Evidence Update Issue 23, 2020

AIDS and Behavior
Sustained Sobriety: A Qualitative Study of Persons with HIV and Chronic Hepatitis C Coinfection and a History of Problematic Drinking. In this study, 14  Human Immunodeficiency Virus/Hepatitis C (HIV/HCV) coinfected persons who endorsed past problematic drinking were interviewed about their path to sustained sobriety. In open-ended interviews, participants often described their drinking in the context of polysubstance use and their decision to become sober as a singular response to a transcendent moment or a traumatic event. All articulated specific, concrete strategies for maintaining sobriety. The perceived effect of the HIV or HCV diagnosis on sobriety was inconsistent, and medical care as an influence on sobriety was rarely mentioned. Qualitative interviews may offer new insights on interventions and support strategies for heavy-drinking persons with HIV/HCV coinfection.

Changing Patterns of Alcohol Use and Probability of Unsuppressed Viral Load Among Treated Patients with HIV Engaged in Routine Care in the United States. The study aimed to estimate the probability of viral non-suppression associated with changes in alcohol use among people with HIV who are prescribed Antiretroviral Therapy (ART). The study examined HIV viral load non-suppression subsequent to person-periods, bookended by two self-reports of alcohol use on a standardised patient-reported outcome assessment among adults in routine HIV care. Increasing alcohol use following a period of abstinence was associated with higher risk of unsuppressed viral load. It is important to consider patterns of alcohol use, beyond just prevalent consumption patterns, when estimating the impact of alcohol use on HIV disease progression and severity.

Culture, Health & Sexuality
PrEP uptake as a social movement among gay and bisexual men. The study addressed the lack of pre-exposure prophylaxis (PrEP) uptake among gay and bisexual men, by exploring Acquired Immune Deficiency Syndrome (AIDS) activism as a way to mobilise gay and bisexual men (GBM) to increase PrEP uptake. Qualitative data was analysed from PrEP & Me, a prospective study based in New York City, with the goal of better understanding PrEP experiences among an urban sample of GBM. Findings suggest that the ways in which GBM communicate about PrEP with peers are consistent with features of AIDS activism. Use of lay knowledge using framing strategies through peer-based intervention could expand PrEP uptake. However, elements of PrEP stigma must be addressed to engage with the wide-ranging HIV prevention needs of GBM.

‘PrEP is like an adult using floaties’: meanings and new identities of PrEP among a niche sample of gay men. This paper explores the ways in which PrEP is signified and some of the new identities it gives rise to through the analysis of PrEP discourses among ‘bugchasers’. Bugchasers comprise a niche group of gay men who eroticise HIV and fantasise with or seek to get infected. The research explores how bugchasers negatively conceptualise PrEP as a barrier to thrill and masculinity and discusses PrEP as a positive intervention that allows them to understand their own desires for risk-taking. Data was extracted from the main bugchasing section of an online forum catering to bugchasers that featured over 64,000 users. The findings highlight how understandings of these identities helps us understand how people make sense of biomedical interventions, the importance of emotional ‘side effects’, and the development of new identity positions. In so doing, it advances existing work on PrEP signification and contributes to ongoing debates about bugchasing.

‘Safe sex’: evaluation of sex education and sexual risk by young adults in Sydney. In this qualitative study, 28 young adults (18-29-year-olds) living in Sydney define ‘safe sex’, report on their experiences of sex education, and reflect on the relationship between the sex education received in school and the reality of sexual activity. Participants had a broadly neoliberal understanding of health and risk as something individuals should manage through an ideal of rational decision-making. Yet regardless of how comprehensive or limited their sex education experiences, most noted a wide gulf between safe sex as taught in the classroom and the reality of actual sexual encounters, arguing that sexual decision-making was rarely rational, and shaped by age and experience, drug use, sexual desire, and complicated interpersonal dynamics. Sex education that aims to empower by presenting individuals as sole decision-makers when it comes to prophylactic use fails to acknowledge the social contexts of sex described by participants. 

‘Somebody that looks like me’ matters: a qualitative study of black women’s preferences for receiving sexual health services in the USA. Twenty-five Black women aged 18- 35 from across nine US states were interviewed to gain insight into their experiences and preferences for receiving sexual health services. Three themes were developed from their accounts: individual and structural barriers affect access to and perceived quality of care; service provider race and gender impact sexual health care experiences; and personalised care improves engagement. Findings suggest the need for culturally informed training for sexual health practitioners working with Black women.

