, older age, gender (men vs. women), higher education, and perceived increased pandemic community violence against women and children were associated with significantly higher likelihood of ever using alcohol. In multivariable analyses, very low food security, relationship status, transactional sex, and lower social support were associated with increased likelihood of alcohol misuse. Qualitative findings revealed: (1) alcohol use as a coping mechanism for stressors (e.g., financial insecurity, refugee-related stigma); and (2) perceived impacts of alcohol use on refugee youth health (e.g., physical, mental). Together findings provide insight into multi-level contexts that shape vulnerability to alcohol mis/use among urban refugee youth in Kampala and signal the need for gender-tailored strategies to reduce socio-environmental stressors.

HIV Vulnerabilities Associated with Water Insecurity, Food Insecurity, and Other COVID-19 Impacts Among Urban Refugee Youth in Kampala, Uganda: Multi-method Findings

Food insecurity (FI) and water insecurity (WI) are linked with HIV vulnerabilities, yet how these resource insecurities shape HIV prevention needs is understudied. We assessed associations between FI and WI and HIV vulnerabilities among urban refugee youth aged 16-24 in Kampala, Uganda through individual in-depth interviews (IDI) (n = 24), focus groups (n = 4), and a cross-sectional survey (n = 340) with refugee youth, and IDI with key informants (n = 15). Quantitative data was analysed via multivariable logistic and linear regression to assess associations between FI and WI with: reduced pandemic sexual and reproductive health (SRH) access; past 3-month transactional sex (TS); unplanned pandemic pregnancy; condom self-efficacy; and sexual relationship power (SRP). We applied thematic analytic approaches to qualitative data. Among survey participants, FI and WI were commonplace (65% and 47%, respectively) and significantly associated with: reduced SRH access (WI: adjusted odds ratio [aOR]: 1.92, 95% confidence interval [CI]: 1.19-3.08; FI: aOR: 2.31. 95%CI: 1.36-3.93), unplanned pregnancy (WI: aOR: 2.77, 95%CI: 1.24-6.17; FI: aOR: 2.62, 95%CI: 1.03-6.66), and TS (WI: aOR: 3.09, 95%CI: 1.22-7.89; FI: aOR: 3.51, 95%CI: 1.15-10.73). WI participants reported lower condom self-efficacy (adjusted β= -3.98, 95%CI: -5.41, -2.55) and lower SRP (adjusted β= -2.58, 95%CI= -4.79, -0.37). Thematic analyses revealed: (1) contexts of TS, including survival needs and pandemic impacts; (2) intersectional HIV vulnerabilities; (3) reduced HIV prevention/care access; and (4) water insecurity as a co-occurring socio-economic stressor. Multi-method findings reveal FI and WI are linked with HIV vulnerabilities, underscoring the need for HIV prevention to address co-occurring resource insecurities with refugee youth.

Kukaa Salama (Staying Safe): a pre-post trial of an interactive informational mobile health intervention for increasing COVID-19 prevention practices with urban refugee youth in Uganda

BACKGROUND

Tailored coronavirus disease 2019 (COVID-19) prevention strategies are needed for urban refugee youth in resource-constrained contexts. We developed an 8-wk interactive informational mobile health intervention focused on COVID-19 prevention practices informed by the Risk, Attitude, Norms, Ability, Self-regulation-or RANAS-approach.

METHODS

We conducted a pre-post trial with a community-recruited sample of refugee youth aged 16-24 y in Kampala, Uganda. Data were collected before (T1) and immediately following (T2) the intervention, and at the 16-wk follow up (T3), to examine changes in primary (COVID-19 prevention self-efficacy) and secondary outcomes (COVID-19 risk awareness, attitudes, norms and self-regulation practices; depression; sexual and reproductive health [SRH] access; food/water security; COVID-19 vaccine acceptability).

RESULTS

Participants (n=346; mean age: 21.2 [SD 2.6] y; cisgender women: 50.3%; cisgender men: 48.0%; transgender persons: 1.7%) were largely retained (T2: n=316, 91.3%; T3: n=302, 87.3%). In adjusted analyses, COVID-19 prevention self-efficacy, risk awareness, attitudes and vaccine acceptance increased significantly from T1 to T2, but were not sustained at T3. Between T1 and T3, COVID-19 norms and self-regulation significantly increased, while community violence, water insecurity and community SRH access decreased.

CONCLUSIONS

Digital approaches for behaviour change hold promise with urban refugee youth but may need booster messaging and complementary programming for sustained effects.

Dissemination of the Women-Centred HIV Care Model: A Multimodal Process and Evaluation

BACKGROUND

Using data from a national cohort study and focus groups, the Women-Centred HIV Care (WCHC) Model was developed to inform care delivery for women living with HIV.

METHODS

Through an evidence-based, integrated knowledge translation approach, we developed 2 toolkits based on the WCHC Model for service providers and women living with HIV in English and French (Canada's national languages). To disseminate, we distributed printed advertising materials, hosted 3 national webinars and conducted 2 virtual capacity-building training series.

RESULTS

A total of 315 individuals attended the webinars, and the average WCHC knowledge increased by 29% (SD 4.3%). In total, 131 service providers engaged in 22 virtual capacity-building training sessions with 21 clinical cases discussed. Learners self-reported increased confidence in 15/15 abilities, including the ability to provide WCHC. As of December 2023, the toolkits were downloaded 7766 times.

CONCLUSIONS

We successfully developed WCHC toolkits and shared them with diverse clinical and community audiences through various dissemination methods.

Exploring a syndemic of poverty, cumulative violence, and HIV vulnerability among refugee youth: multi-method insights from a humanitarian setting in Uganda

Synergistic associations between social inequities and HIV vulnerabilities - known as a syndemic - are understudied with youth in humanitarian settings. We explored refugee youths' HIV prevention needs in Bidi Bidi Refugee Settlement, Uganda. This multi-methods study involved 6 focus groups and 12 in-depth individual interviews (IDI) with refugee youth (n = 60) aged 16-24, and IDI with refugee elders (n = 8) and healthcare providers (n = 8). We then conducted cross-sectional surveys with refugee youth (16-24 years) (n = 115) to assess: poverty, recent sexual and gender-based violence (SGBV), and condom engagement motivation (CEM) (wanting to learn about condoms for HIV prevention). Multivariable logistic regression was used to estimate adjusted odds ratios for associations between poverty and SGBV with CEM. Qualitative narratives revealed poverty and trauma elevated substance use, and these converged to exacerbate SGBV. SGBV and transactional sex increased HIV vulnerabilities. Among survey participants, poverty and recent SGBV were associated with reduced odds of CEM. The interaction between poverty and recent SGBV was significant: the predicted probability of CEM among youth who experienced both poverty and SGBV was almost half than among youth who experienced poverty alone, SGBV alone, or neither. Findings signal the confluence of poverty, violence, and substance use elevate refugee youth HIV vulnerabilities.

