BACKGROUND:Sexually transmitted infections (STIs) including Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis during pregnancy are associated with adverse birth outcomes. However, there are limited published data available on cost estimates for implementing such screening. The aim of this study was to estimate the cost of integrating point-of-care STI screening into antenatal care in Harare, Zimbabwe, compared with a modelled standard of care (syndromic management). METHODS:We implemented screening for C. trachomatis, N. gonorrhoeae and T. vaginalis in antenatal care at two primary healthcare clinics in Harare, Zimbabwe, between 12 January 2023 and 23 October 2023. Economic costs required to deliver the testing strategy from a health system perspective were collected using a bespoke cost extraction tool based on study records, staff interviews, time-and-motion studies, local authority salary scales and other secondary sources. During the study, implementation within high-volume settings was found to not be operationally feasible, so implementation within a low-volume setting in routine care, without time required for research processes, was modelled for a 12-month period. The incremental cost per person screened and treated was calculated comparing point-of-care testing to a modelled standard of care using syndromic management. RESULTS:The composite prevalence of C. trachomatis, N. gonorrhoeae and/or T. vaginalis as measured in the intervention was 28.3% (283/1000). As a proportion of the total cost of the intervention, the largest components were test kits (55.4%), personnel (31.0%), and equipment costs (7.5%). The costs per person screened and treated were $41 and $146, respectively. The incremental costs per person screened and treated compared with syndromic management were $41 and $169, respectively. CONCLUSION:The incremental cost per person screened and treated for an STI using a point-of-care antenatal screening strategy was driven by test kit and personnel costs, underlining the need for lower cost point-of-care STI diagnostics. TRIAL REGISTRATION NUMBER:NCT05541081.

Background:Adverse childhood experiences and HIV represent interconnected public health issues. However, studies characterizing the prevalence and associations remain limited among sexual and gender minorities (i.e., lesbian, gay, bisexual, transgender, and queer/questioning individuals, collectively referred to as LGBTQ+), especially in China. This study aimed to examine adverse childhood experiences patterns, association with risk of living with HIV, and potential mediating factors among LGBTQ+ individuals in China. Methods:An online survey was provided to LGBTQ+ people and the eligibility criteria were aged 16 or older and self-identified as LGBTQ+. Participants were enrolled in Chengdu, China, between August 2023 and March 2025. Adverse childhood experiences were assessed using a validated 10-item scale. Living with HIV was based on self-report. Cluster analysis based on the k-modes algorithm was used to identify distinct patterns of adverse childhood experiences. Unconditional logistic regression models were employed to explore the associations between adverse childhood experiences and living with HIV. Mediation analyses were conducted to quantify the mediating effects of modifiable psychosocial factors on the observed associations. Sex assigned at birth, age, ethnicity, number of siblings, and gender identity were adjusted in the above analyses. Findings:A total of 10,305 LGBTQ+ individuals were enrolled and 8384 met eligibility criteria. The median age of the participants was 26 years (interquartile range, 23-31 years). Overall, 63.5% (5325/8384) of participants reported at least one adverse childhood experience. Among specific adverse childhood experiences, physical abuse was most prevalent (34.4%, 2884/8384), closely followed by emotional abuse (34.1%, 2858/8384). Exposure to any adverse childhood experiences was significantly associated with higher risks of living with HIV (adjusted odds ratio [aOR] = 1.38, 95% CI: 1.14-1.66). Subgroup analyses revealed that exposure to any ACE was significantly associated with living with HIV risk among male (1.34, 1.11-1.61), cisgender gay man (1.38, 1.08-1.76) and queer/questioning + individuals (1.57, 1.06-2.33). Mediation analysis revealed that substance use and mental health problems were significant mediators of the association between specific ACEs and living with HIV. Interpretation:Adverse childhood experiences were associated with higher burden of living with HIV among LGBTQ+ people in China. These findings highlight the importance of integrating trauma-informed, identity-tailored sexual-health services into LGBTQ+ -competent care pathways. Funding:National Natural Science Foundation of China; Natural Science Foundation of Sichuan; West China Hospital, Sichuan University; Jiangsu Provincial Professorship Career Development Grant; Nanjing Medical University Career Development Grant.