Localocentricity, mental health and medical poverty in communication about sex work, HIV and AIDS among trans women engaged in sex work. This study employed localocentricity (culture-centred vocalisations concerning how individuals and communities narrate, and hence, make shared meanings, of health and well-being), situated within a cultured-centred approach, as a theoretical framework to document health narratives among 29 trans women who had knowledge of or experience in sex work. This theoretical framing draws attention to the articulations between health and illness expressed by trans women in sex work in USA. Research participants emphasised how their health was affected by extreme socio-political-cultural marginalisation as well as medical poverty and mental health issues.

Delivering PrEP to adults with “low” or “no” HIV risk and youth: experiences and perspectives of PrEP providers. In this study, semi-structured qualitative interviews were conducted with 20 PrEP providers in Los Angeles, California to explore their experiences and perspectives prescribing PrEP. Overall, the findings indicate that providers generally adhered to clinical guidelines in determining PrEP eligibility. However, they also identified special considerations with respect to adults with “low” or “no” HIV risk. Findings highlight the importance of providing PrEP to patients who could potentially benefit from adoption, whether or not they present with clear behavioural indicators for PrEP. Providers should also consider the potential barriers to delivering PrEP to youth to ensure successful adoption among members of this population.

“You put yourself at risk to keep the relationship:” African American women’s perspectives on womanhood, relationships, sex and HIV. The study used Collins’ Black Feminist Thought to examine the attitudes and perceptions around HIV and sexual risk behaviours among African American women aged 50 years and older.  Overarching themes and subthemes were found, including those of expectations among African American women, risk factors and protective factors. Findings from this study have implications for the development of future HIV prevention programmes involving older African American women, who have largely been overlooked by past and ongoing HIV prevention trials and safer sex promotion efforts.

Harm Reduction Journal
A qualitative study of facilitators and barriers to participate in a needle exchange program for women who inject drugs. The aim of this study was to investigate reasons for, and barriers to, participation in needle exchange programs (NEP) among women who inject drugs (WWID) in Sweden, and to identify measures that could be taken to strengthen the program and increase participation among WWID. In-depth interviews were conducted with WWID who had participated in the Stockholm NEP for at least six months and were over 18 years old, and qualitative analysis was conducted to identify themes. This study identified factors that may increase uptake of NEP among WWID. Additional sexual and reproductive health services and “women only” access are recommended to be implemented and evaluated as part of NEP. These findings may inform and improve the current scale-up of NEPs in Sweden to ensure equal access to services.

Health Promotion Journal of Australia
Dissonances in communication with sexual health consumers in an inner‐Sydney sexual health clinic in relation to health literacy: A mixed‐methods study. This study examined the navigation of health care interactions by health consumers attending a sexual health clinic in Sydney, Australia. The researchers aimed to assess the accessibility and appropriateness of communications between the centre and patients in the context of health literacy. Semi‐structured interviews were conducted with health consumers, assessing health literacy using the Short Health Literacy Assessment for English‐Speaking Adults and a focus group with clinical staff. Dissonances around assumed knowledge in communications between health professionals and health consumers, which were most apparent when lack of knowledge about sexual health, HIV and PrEP intersected with poor English fluency were identified. These findings suggest existing models of access for HIV treatment and PrEP in Australia have been developed for high health literacy and may not support consumers who experience communication barriers due to low health literacy. 

International Journal of STD and AIDS
Examining patient characteristics and HIV-related risks among women with syphilis as indicators for pre-exposure prophylaxis in a nurse-led program (PrEP-RN). To better understand HIV-related risks and assess intentions for PrEP use among women, the researchers undertook an 18- month retrospective review of syphilis diagnoses within a group of women in Ottawa, Canada. This group was selected as they had been participants in the first nurse-led PrEP program in Canada, known as PrEP-RN. As part of this review, 23 patient files were examined noting their unique characteristics, socio-behavioural risk factors, and noted barriers to PrEP uptake. While none of the women diagnosed with syphilis were diagnosed with HIV, the findings raise some important considerations to facilitate opportunities for HIV prevention among non-men who have sex with men (MSM) which must take into consideration individual risk practices, sexual health histories, and population groups.

Genital herpes – diagnosis, treatments, attitudes and response to disclosure amongst members of the UK Herpes Viruses Association. The study explored data from questionnaires relating to various issues surrounding herpes, that is disseminated to patients who seek support from the Herpes Viruses Association (HVA), a UK patient support organisation. After analysis, the study identified preferred treatment methods and reports of psychological distress and neuropathic pain. Antiviral treatment was found to be refused by some healthcare providers. There still appears to be a considerable degree of stigma experienced by patients which can be mitigated by support from patients’ support groups such as the HVA.