Associations between climate change-related factors and sexual health: A scoping review

There is growing attention to the ways in which climate change may affect sexual health, yet key knowledge gaps remain across global contexts and climate issues. In response, we conducted a scoping review to examine the literature on associations between climate change and sexual health. We searched five databases (May 2021, September 2022). We reviewed 3,183 non-duplicate records for inclusion; n = 83 articles met inclusion criteria. Of these articles, n = 30 focused on HIV and other STIs, n = 52 focused on sexual and gender-based violence (GBV), and n = 1 focused on comprehensive sexuality education. Thematic analysis revealed that hurricanes, drought, temperature variation, flooding, and storms may influence HIV outcomes among people with HIV by constraining access to antiretroviral treatment and worsening mental health. Climate change was associated with HIV/STI testing barriers and worsened economic conditions that elevated HIV exposure (e.g. transactional sex). Findings varied regarding associations between GBV with storms and drought, yet most studies examining flooding, extreme temperatures, and bushfires reported positive associations with GBV. Future climate change research can examine understudied sexual health domains and a range of climate-related issues (e.g. heat waves, deforestation) for their relevance to sexual health. Climate-resilient sexual health approaches can integrate extreme weather events into programming.

Brief Report: Social Factors Associated With Trajectories of HIV-Related Stigma and Everyday Discrimination Among Women Living With HIV in Vancouver, Canada: Longitudinal Cohort Findings

INTRODUCTION

Women living with HIV (WLHIV) experience stigma rooted in social inequities. We examined associations between social factors (food insecurity, housing insecurity, violence, sexual minority identity, and substance use) and HIV-related stigma and Everyday Discrimination trajectories among WLHIV.

METHODS

This community-based open longitudinal cohort study with WLHIV living in and/or accessing HIV care in Metro Vancouver, Canada, plotted semiannual averages (2015-2019) of recent (past 6-month) HIV-related stigma and Everyday Discrimination. We examined distinct trajectories of HIV-related stigma and Everyday Discrimination using latent class growth analysis (LCGA) and baseline correlates of each trajectory using multinomial logistic regression.

FINDINGS

Among participants (HIV-related stigma sample: n = 197 participants with n = 985 observations; Everyday Discrimination sample: n = 203 participants with n = 1096 observations), LCGA identified 2 distinct HIV-related stigma and Everyday Discrimination trajectories: sustained low and consistently high. In multivariable analysis, concurrent food and housing insecurity (adjusted odds ratio [AOR]: 2.15, 95% confidence interval [CI] 1.12-4.12) and physical/sexual violence (AOR: 2.57, 95% CI: 1.22-5.42) were associated with higher odds of the consistently high (vs. sustained low) HIV-related stigma trajectory. Sexual minority identity (AOR: 2.84, 95% CI: 1.49-5.45), concurrent food and housing insecurity (AOR: 2.65, 95% CI: 1.38-5.08), and noninjection substance use (less than daily vs. none) (AOR: 2.04, 95% CI: 1.03-4.07) were associated with higher odds of the consistently high (vs. sustained low) Everyday Discrimination trajectory.

CONCLUSIONS

Social inequities were associated with consistently high HIV-related stigma and Everyday Discrimination among WLHIV. Multilevel strategies can address violence, economic insecurity, intersecting stigma, and discrimination to optimize health and rights among WLHIV.

Findings from the Tushirikiane mobile health (mHealth) HIV self-testing pragmatic trial with refugee adolescents and youth living in informal settlements in Kampala, Uganda

INTRODUCTION

Urban refugee youth remain underserved by current HIV prevention strategies, including HIV self-testing (HIVST). Examining HIVST feasibility with refugees can inform tailored HIV testing strategies. We examined if HIVST and mobile health (mHealth) delivery approaches could increase HIV testing uptake and HIV status knowledge among refugee youth in Kampala, Uganda.

METHODS

We conducted a three-arm pragmatic controlled trial across five informal settlements grouped into three sites in Kampala from 2020 to 2021 with peer-recruited refugee youth aged 16-24 years. The intervention was HIVST and HIVST + mHealth (HIVST with bidirectional SMS), compared with standard of care (SOC). Primary outcomes were self-reported HIV testing uptake and correct status knowledge verified by point-of-care testing. Some secondary outcomes included: depression, HIV-related stigma, and adolescent sexual and reproductive health (SRH) stigma at three time points (baseline [T0], 8 months [T1] and 12 months [T2]). We used generalized estimating equation regression models to estimate crude and adjusted odds ratios comparing arms over time, adjusting for age, gender and baseline imbalances. We assessed study pragmatism across PRECIS-2 dimensions.

RESULTS

We enrolled 450 participants (50.7% cisgender men, 48.7% cisgender women, 0.7% transgender women; mean age: 20.0, standard deviation: 2.4) across three sites. Self-reported HIV testing uptake increased significantly from T0 to T1 in intervention arms: HIVST arm: (27.6% [n = 43] at T0 vs. 91.2% [n = 135] at T1; HIVST + mHealth: 30.9% [n = 47] at T0 vs. 94.2% [n = 113] at T1]) compared with SOC (35.5% [n = 50] at T0 vs. 24.8% [ = 27] at T1) and remained significantly higher than SOC at T2 (p<0.001). HIV status knowledge in intervention arms (HIVST arm: 100% [n = 121], HIVST + mHealth arm: 97.9% [n = 95]) was significantly higher than SOC (61.5% [n = 59]) at T2. There were modest changes in secondary outcomes in intervention arms, including decreased depression alongside increased HIV-related stigma and adolescent SRH stigma. The trial employed both pragmatic (eligibility criteria, setting, organization, outcome, analysis) and explanatory approaches (recruitment path, flexibility of delivery flexibility, adherence flexibility, follow-up).

CONCLUSIONS

Offering HIVST is a promising approach to increase HIV testing uptake among urban refugee youth in Kampala. We share lessons learned to inform future youth-focused HIVST trials in urban humanitarian settings.

Pathways From HIV-Related Stigma, Racial Discrimination, and Gender Discrimination to HIV Treatment Outcomes Among Women Living With HIV in Canada: Longitudinal Cohort Findings

BACKGROUND

HIV-related stigma, gender discrimination, and racial discrimination harm mental health and hamper HIV treatment access for women living with HIV. Maladaptive coping strategies, such as substance use, can further worsen HIV treatment outcomes, whereas resilience can improve HIV outcomes. We examined resilience and depression as mediators of the relationship between multiple stigmas and HIV treatment outcomes among women living with HIV.

SETTING

Ontario, British Columbia, and Quebec, Canada.

METHODS

We conducted a longitudinal study with 3 waves at 18-month intervals. We used structural equation modeling to test the associations of multiple stigmas (HIV-related stigma, racial discrimination, and gender discrimination) or an intersectional construct of all 3 stigmas at wave 1 on self-reported HIV treatment cascade outcomes (≥95% antiretroviral treatment [ART] adherence, undetectable viral load) at wave 3. We tested depression and resilience at wave 2 as potential mediators and adjusted for sociodemographic factors.