Adolescents and young adults (AYA) face disproportionately worse outcomes along the HIV prevention and care continuum. Despite global commitments to AYA engagement, AYA remain underrepresented in research, programming, and policy development. We summarize recent innovations in AYA engagement within the HIV literature and reflect on the 2023 Blueprint Collaborative, a UNICEF/WHO/UNAIDS initiative where AYA (ages 10–30) shaped global adolescent HIV strategy. Our review found examples of AYA engagement across the intervention life cycle, including in shaping research agendas, designing interventions, and building AYA capacity for sustainability. For the Blueprint Collaborative, which featured a AYA-led evidence synthesis and global open call, we assessed AYA engagement using the RIGHTS framework. A major strength of the Blueprint Collaborative was the robust AYA engagement, moving beyond AYA consultations to AYA leadership. AYA shared decision-making authority with adults as researchers, organizers, and open call judges. Through a “learning by doing” approach, AYA gained skills in research and multidisciplinary collaboration. Blueprint results were presented to senior leadership, developed into strategy, and disseminated through publications and AYA networks. AYA leadership can provide several benefits for AYA research and programming, such as institutionalizing community engagement, improving research relevance, and advancing equity. AYA are eager and capable of driving HIV strategy and policy, but senior partners should step back to enable these opportunities. Senior partners might better serve to support AYA leadership in strategic planning to align programming with AYA priorities and build research and advocacy skills.

IntroductionSustaining evidence-based HIV prevention interventions remains a persistent challenge, particularly in low- and middle-income countries where programs often rely on time-limited funding. This study explored youth-generated strategies for sustaining HIV prevention interventions among adolescents and young adults (AYA) in Nigeria following initial implementation.MethodsWe conducted a national crowdsourcing open call inviting Nigerian AYA (aged 14–24 years) to propose strategies for sustaining HIV prevention services through maintaining intervention activities (A), preserving benefits (B), and strengthening capacity (C). The open call was part of the 4 Youth By Youth (4YBY) initiative. Submissions were received as text, images, or short videos and were de-identified prior to analysis. Two trained qualitative researchers conducted inductive thematic analysis with iterative codebook development. Emergent findings were subsequently interpreted using the PLAN (People, Learning, Adaptation, and Nurturing) framework and the Dynamic Sustainability Framework to examine youth-defined sustainment mechanisms. Demographic data were analyzed descriptively.ResultsOf 105 submissions received, 70 met eligibility criteria and were included in the analysis. Youth proposed actionable strategies across three sustainment domains: maintaining delivery activities, preserving intervention value, and strengthening enabling infrastructure. Strategies included youth leadership development, institutional integration, digital adaptation, stigma reduction, participatory monitoring, and diversified financing. Across domains, youth emphasized relational engagement, adaptive learning, and capacity building as mechanisms for long-term viability.ConclusionNigerian AYA articulated practical, context-responsive strategies for sustaining HIV prevention interventions. Centering youth perspectives highlights relational, structural, and adaptive mechanisms necessary for sustaining evidence-based interventions in resource-limited settings.