Journal of Adolescent Health
Models of HIV Pre-Exposure Prophylaxis Care Used in Title X Family Planning Clinics in the Southern U.S. The study explored the role of Family Planning clinics as PrEP delivery sites for adolescent and young adult women in the southern states of the United States. Models of PrEP care in clinics in the South and clinic resources that are needed to facilitate PrEP provision were explored. Providers and administrators from 38 clinics participated in qualitative interviews. Barriers were identified, including funding and staff-related resource barriers. The study concluded that increasing onsite PrEP services will require addressing concerns related to training, educational materials, cost, and staffing.

Sexual and Gender Minority Youth and Sexual Health Education: A Systematic Mapping Review of the Literature. The study aimed to synthesize the available literature on sexual and gender minority youth (SGMY) and sexual health education. A systematic search was conducted, and a total of 32 articles were included for review. The findings highlight key perspectives underscoring how youth gained inadequate knowledge from sexual health education experiences and received content that excluded their identities and behaviours. Future research on SGMY experiences should incorporate populations understudied, including younger adolescents, sexual minority girls, and transgender persons. Further, the effectiveness of inclusive sexual health education in general population settings requires further study.

Implementing Routine HIV Screening in an Urban Adolescent Population at a General Pediatric Clinic. The researchers sought to increase the rate of routine HIV screening during preventative visits for adolescent patients aged 15 to 21 in a paediatric and adolescent clinic in accordance with national recommendations. Four plan-do-study-act cycles were conducted from May 2016 to February 2020. Interventions included education of and reminders for the multidisciplinary team on guidelines and testing, creation of a standardised workflow, introduction of a rapid point-of-care HIV antibody test (POCT), and implementation of an opt-out, medical assistant/nursing-driven protocol for HIV rapid POCT. The primary outcome measure was the monthly percentage of adolescents screened for HIV during preventative visits. Rates of routine HIV screening at preventative visits for youth aged 15 to 21 increased over four cycles. This was in large part due to testing with a rapid HIV POCT and a clinic protocol allowing medical assistants and nurses to order the protocol. The researchers suggest this model can be used for other clinics. 

“No One Stays Just on Blockers Forever”: Clinicians’ Divergent Views and Practices Regarding Puberty Suppression for Nonbinary Young People. This study aimed to explore the views and practices of Australian clinicians working with transgender or gender diverse young people regarding puberty suppression for nonbinary youth, including requests for ongoing puberty suppression into adulthood. Semi-structured  interviews were conducted with 14 clinicians (medical and mental health). After analysis, it was found that requests for puberty suppression from nonbinary young people are occurring, with 12 of 14 clinicians reporting they have received such requests. To conclude, the decision of whether to provide puberty suppression, particularly long-term, to a nonbinary young person is both ethically and clinically complex. There is currently a diversity of practice in this area, and evidence-based ethical guidelines and outcome data could promote more informed decision-making and support clinicians working in this complex area.

Journal of Medical Internet Research 
Promoting Safe Injection Practices, Substance Use Reduction, Hepatitis C Testing, and Overdose Prevention Among Syringe Service Program Clients Using a Computer-Tailored Intervention: Pilot Randomized Controlled Trial. The study assessed the effect of a computer-tailored behavioural intervention, called Hep-Net, on safe injection practices, substance use reduction, overdose prevention, and hepatitis C virus (HCV) testing among syringe-service program clients. Participants completed a computerised survey and were then assigned to receive the Hep-Net intervention. A 3 month follow-up assessed behaviour change. Findings indicated individuals who received the Hep-Net intervention were more likely to undergo HCV testing, however intervention participants did not appear to reduce the frequency of drug use or increase their readiness to reduce drug use more than control participants. Brief computerised interventions may not be robust enough to overcome the challenges associated with reducing and ceasing drug use. 

Event-Level Association Between Daily Alcohol Use and Same-Day Nonadherence to Antiretroviral Therapy Among Young Men Who Have Sex With Men and Trans Women Living With HIV: Intensive Longitudinal Study. The aim of this analysis is to characterize the association between daily alcohol use and same-day ART nonadherence captured by an ecological momentary assessment (EMA) study of young MSM and transwomen (TW) living with HIV in San Francisco. Data on alcohol and ART use were collected by daily EMA surveys administered via text messaging and were analysed over 30 days of follow-up. Daily alcohol use was associated with higher same-day ART nonuse. Results underscore the importance of individually targeted interventions that are sensitive to each participant’s dynamic risk environment.