RESULTS

There were 1422 participants at wave 1, half of whom were Black (29%) or Indigenous (20%). Most participants reported high ART adherence (74%) and viral suppression (93%). Racial discrimination was directly associated with having a detectable viral load, while intersectional stigma was directly associated with lower ART adherence. Resilience mediated associations between individual and intersectional stigmas and HIV treatment cascade outcomes, but depression did not. Racial discrimination was associated with increased resilience, while intersectional and other individual stigmas were associated with reduced resilience.

CONCLUSION

Race, gender and HIV-related stigma reduction interventions are required to address intersectional stigma among women living with HIV. Including resilience-building activities in these interventions may improve HIV treatment outcomes.

A syndemic of inequitable gender norms and intersecting stigmas on condom self-efficacy and practices among displaced youth living in urban slums in Uganda: a community-based cross-sectional study

BACKGROUND

Adverse socio-cultural factors compromise the implementation of HIV prevention strategies among displaced youth. While condoms are an affordable and effective HIV prevention strategy for youth, stigma and inequitable gender norms may constrain condom self-efficacy (i.e., knowledge, intentions, and relationship dynamics that facilitate condom negotiation) and use. Further, knowledge of contextually appropriate HIV prevention approaches are constrained by limited understanding of the socio-cultural conditions that affect condom self-efficacy and use among displaced youth. Guided by syndemics theory, we examine independent and joint effects of adverse socio-cultural factors associated with condom self-efficacy and use among displaced youth living in urban slums in Kampala, Uganda.

METHODS

We conducted a community-based cross-sectional survey of displaced youth aged 16-24 years living in five slums in Kampala. We used multivariable logistic regression and multivariate linear regression to assess independent and two-way interactions among adverse socio-cultural factors (adolescent sexual and reproductive health-related stigma [A-SRH stigma], perceived HIV-related stigma, and beliefs in harmful inequitable gender norms) on condom self-efficacy and recent consistent condom use. We calculated the prevalence and co-occurrence of adverse socio-cultural factors; conducted regression analyses to create unique profiles of adverse socio-cultural factors; and then assessed joint effects of adverse socio-cultural factors on condom self-efficacy and practices.

RESULTS

Among participants (mean age: 19.59 years; SD: 2.59; women: n = 333, men: n = 112), 62.5% were sexually active. Of these, only 53.3% reported recent consistent condom use. Overall, 42.73% of participants reported two co-occurring adverse socio-cultural factors, and 16.63% reported three co-occurring exposures. We found a joint effect of beliefs in harmful inequitable gender norms with high A-SRH stigma (β = - 0.20; p < 0.05) and high A-SRH stigma with high perceived HIV stigma (β = - 0.31; p < 0.001) on reduced condom self-efficacy. We found a multiplicative interaction between high A-SRH stigma with high perceived HIV stigma (aOR = 0.52; 95% CI 0.28, 0.96) on recent consistent condom use. Additionally, we found that condom self-efficacy (aOR = 1.01; 95% CI 1.05, 1.16) and safer sexual communication (aOR = 2.12; 95% CI 1.54, 2.91) acted as protective factors on inconsistent condom use.

CONCLUSIONS

Displaced youth living in urban slums exhibited low consistent condom use. Intersecting stigmas were associated with lower condom self-efficacy-a protective factor linked with increased consistent condom use. Findings highlight the importance of gender transformative and intersectional stigma reduction approaches to increase sexual agency and safer sex practices among Kampala's slum-dwelling displaced youth.

A longitudinal investigation of the effects of the COVID-19 pandemic on 2SLGBTQ+ youth experiencing homelessness

INTRODUCTION

The objective of this study was to examine the impacts of the coronavirus 2019 (COVID-19) pandemic on various dimensions of wellbeing among 2SLGBTQ+ youth experiencing homelessness over a 12-month period during the COVID-19 pandemic.

METHODS

2SLGBTQ+ youth (recruited using a convenience sampling method) participated in three online surveys to assess mental health (depression, anxiety, suicidality), substance and alcohol use, health care access, and violence for 12-months between 2021-2022. Quantitative data analysis included non-parametric one-sample proportion tests, paired t-test and McNemar's test. Longitudinal data collected across all three timepoints were treated as paired data and compared to baseline data using non-parametric exact multinomial tests, and if significant, followed by pairwise post-hoc exact binomial tests. For the purposes of analysis, participants were grouped according to their baseline survey based on pandemic waves and public health restrictions.

RESULTS

2SLGBTQ+ youth experiencing homelessness (n = 87) reported high rates of mental health challenges, including anxiety and depression, over 12-months during the pandemic. Youth participants reported experiencing poor mental health during the early waves of the pandemic, with improvements to their mental health throughout the pandemic; however, results were not statistically significant. Likewise, participants experienced reduced access to mental health care during the early waves of the pandemic but mental health care access increased for youth throughout the pandemic.

CONCLUSION

Study results showed high rates of mental health issues among 2SLGBTQ+ youth, but reduced access to mental health care, due to the COVID-19 pandemic. Findings highlight the need for 2SLGBTQ+ inclusive and affirming mental health care and services to address social and mental health issues that have been exacerbated by the pandemic.

Examining Pathways from Food Insecurity to Safer Sex Efficacy Among Northern and Indigenous Adolescents in the Northwest Territories, Canada

BACKGROUND

Food insecurity is a social determinant of health linked with elevated HIV exposure. Safer sex efficacy (SSE), the ability to navigate sexual decision-making and condom use, is an important marker of sexual wellbeing. Pathways from food insecurity to SSE are understudied, particularly among adolescents in Arctic regions who are at the nexus of food insecurity and sexual health disparities. We examined pathways from food insecurity to SSE among adolescents in the Northwest Territories (NWT), Canada.

METHODS

We implemented cross-sectional surveys with adolescents aged 13-18 recruited through venue-based sampling in 17 NWT communities. We conducted multivariable logistic regression to assess socio-demographic factors associated with food insecurity. We then conducted structural equation modeling (SEM) using maximum likelihood estimation to assess direct effects of food insecurity on SSE and indirect effects via resilience, depression, and relationship power inequity. We assessed both condom use SSE (e.g., confidence in using condoms) and situational SSE (e.g., SSE under partner pressure).

RESULTS

Most participants (n = 410) identified as Indigenous (79%) and 45% reported experiencing food insecurity. In SEM, we did not find a significant direct effect from food insecurity to SSE; however, we found indirect effects from food insecurity to condom use SSE through resilience and depression and from food insecurity to situational SSE through resilience.

CONCLUSIONS

Findings call for structural interventions to address food insecurity, alongside resilience-focused strategies that address the intersection of sexual and mental health. Sexual health strategies focused on individual behavior change are insufficient to address larger contexts of poverty among Northern youth.

Community and Health Care Provider Preferences for Bacterial Sexually Transmitted Infection Testing Interventions for Gay, Bisexual, and Other Men Who Have Sex With Men: e-Delphi Study

BACKGROUND

Canadian clinical guidelines recommend at least annual and up to quarterly bacterial sexually transmitted infection (STI) testing among sexually active gay, bisexual, and other men who have sex with men (GBM). However, testing rates are suboptimal. Innovative solutions are needed to close the gap because there is currently limited knowledge on how best to approach this issue.