Abstract Background Adolescent and young adult (AYA; 14-24 years old) engagement in HIV programs is often transient, and socioeconomically marginalized AYA are less engaged. Few studies have examined whether engagement can be sustained over time in HIV prevention programs. This study examines correlates of sustained AYA engagement over 24 months in an HIV prevention program in Nigeria. Methods We conducted a secondary data analysis of longitudinal data from an HIV prevention program among AYA in 32 local communities in Nigeria from 2021 to 2023. In the study, participants were invited to join crowdsourcing open calls, peer-led support meetings, and other activities. Engagement was assessed using a modified 12-item Tiffany-Eckenrode Program Participation Scale (0-4 per item) at months 3, 6, 12, 18, and 24. Sustained AYA engagement was defined as a mean score ≥3.0/4.0 in at least three consecutive contacts (approximately 12 months). Longitudinal analysis was conducted using generalized estimating equations, and state-level contextual analysis was done using a linear mixed model. Results A total of 1,259 AYA were included. The mean age was 19.8 ± 2.7 years; most were students (n=954,75.8%) and unemployed (n=810,64.3%). The mean participation score remained consistently high throughout the 24 months (3.245 ±0.535 to 3.319 ±0.556), with 73.0% demonstrating sustained engagement. Students were less likely to sustain engagement compared to non-students (aRR = 0.91; 95% CI: 0.84-0.97). Unemployed AYA were more likely to sustain engagement than employed AYA (aRR= 1.09; 95% CI:1.03-1.14). States with higher poverty had significantly greater sustained AYA engagement. All the main findings were robust in sensitivity analyses. Conclusion AYA engagement in the HIV self-testing implementation was high and sustained over 24 months, especially among socio-economically disadvantaged populations. This study supports the use of a participatory, AYA-led approach in sustaining AYA engagement in HIV prevention programs and has implications for the equity of HIV programs.

Pneumococcal vaccination reduces morbidity and mortality among older adults, yet coverage remains suboptimal in China. This study aimed to assess the effectiveness of a pay-it-forward intervention (covering two-thirds of the pneumococcal vaccination cost and offering the option to donate) in increasing pneumococcal vaccination among older adults (aged 60 years or older) in China, compared to standard-of-care self-paid vaccination. We used block randomization (block size = 4) to assign participants to a pay-it-forward arm and a standard-of-care arm in a 1:1 ratio. The primary outcome was pneumococcal vaccination. Secondary outcomes included influenza vaccine uptake, vaccine confidence, successful vaccine referral, and cost-effectiveness. Logistic regression analysis was used to compare PPSV-23 and influenza vaccination coverage and vaccine confidence between the two groups. The cost-effectiveness of the interventions was assessed using a micro-costing approach from the healthcare provider’s perspective. From January to September 2024, 221 older adults were randomized (110 in the pay-it-forward group and 111 in the standard-of-care group). Pneumococcal and influenza vaccine uptake were significantly higher in the pay-it-forward arm (70.9

BACKGROUND:Youth participation is critical to improving HIV prevention outcomes, yet evidence on the quality of adolescent and young adult (AYA) participation in HIV self-testing programs in low- and middle-income countries remains limited. This study assessed levels and correlates of AYA participation in HIV self-testing interventions implemented in Nigeria. METHODS:We conducted a secondary analysis of data from the Innovative Tools to Expand Youth-friendly HIV Self-Testing study, which recruited AYA aged 14-24 years from four Nigerian sites (September 2019-March 2020). Participation was measured using an adapted 12-item Tiffany-Eckenrode Program Participation Scale across four domains: ownership, voice/influence, support and community participation. Scores ranged from 0 (strongly disagree) to 4 (strongly agree) and were categorized as minimal (<3.5), moderate (3.5-4.0) or substantial (>4.0). Chi-squared tests examined associations between participation levels and sociodemographic variables, with Cramér's V summarizing effect sizes. RESULTS:Among 388 AYA (mean age 21 ± 2 years; 58% male), overall participation was high (M = 4.04 ± 0.24). Domain-specific analyses showed substantial participation in support (M = 4.08 ± 0.23), community participation (M = 4.04 ± 0.24) and ownership (M = 3.94 ± 0.27), whereas voice/influence was moderate (M = 3.87 ± 0.32). Education (χ2 = 43.23, P < 0.001; V = 0.33), employment (χ2 = 122.70, P < 0.001; V = 0.56) and income (χ2 = 119.68, P < 0.001; V = 0.55) were significantly associated with participation, whereas age, sex and marital status were not. CONCLUSION:These findings highlight generally high AYA participation in HIV self-testing interventions, but underscore socioeconomic disparities that may shape participation quality. Programs should prioritize equitable engagement strategies for youth with fewer resources.