Journal of Viral Eradication
Time for a revolution? Enhancing meaningful involvement of people living with HIV and affected communities in HIV cure-focused science. This paper reports on an Australian project, the INSPIRE project (Improve, Nurture and Strengthen education, collaboration, and communication between people living with HIV (PLHIV) and researchers, which aimed to explore barriers and enablers to enactment of the principles of meaningful involvement of PLHIV  and affected communities in HIV cure-focused research. Qualitative, thematic analysis was undertaken from data collected at workshops attended by 40 stakeholders in HIV care, research and advocacy. Workshop discussions revealed community stakeholders often feel their involvement in HIV clinical research is undervalued, evidenced by limited financial remuneration and minimal capacity to influence the research design or processes. Building long-term, formal and informal relationships between community organizations, PLHIV, researchers and research teams or laboratories was identified as a strategy to support MIPA at all stages of a clinical trial, from design to dissemination of findings.

Price of a hepatitis C cure: Cost of production and current prices for direct-acting antivirals in 50 countries. This study sought to describe current prices for originator direct-acting antivirals (DAAs) in 50 countries and evaluate the relationship between prices and GDP per capita. Data on prices were collected from national databases for 50 countries. Cost-based generic prices were estimated using an established algorithm. Prices of DAAs were found to vary widely across countries. DAA prices in most countries remain many times higher than estimated cost-based generic prices. DAAs pricing remains a barrier for those seeking treatment for hepatitis C. 

Journal of Viral Hepatitis 
Hepatitis C and HIV combined screening in primary care: A cluster randomized trial. The study aimed to evaluate the effect of a combined screening programme, which included a risk‐assessment questionnaire and rapid tests for point‐of‐care diagnosis, on screening and new diagnosis rates of HCV and HIV. This prospective, cluster randomized study was carried out in a primary care setting. The findings suggest a simple operational programme can lead to an increase in HCV and HIV screening rates, compared to an exclusively educational programme. The selection of at‐risk patients with a self‐questionnaire and the use of rapid tests significantly increased the diagnostic rate of HCV infection.

Sexually Transmitted Infections
Factors associated with sexually transmitted infection diagnosis in women who have sex with women, women who have sex with men and women who have sex with both. The study compared risk factors and STIs in self-identified women who have sex with women (WSW), women who have sex with both men and women (WSB) and how these compare to women who have sex with men only  (WSM) attending two STI clinics in Baltimore, Maryland. Analysis was conducted using data from a database of first clinic visits during 2005–2016. It was found that WSB in these clinics bear an equal or higher burden of most STIs, have more partners and report more substance use than WSM. WSW carry a lower, but still substantial burden of STIs, and many report substance use. Factors predicting STI diagnosis differ between WSW, WSB and WSM suggesting that tailored STI prevention and testing approaches are needed in these groups.

Factors associated with lower knowledge of HIV and STI transmission, testing and treatment among MSM in Ireland: findings from the MSM Internet Survey Ireland (MISI) 2015. The aim of this study was to identify factors associated with having lower knowledge of HIV and STI transmission, testing and treatment among MSM. The MSM Internet Survey Ireland 2015 was a self-completed online national survey available to MSM living in Ireland. Thirteen factual statements were used to assess participants’ knowledge of HIV and STI transmission, testing and treatment. After data analysis from the survey, the factors associated with having lower knowledge included being 18–24 years of age, born in Ireland and being out to none of their contacts. Knowledge was also lower among those who never tested for HIV and among MSM who never visited an MSM-specific health promotion website.Engagement with the main national MSM-specific sexual health promotion website was associated with higher knowledge levels.

Potential interactions between the pathways to diagnosis of HIV and other STIs and HIV self-testing: insights from a qualitative study of gay, bisexual and other men who have sex with men in Singapore. This study draws on qualitative insights on the barriers and facilitators to HIV testing, as well as perceptions of HIV self-testing (HIVST), to propose a framework to understand not only the benefits but also potential knock-on implications of introducing HIVST in the context of other STI testing. Interviews with 30 gay, bisexual and other MSM aged 18 to 39 years old in Singapore were analysed. Pathways to HIV and other STI testing were identified. The findings suggest that introducing HIVST might weaken linkages to other STI testing if alternative strategies of promoting other STI testing are not simultaneously implemented. Future interventions are recommended to address both the risks of HIV and other STIs simultaneously.