OBJECTIVE

Our aim was to build consensus regarding interventions with the greatest potential for improving local STI testing services for GBM communities in Toronto, Ontario, Canada, using a web-based e-Delphi process.

METHODS

The e-Delphi method involves using a panel format to conduct successive rounds of prioritization, with feedback between rounds, to determine priorities among groups. We recruited experts separately from the community (GBM who sought or underwent STI testing in the preceding 18 months; conducted between October 2019 and November 2019) and health care providers (those who offered STI testing to GBM in the past 12 months; conducted between February 2020 and May 2020). The experts prioritized 6 to 8 potential interventions on a 7-point Likert scale ranging from definitely not a priority to definitely a priority over 3 survey rounds and ranked their top 3 interventions. Consensus was defined as ≥60% within a ±1 response point. Summaries of responses were provided in successive rounds. We reported the percentage of a priority (encompassing somewhat a priority, a priority, and definitely a priority responses) at the end of the final round of the survey.

RESULTS

Of the community experts (CEs), 84% (43/51) completed all rounds; 19% (8/43) were living with HIV; 37% (16/43) were HIV negative and on pre-exposure prophylaxis; and 42% (18/43) were HIV negative and not on pre-exposure prophylaxis. We reached consensus on 6 interventions: client reminders (41/43, 95%), express testing (38/43, 88%), routine testing (36/43, 84%), an online booking app (36/43, 84%), online-based testing (33/43, 77%), and nurse-led testing (31/43, 72%). The CEs favored convenient interventions that also maintain a relationship with their provider. Of the provider experts (PEs), 77% (37/48) completed all rounds; 59% (22/37) were physicians. Consensus was reached on the same 6 interventions (range 25/37, 68%, to 39/39, 100%) but not for provider alerts (7/37, 19%) and provider audit and feedback (6/37, 16%). Express testing, online-based testing, and nurse-led testing were prioritized by >95% (>37/39) of the PEs by the end of round 2 because of streamlined processes and decreased need to see a provider.

CONCLUSIONS

Both panels were enthusiastic about innovations that make STI testing more efficient, with express testing rating highly in both the prioritizations and top 3 rankings. However, CEs preferred convenient interventions that involved their provider, whereas PEs favored interventions that prioritized patient independence and reduced patient-provider time.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/13801.

A Participatory Comic Book Workshop to Improve Youth-Friendly Post-Rape Care in a Humanitarian Context in Uganda: A Case Study

BACKGROUND

Graphic medicine formats, such as comic books in which health information is presented alongside images, may be a useful learning tool to improve post-rape care and youth-friendly service provision among health care providers in humanitarian contexts. We describe the development and pilot-testing of a workshop using a comic book to improve youth-friendly post-rape care with providers in Bidi Bidi refugee settlement, Uganda.

PROGRAM DEVELOPMENT AND PILOTING

We conducted 6 focus groups with refugee young men (n=3) and women (n=3) aged 16-24 years and 28 in-depth individual interviews (refugee youth: n=12; health care providers: n=8; elders: n=8). Findings informed the development of a workshop that included a participatory comic book on sexual and gender-based violence (SGBV) and youth, SGBV stigma, youth-friendly health care, and post-exposure prophylaxis. Comic book illustrations specifically addressed health care confidentiality and examples of being a supportive health care provider. Then, we conducted a 1-day workshop with health care providers (n=20) that included structured activities addressing SGBV impacts and related stigma and included comic book discussions. Open-ended survey data were collected 8 weeks after the workshop to explore health care providers' experiences with the workshop, perceived impact of the intervention on their work, and support required to implement youth-friendly services for SGBV survivors. Qualitative data were analyzed using thematic approaches. Open-ended response data indicated that: comic book methods were informative and interactive; health care providers felt more empowered to offer youth-friendly services and spaces; and health care providers want additional SGBV training and institutional support for youth-friendly spaces and community engagement.

IMPLICATIONS

A comic book intervention has the potential to meaningfully engage health care providers in humanitarian contexts to provide youth-friendly health care, acquire skills for engaging in SGBV prevention, create youth-friendly clinic spaces, and identify health care and community SGBV prevention needs.

"Coming out of the closet about sexual assault": Intersectional sexual assault stigma and (non) disclosure to formal support providers among survivors using Reddit

Sexual assault is a pervasive, violent and often gendered crime that can result in significant negative consequences. Many sexual assault survivors consider disclosing to health and social care providers, therapists, and others who collectively fall under the banner of formal support, in order to access information, referrals, treatment and/or emotional support, however barriers to disclosure remain. This qualitative study is unique in its application of an intersectional sexual assault stigmatization framework to understand (non)disclosure to formal support providers among diverse sexual assault survivors. Through anonymous online narratives posted to the platform Reddit, survivors documented experiences of intersectional sexual assault stigma (perceived, internalized, anticipated, experienced) showing that they were not only stigmatized through negative gender stereotyping, but they were also marginalized through other structural inequities. The experience of multiple marginalization that arose from intersectional sexual assault stigma often impeded survivors in accessing and/or utilizing the formal support they wished for. The findings suggest that formal support providers could benefit from stigma reduction training related specifically to sexual assault survivors and that current models of stigma and discrimination training need to be expanded to include intersectional stigma. Further, the findings suggest that beyond training at an organizational level, a broader intervention aimed at reducing structural stigma and discrimination toward sexual assault survivors at a societal level appears warranted. Implications for future research related to the unique disclosure, health, and social care needs of diverse sexual assault survivors and support-seeking online alongside or in lieu of formal support are discussed.

Intersectional Stigma and Implementation of HIV Prevention and Treatment Services for Adolescents Living with and at Risk for HIV: Opportunities for Improvement in the HIV Continuum in Sub-Saharan Africa

Adolescents in sub-Saharan Africa, specifically adolescent girls and young women, young men who have sex with men, transgender persons, persons who use substances, and adolescents experiencing homelessness experience intersectional stigma, have a high incidence of HIV and are less likely to be engaged in HIV prevention and care. We conducted a thematic analysis informed by the Health and Discrimination Framework using a multiple case study design with five case studies in 3 sub-Saharan African countries. Our analysis found commonalities in adolescents' intersectional stigma experiences across cases, despite different contexts. We characterize how intersectional stigma impacts the uptake and implementation of HIV prevention and treatment services along the continuum for adolescents. Findings reveal how intersectional stigma operates across social-ecological levels and worsens HIV-related outcomes for adolescents. We identify opportunities for implementation science research to address stigma-related barriers to the uptake and delivery of HIV services for adolescents in sub-Saharan Africa.

HIV care cascade for women living with HIV in the Greater Toronto Area versus the rest of Ontario and Canada

BACKGROUND

The Greater Toronto Area (GTA) is home to 39% of Canada's population living with HIV. To identify gaps in access and engagement in care and treatment, we assessed the care cascade of women living with HIV (WLWH) in the GTA versus the rest of Ontario and Canada (in this case: Quebec and British Columbia).

METHODS

We analyzed 2013-2015 self-reported baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study for six care cascade stages: linked to care, retained in care, initiated antiretroviral therapy (ART), currently on ART, ART adherence (≥90%), and undetectable (<50 copies/mL). Multivariable logistic regression was used to reveal associations with being undetectable.

RESULTS

Comparing the GTA to the rest of Ontario and Canada, respectively: 96%, 98%, 100% were linked to care; 92%, 94%, 98% retained in care; 72%, 89%, 96% initiated ART; 67%, 81%, 90% were currently using ART; 53%, 66%, 77% were adherent; 59%, 69%, 81% were undetectable. Factors associated with viral suppression in the multivariable model included: living outside of the GTA (Ontario: aOR = 1.72, 95% CI: 1.09-2.72; Canada: aOR = 2.42, 95% CI: 1.62-3.62), non-Canadian citizenship (landed immigrant/permanent resident: aOR = 3.23, 95% CI: 1.66-6.26; refugee/protected person/other status: aOR = 4.77, 95% CI: 1.96-11.64), completed high school (aOR = 1.77, 95% CI: 1.15-2.73), stable housing (aOR = 2.13, 95% CI: 1.33-3.39), income of ≥$20,000 (aOR = 1.52, 95% CI: 1.00-2.31), HIV diagnosis <6 years (6-14 years: aOR = 1.75, 95% CI: 1.16-2.63; >14 years: aOR = 1.87, 95% CI: 1.19-2.96), and higher resilience (aOR = 1.02, 95% CI: 1.00-1.04).

CONCLUSION

WLWH living in the GTA had lower rates of viral suppression compared to the rest of Ontario and Canada even after adjustment of age, ethnicity, and HIV diagnosis duration. High-impact programming for WLWH in the GTA to improve HIV outcomes are greatly needed.

Multi-method findings on COVID-19 vaccine acceptability among urban refugee adolescents and youth in Kampala, Uganda

ABSTRACTScant studies have explored COVID-19 vaccine acceptability among refugees. However, contexts of forced migration may elevate COVID-19 vulnerabilities, and suboptimal refugee immunisation rates are reported for other vaccine-preventable diseases. We conducted a multi-methods study to describe COVID-19 vaccine acceptability among urban refugee youth in Kampala, Uganda. This study uses cross-sectional survey data from a cohort study with refugees aged 16-24 in Kampala to examine socio-demographic factors associated with vaccine acceptability. A purposively sampled cohort subset (n = 24) participated in semi-structured in-depth individual interviews, as did key informants (n = 6), to explore COVID-19 vaccine acceptance. Among 326 survey participants (mean age: 19.9; standard deviation 2.4; 50.0% cisgender women), vaccine acceptance was low (18.1% reported they were very likely to accept an effective COVID-19 vaccine). In multivariable models, vaccine acceptance likelihood was significantly associated with age and country of origin. Qualitative findings highlighted COVID-19 vaccine acceptability barriers and facilitators spanning social-ecological levels, including fear of side effects and mistrust (individual level), misinformed healthcare, community and family attitudes (community level), tailored COVID-19 services for refugees (organisational and practice setting), and political support for vaccines (policy environment). These data signal the urgent need to address social-ecological factors shaping COVID-19 vaccine acceptability among Kampala's young urban refugees.Trial registration: ClinicalTrials.gov identifier: NCT04631367.

Factors associated with motherhood among urban refugee adolescent girls and young women in informal settlements in Kampala, Uganda

Adolescent girls and young women (AGYW) in sub-Saharan Africa face a high risk of unintended pregnancy. This risk is compounded in informal settlements, where resources are scarce and access to sexual and reproductive health services is limited. Being a young mother in informal settlements could exacerbate existing experiences of resource scarcity and poor access to sexual and reproductive health services. To explore this, we analyzed the factors associated with motherhood among refugee AGYW in Kampala, Uganda. Between January and March 2018, peer researchers recruited refugee youth aged 15-24 and living in five informal settlements in Kampala to participate in this study. We used a backwards generalized linear model with a log binomial regression to determine if mental health, resource insecurity and sexual and reproductive health variables were associated with motherhood among study participants. Our analysis included 333 AGYW with a mean age of 19.3 years (standard deviation: 2.6). Nearly one-quarter (23 percent; n = 76) of AGYW had children. Having children was associated with greater likelihood of reporting food insecurity (adjusted prevalence ratio [aPR]: 1.96, 95 percent confidence interval [CI]: 1.07-3.61), depressive symptoms (aPR: 2.03, 95 percent CI: 1.09-3.80), and contraception uptake (aPR: 2.37, 95 percent CI: 1.58-3.56) compared to not having children. Mental health and resource insecurity interventions are required for refugee AGYW with children in informal settlements. Sexual and reproductive health services should be promoted to refugee AGYW regardless of motherhood status to prevent unplanned pregnancy.

Mixed-methods findings from the Ngutulu Kagwero (agents of change) participatory comic pilot study on post-rape clinical care and sexual violence prevention with refugee youth in a humanitarian setting in Uganda

There is a dearth of evidence-based post-rape clinical care interventions tailored for refugee adolescents and youth in low-income humanitarian settings. Comics, a low-cost, low-literacy and youth-friendly method, integrate visual images with text to spark emotion and share health-promoting information. We evaluated a participatory comic intervention to increase post-exposure prophylaxis (PEP) knowledge and acceptance, and prevent sexual and gender-based violence, in Bidi Bidi refugee settlement, Uganda. Following a formative qualitative phase, we conducted a pre-test post-test pilot study with refugee youth (aged 16-24 years) (n = 120). Surveys were conducted before (t0), after (t1), and two-months following (t2) workshops. Among participants (mean age: 19.7 years, standard deviation: 2.4; n = 60 men, n = 60 women), we found significant increases from t0 to t1, and from t0 to t2 in: (a) PEP knowledge and acceptance, (b) bystander efficacy, and (c) resilient coping. We also found significant decreases from t0 to t1, and from t0 to t2 in sexual violence stigma and depression. Qualitative feedback revealed knowledge and skills acquisition to engage with post-rape care and violence prevention, and increased empathy to support survivors. Survivor-informed participatory comic books are a promising approach to advance HIV prevention through increased PEP acceptance and reduced sexual violence stigma with refugee youth.Trial registration: ClinicalTrials.gov identifier: NCT04656522.

Reducing HIV-related stigma among young people attending school in Northern Uganda: study protocol for a participatory arts-based population health intervention and stepped-wedge cluster-randomized trial

BACKGROUND

HIV-related stigma negatively impacts HIV prevention, treatment, and care, particularly among children and adolescents in sub-Saharan Africa. Interventions that are culturally grounded and relevant for addressing root causes may reduce the stigma experienced by HIV-positive and HIV-affected young people. This study, to be conducted in a post-conflict, rural setting in Omoro District, Uganda, will develop and evaluate a transformative  arts-based HIV-related stigma intervention rooted in local cultural knowledge to reduce stigma and improve HIV prevention and care for young people living with HIV. The intervention will be delivered to young people attending school by community Elders, with the support of teachers, through the transfer of local cultural knowledge and practices with the aim of re-establishing the important cultural and social role of Elders within a community that has suffered the loss of intergenerational transfer of cultural knowledge throughout a 25-year civil war.

METHODS

A formative research phase consisting of interviews with students, teachers, and Elders will inform the intervention and provide data for study objectives. Workshops will be delivered to Elders and teachers in participating schools to build capacity for arts-based, educational workshops to be conducted with students in the classroom. The intervention will be evaluated using a stepped-wedge cluster-randomized trial. Government-funded schools in Omoro District will be randomized into three blocks, each comprised of two primary and two secondary schools (n=1800 students). Schools will be randomly assigned to a crossover sequence from control to intervention condition in 8-week intervals. A process evaluation will be implemented throughout the study to evaluate pathways between intervention development, implementation, and effects.

DISCUSSION

This study will generate comprehensive, in-depth participatory research and evaluation data to inform an effective and sustainable protocol for implementing arts-based HIV stigma interventions for young people in school settings. Findings will have widespread implications in post-conflict settings for HIV prevention, treatment, and care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04946071 . Registered on 30 June 2021.

Addressing Health Inequities in Digital Clinical Trials: A Review of Challenges and Solutions From the Field of HIV Research

Clinical trials are considered the gold standard for establishing efficacy of health interventions, thus determining which interventions are brought to scale in health care and public health programs. Digital clinical trials, broadly defined as trials that have partial to full integration of technology across implementation, interventions, and/or data collection, are valued for increased efficiencies as well as testing of digitally delivered interventions. Although recent reviews have described the advantages and disadvantages of and provided recommendations for improving scientific rigor in the conduct of digital clinical trials, few to none have investigated how digital clinical trials address the digital divide, whether they are equitably accessible, and if trial outcomes are potentially beneficial only to those with optimal and consistent access to technology. Human immunodeficiency virus (HIV), among other health conditions, disproportionately affects socially and economically marginalized populations, raising questions of whether interventions found to be efficacious in digital clinical trials and subsequently brought to scale will sufficiently and consistently reach and provide benefit to these populations. We reviewed examples from HIV research from across geographic settings to describe how digital clinical trials can either reproduce or mitigate health inequities via the design and implementation of the digital clinical trials and, ultimately, the programs that result. We discuss how digital clinical trials can be intentionally designed to prevent inequities, monitor ongoing access and utilization, and assess for differential impacts among subgroups with diverse technology access and use. These findings can be generalized to many other health fields and are practical considerations for donors, investigators, reviewers, and ethics committees engaged in digital clinical trials.

Sexual and reproductive health factors associated with child, early and forced marriage and partnerships among refugee youth in a humanitarian setting in Uganda: Mixed methods findings

Preventing early and forced marriage is a global priority, however, sexual and reproductive health (SRH) among youth remains understudied in humanitarian settings. This study examined child, early and forced marriage and partnership (CEFMP) among young refugees in Bidi Bidi refugee settlement, Uganda, and associations with SRH outcomes among young women. This mixed-methods study involved a qualitative phase with young (16-24 years) sexual violence survivors (n=58), elders (n=8) and healthcare providers (n=10), followed by a quantitative phase among refugee youth (16-24 years; n=120) during which sociodemographic and SRH data were collected. We examined SRH outcome differences by CEFMP using Fisher's exact test. Qualitative data showed that CEFMP was a significant problem facing refugee young women driven by stigma, gender norms and poverty. Among youth refugee survey participants, nearly one-third (31.7%) experienced CEFMP (57.9% women, 42.1% men). Among women in CEFMP compared to those who were not, a significantly higher proportion reported forced pregnancy (50.0% vs. 18.4%, p-value=0.018), forced abortion (45.4% vs. 7.0%, p-value=0.002), and missed school due to sexual violence (94.7% vs. 63.0%, p-value=0.016). This study illustrates the need for innovative community-engaged interventions to end CEFMP in humanitarian contexts in order to achieve sexual and reproductive health and rights for youth.

"Every day I grew stronger and stronger being there".: empowerment through land-and art-based Peer Leader retreats with Indigenous and Northern young people

Indigenous adolescents in Canada are among those shouldering the impacts of colonialism and racism. Peer approaches and art-and-land-based programming have demonstrated promise to support empowerment and well-being, yet little is known about their efficacy with Northern and Indigenous adolescents in Canada or of how this group conceptualises empowerment. Fostering Open eXpression among Youth (FOXY) and Strength, Masculinities, and Sexual Health (SMASH) conduct land-and-arts-based Peer Leader Retreats with adolescents from the Northwest Territories, Nunavut and the Yukon Territories. Retreats (2017–2019) included 286 participants (n=196 women [trans-inclusive], n=84 men [trans-inclusive], n=5 non-binary), aged 12–19, the majority of whom (n=235) were Indigenous. Participants completed surveys immediately before and following retreats and 6 months after. Focus group discussions (FGDs) (n=24) were conducted with participants (peer leaders and apprentices) (n=232) following the retreat, and youth staff members (peer facilitators) (aged 14–21, n=7 FGDs). Applying thematic analysis, we explored retreat experiences (FGDs), and Wilcoxon signed-rank tests to examine pre/post retreat changes in leadership, empowerment, and self-confidence (surveys). Quantitatively, there were statistically significant increases in leadership and empowerment in post-retreat scores compared to pre-retreat. Qualitatively, findings demonstrate how Peer Leader Retreats premised on land-and-art-based approaches can support empowerment, confidence, leadership, and social-connectedness.

Todurujo na Kadurok (empowering youth): study protocol of an HIV self-testing and edutainment comic cluster randomised trial among refugee youth in a humanitarian setting in Uganda

INTRODUCTION

Refugees experience HIV vulnerabilities due to the confluence of displacement, violence and poverty. HIV self-testing, understudied with refugees, is a promising method to increase testing uptake, yet challenges remain with linkages to confirmatory testing following a positive HIV self-test. This study aims to evaluate the effectiveness of HIV self-testing kits and 'edutainment' comics in increasing HIV testing and HIV status knowledge among refugee youth aged 16-24 years in Bidi Bidi Refugee Settlement, Uganda.

METHODS AND ANALYSIS

This study will be conducted in Bidi Bidi. We conducted a qualitative formative phase with focus groups (n=40) to generate knowledge of barriers and facilitators of HIV prevention, testing and care among refugee youth (aged 16-24) in Bidi Bidi. These findings were used to create comic scenarios aligning with edutainment approaches to health promotion and inform a four-arm cluster randomised controlled trial in Bidi Bidi using a 2×2 factorial design: (1) HIV self-testing alongside edutainment comics, (2) HIV self-testing alone, (3) edutainment comic alone and (4) standard of care. The target sample size will be 120 youth (30 per arm), who will be enrolled in the trial and followed for 3 months. Data will be collected at baseline and 3 months after enrolment. The primary outcomes (HIV testing frequency, HIV status knowledge) and secondary outcomes (linkage to confirmatory HIV testing, HIV care linkage, HIV self-test kit use, HIV-related stigma, HIV knowledge, safer sex efficacy, condom use, adolescent sexual and reproductive health (SRH) stigma, sexual relationship power, access to SRH services) will be evaluated using descriptive statistics and regression analyses.

ETHICS AND DISSEMINATION

This study was approved by the University of Toronto Research Ethics Board, Mildmay Uganda Research Ethics Committee and the Uganda National Council for Science and Technology. Results will be shared in peer-reviewed publications and community knowledge sharing.

TRIAL REGISTRATION NUMBER

NCT05213689.

Correlates of wanting to seek help for mental health and substance use concerns by sexual and gender minority young adults during the COVID-19 pandemic: A machine learning analysis

The COVID-19 pandemic has worsened the mental health and substance use challenges among many people who are Two Spirit, lesbian, gay, bisexual, transgender, queer, questioning, and intersex (2SLGBTQI+). We aimed to identify the important correlates and their effects on the predicted likelihood of wanting to seek help among 2SLGBTQI+ young adults for mental health or substance use concerns during the pandemic. A cross-sectional survey was conducted in 2020-2021 among 2SLGBTQI+ young adults aged 16-29 living in two Canadian provinces (Ontario and Quebec). Among 1414 participants, 77% (n = 1089) wanted to seek help for their mental health or substance use concerns during the pandemic, out of these, 69.8% (n = 760) reported delay in accessing care. We built a random forest (RF) model to predict the status of wanting to seek help, which achieved moderately high performance with an area under the receiver operating characteristic curve (AUC) of 0.85. The top 10 correlates of wanting to seek help were worsening mental health, age, stigma and discrimination, and adverse childhood experiences. The interactions of adequate housing with certain sexual orientations, gender identities and mental health challenges were found to increase the likelihood of wanting to seek help. We built another RF model for predicting risk of delay in accessing care among participants who wanted to seek help (n = 1089). The model identified a similar set of top 10 correlates of delay in accessing care but lacked adequate performance (AUC 0.61). These findings can direct future research and targeted prevention measures to reduce health disparities for 2SLGBTQI+ young adults.

Intersectional stigmas are associated with lower viral suppression rates and antiretroviral therapy adherence among women living with HIV

OBJECTIVES

To explore the associations between intersectional poverty, HIV, sex, and racial stigma, adherence to antiretroviral therapy (ART), and viral suppression among women with HIV (WHIV).

DESIGN

We examined intersectional stigmas, self-report ART adherence, and viral suppression using cross-sectional data.

METHODS

Participants were WHIV ( N  = 459) in the Women's Adherence and Visit Engagement, a Women's Interagency HIV Study substudy. We used Multidimensional Latent Class Item Response Theory and Bayesian models to analyze intersectional stigmas and viral load adjusting for sociodemographic and clinical covariates.

RESULTS

We identified five intersectional stigma-based latent classes. The likelihood of viral suppression was approximately 90% lower among WHIV who experienced higher levels of poverty, sex, and racial stigma or higher levels of all intersectional stigmas compared with WHIV who reported lower experiences of intersectional stigmas. ART adherence accounted for but did not fully mediate some of the associations between latent intersectional stigma classes and viral load.

CONCLUSION

The negative impact of intersectional stigmas on viral suppression is likely mediated, but not fully explained, by reduced ART adherence. We discuss the research and clinical implications of our findings.

Associations between water insecurity and depression among refugee adolescents and youth in a humanitarian context in Uganda: cross-sectional survey findings

BACKGROUND

Water insecurity is linked to poor mental health through intrapersonal, relational and community-based stressors. We examined water insecurity and depression among refugee youth in Bidi Bidi, Uganda.

METHODS

We conducted a cross-sectional survey and multivariable ordinal logistic regression to examine associations between water insecurity and depression severity, adjusting for gender, resilience, social support and food insecurity.

RESULTS

Among participants (n=115; mean age: 19.7 y, SD 2.3), 80.0% reported water insecurity and 18.3% had moderate/severe depression symptoms. Water insecurity was independently associated with higher levels of depression severity (adjusted OR: 5.61; 95% CI 1.20 to 26.30; p=0.03).

CONCLUSIONS

Findings suggest water insecurity was commonplace and associated with depression. Water insecurity could be integrated in refugee mental health promotion by policymakers and community-based programmers.

Sexual and reproductive health outcomes for forcibly displaced persons living in urban environments in low- and middle-income countries: a scoping review protocol

OBJECTIVE

The objective of this review is to characterize the state of literature regarding forcibly displaced persons' sexual and reproductive health in urban areas in low- and middle-income countries. Specific objectives include describing the sexual and reproductive health outcomes among forcibly displaced persons relocating in urban environments.

INTRODUCTION

As a result of persecution, conflict, violence, human rights violations, and disruptive events, 89.3 million people worldwide were forcibly displaced as of the end of 2021. Forcibly displaced people face a wide range of sexual and reproductive health challenges in their countries of origin, en route to final destinations, and on arrival in host communities. There is a growing urbanization of forcibly displaced persons, yet there is limited attention on sexual and reproductive health outcomes of this population.

INCLUSION CRITERIA

This review will consider studies that include sexual and/or reproductive health outcomes and needs of forcibly displaced persons within urban environments in low- and middle-income countries. Published and unpublished evidence, including quantitative, qualitative, mixed methods research, and gray literature, will be eligible for inclusion.

METHODS

MEDLINE, Embase, PsycINFO, CINAHL, IBSS, ASSIA, SSCI, and Global Medicus Index will be searched for English-language articles. Titles and abstracts will be screened against the inclusion criteria, followed by full-text review of potentially eligible studies, which will be independently assessed by 2 reviewers. Eligible articles will be extracted and charted. Results from extracted data will be tabulated and accompanied by a narrative summary to summarize and contextualize the extracted data to describe how the results relate to the review's objectives and question.

Community perspectives on ideal bacterial STI testing services for gay, bisexual, and other men who have sex with men in Toronto, Canada: a qualitative study

BACKGROUND

Innovation is needed to produce sustained improvements in bacterial sexually transmitted infections (STI) testing given suboptimal access and uptake among sexually active gay, bisexual or other men who have sex with men (GBM). Yet, the STI testing processes and technologies that best address local testing barriers among GBM in Toronto is unknown. We aimed to explore men's perspectives regarding STI testing services for GBM to identify and prioritize new STI testing interventions in Toronto, Ontario, Canada.

METHODS

We conducted four focus groups with twenty-seven GBM in 2017: two with cisgender men living with HIV, one with cisgender HIV-negative men, and one with transgender men. Twenty-seven men participated in the focus groups with 40% 18-30 years of age, 48% self-identifying as white, and the remainder self-identifying as Middle Eastern, Latino/Hispanic, Asian/Pacific Islander, South Asian, First Nations, African/Caribbean/Black, or mixed race. 59% of participants self-identified as living with HIV. Participants were asked about their STI testing experiences in Toronto, barriers and facilitators to testing, and ideal STI testing process. Focus groups were audio recorded, transcribed verbatim, and analyzed using thematic analysis.

RESULTS

Core concepts included how clinical context, bacterial STI testing delivery, and interactions with healthcare providers can create barriers and recommendations for ways to improve. Regarding clinical context, participants desired more clinics with accessible locations/hours; streamlined testing that minimized use of waiting rooms and wait times; and improved clinic ambience. Bacterial STI testing delivery recommendations included standardization to ensure consistency in sexual history intake, tests offered, follow-up and public health reporting between clinics. Men also recommended reducing the multistep process testing by offering components such as lab requisitions and results online. Participants also recommended interactions with healthcare providers be professional and non-judgmental, offer compassionate and competent care with destigmatizing and lesbian, gay, bisexual and trans (LGBT) affirming communication.

CONCLUSION

Concrete and practical solutions for improving existing sexual health services and facilitating optimal STI testing include streamlining testing options and providing patient-centred, LGBT-affirming care to enable optimal STI testing.

The Importance of Sexual Orientation in the Association Between Social Cohesion and Client Condom Coercion Among Women Who Exchange Sex in Baltimore, Maryland

Among women who exchange sex (WES), social cohesion is associated with multi-level HIV-risk reduction factors, and client condom coercion (CCC) is associated with increased HIV-risk. Sexual minority WES (SM-WES) face exacerbated HIV-risk, yet relevant research is scant. We examined the role of sexual orientation in the relationship between social cohesion and CCC among cisgender WES (n = 384) in Baltimore, Maryland using stratified logistic regression, controlling for potential confounders. Forty-five percent of WES experienced CCC. SM-WES reported significantly higher social cohesion than heterosexual WES. The relationship between social cohesion and CCC differed by sexual orientation. Among SM-WES, higher social cohesion was independently associated with decreased odds of experiencing CCC, controlling for food insecurity, crack use, police harassment, and method of finding clients. Among heterosexual WES, no significant association was found. Ongoing research and practice with WES should (1) collect sexual orientation data to allow for deeper understanding and tailored interventions, (2) leverage and nurture social cohesion and (3) tailor interventions to populations with attention to sexual orientation.

Short Communication: Awareness of HIV Self-Care Interventions Across Global Regions: Results from a Values and Preferences Survey

The high burden of HIV in sub-Saharan Africa places significant demands on health care services. Interventions such as HIV self-testing, and pre- and post-exposure prophylaxis (PrEP and PEP) could empower individuals to determine their HIV status and prevent HIV acquisition. In 2018, the World Health Organization disseminated an online, anonymous, global values and preferences survey to adults 18 years of age and older. The survey aimed to inform guidance on awareness, use, and preferences around self-care interventions for sexual and reproductive health. We conducted a cross-sectional analysis using Pearson's chi-squared test to compare awareness of HIV self-testing, PrEP and PEP across five global regions. Our analysis included 814 participants from 110 countries. We noted that respondents from Africa reported higher awareness of HIV interventions than participants from Europe, Latin America and the Caribbean, North America, and Asia. Our finding highlights an opportunity to expand self-care interventions for HIV prevention and management in Africa.

Relational Factors and HIV Testing Practices: Qualitative Insights from Urban Refugee Youth in Kampala, Uganda

Despite the global phenomenon of refugee urbanization, little is known of relational contexts that shape HIV testing among urban refugee youth. We explored perspectives, experiences, and preferences for social support in HIV testing among refugee youth aged 16-24 in Kampala, Uganda. We conducted five focus groups with refugee youth (n = 44) and five in-depth key informant interviews. Participant narratives signaled relational contexts shaping HIV testing included informal sources (intimate partners and family members) and formal sources (peer educators and professionals). There was heterogeneity in perspectives based on relationship dynamics. While some felt empowered to test with partners, others feared negative relationship consequences. Participant narratives reflected kinship ties that could facilitate testing with family, while others feared coercion and judgment. Peer support was widely accepted. Professional support was key for HIV testing as well as conflict-related trauma. Findings emphasize bonding and bridging social capital as salient components of enabling HIV testing environments.

Examining the substance use, violence, and HIV and AIDS (SAVA) syndemic among urban refugee youth in Kampala, Uganda: cross-sectional survey findings

Background

Interactions between substance use, violence, HIV and AIDS, known as the ‘SAVA’ syndemic, are understudied among refugee youth. We assessed the synergistic effects of frequent alcohol use, depression and violence on HIV vulnerability among urban refugee youth aged 16–24 years in Kampala, Uganda.

Methods

We conducted a cross-sectional survey between January and April 2018 with a convenience sample of refugee youth aged 16–24 years living in informal settlements in Kampala (Kabalagala, Rubaga, Kansanga, Katwe, Nsambya). We assessed non-communicable health conditions (frequent [≥3 times per week] alcohol use [FAU]; depression); violence (young adulthood violence [YAV] at age ≥16 years, intimate partner violence [IPV]), and HIV vulnerability (past 12-month transactional sex; recent [past 3-month] multiple [≥2] sex partners). We calculated the prevalence and co-occurrence of non-communicable health conditions, violence and HIV vulnerability variables. We then conducted multivariable logistic regression analyses to first create unique profiles of FAU, depression, YAV and IPV exposures, and second to assess for interactions between exposures on HIV vulnerability outcomes.

Results

Most participants (n=445; mean age: 19.59, SD: 2.6; women: n=333, 74.8%, men: n=112, 25.2%) reported at least one non-communicable health condition or violence exposure (n=364, 81.8%), and over half (n=278, 62.4%) reported co-occurring exposures. One-fifth reported FAU (n=90; 20.2%) and one-tenth (n=49; 11%) major depression. In logistic regression models including all two-way product terms, adjusted for sociodemographics, we found (a) multiplicative interaction for joint effects of FAU and IPV (adjusted OR (aOR)=4.81, 95% CI: 1.32 to 17.52) on multiple sex partners, and (b) multiplicative interaction for joint effects of FAU and IPV (aOR=3.72, 95% CI: 1.42 to 9.74), and YAV and depression (aOR=7.13, 95% CI: 1.34 to 37.50), on transactional sex.

Conclusion

Findings signal the importance of addressing the SAVA syndemic among urban refugee youth in Uganda. Synergistic interactions indicate that addressing FAU, depression or violence may concomitantly reduce HIV vulnerability with urban refugee youth.

Syndemics and clinical science

The theory of syndemics has received increasing attention in clinical medicine since the onset of the COVID-19 pandemic, due to the synergistic interactions of the disease with pre-existing political, structural, social and health conditions. In simple terms, syndemics are synergistically interacting epidemics that occur in a particular context with shared drivers. When policymakers ask why some communities have higher death rates from COVID-19 compared with other communities, those working from a syndemics framework argue that multiple factors synergistically work in tandem, and populations with the highest morbidity and mortality experience the greatest impact of these interactions. In this Perspective, we use specific case examples to illustrate these concepts. We discuss the emergence of syndemics, how epidemics interact, and what scientists, clinicians and policymakers can do with this information.