[This corrects the article DOI: 10.1371/journal.pone.0339359.].

BACKGROUND:Implementation strategies to support equitable uptake of doxycycline post-exposure prophylaxis (doxy-PEP) for sexually transmitted infections have not been examined. We compared three layered community-engaged implementation strategies to increase doxy-PEP use among men who have sex with men (MSM) in China. METHODS:DoxyForward (ChiCTR2300074903) was a three-group, open-label, randomised controlled trial conducted at community-based organisations in seven provinces in China. MSM receiving sexual health services at community-based organisations were randomly allocated in a 1:1:1 ratio using permuted blocks to either co-creation alone (co-creation group), which provided educational materials introducing doxy-PEP co-created with local MSM community members; co-creation plus pay-it-forward (CC + PIF group), which additionally offered free doxy-PEP supported by peer donations with an optional invitation to donate; or co-creation plus pay-it-forward with social network distribution (CC + PIF + SND group), which provided additional doxy-PEP to distribute to peers. To be eligible, participants needed to be 16 years or older, identify as a cisgender man or transgender woman, and report one or more sexually transmitted infection (STI) risk behaviour in the past 12 months. Randomly allocated participants (ie, index participants) from the co-creation and CC + PIF + SND groups recruited MSM peers (ie, alter participants). The primary outcome was doxy-PEP use within 72 h of condomless anal or oral sex with a male partner on one or more occasions at 6 months. All index participants were included in the primary analysis, with missing data addressed using multiple imputation. Proportions of alter participants who achieved the primary outcome were compared between the co-creation and CC + PIF + SND groups. FINDINGS:Between July 9 and Dec 27, 2024, 483 community-based organisation attendees were screened, and 399 (83%) were enrolled as index participants. All participants were cisgender men, and median age was 30 years (IQR 25-39). Before joining this study, 140 (35%) had heard of doxy-PEP, and 27 (7%) had used doxy-PEP. 6-month follow-up was completed by 343 (86%) of the 399 index participants. Doxy-PEP use after condomless sex at six months was reported by 48 (41%) of 117 of index participants in the co-creation group, 89 (76%) of 117 in the CC + PIF group (risk difference [RD] 31·3 vs co-creation group [95% CI 19·1-43·6]; p<0·0001), and 80 (73%) of 109 in the CC + PIF + SND group (RD 34·3 vs co-creation group [22·5-46·2]; p<0·0001). Doxy-PEP use was also higher among alter participants who received doxy-PEP through social network distribution than referral to community-based organisations (32 [68%] of 47 vs 39 [40%] of 98; RD 28·3 [95% CI 11·8-44·8]; p<0·0001). INTERPRETATION:Community-engaged implementation strategies significantly increased doxy-PEP uptake in a setting with low baseline use. Co-creation and pay-it-forward worked synergistically to increase doxy-PEP use. FUNDING:Dermatology Hospital of Southern Medical University, United States National Institutes of Health (R01AI158826). TRANSLATION:For the Chinese translation of the abstract see Supplementary Materials section.

BACKGROUND:The HIV incidence among Chinese men who have sex with men (MSM) has still been high over the past decade. Despite HIV pre-exposure prophylaxis (PrEP) being an effective prevention strategy, few studies have examined PrEP uptake and adherence in China. This study examined PrEP initiation and adherence among Chinese MSM enrolled in a multi-site PrEP demonstration trial. METHODS:Three-month data for this study were drawn from a PrEP demonstration project in Guangzhou and Wuhan, China. The project aimed to increase the engagement of MSM in China for HIV/STI screening, HIV risk reduction, and PrEP initiation and adherence through the use of a mobile phone app and community engagement with crowdsourcing of messages and study images. Part of the intervention was the provision of tenofovir/emtricitabine as PrEP through two types of modalities: (1) once-daily oral dose (Daily-PrEP), or (2) event-driven dose (i.e. the 2 + 1 + 1 approach, Event-Driven PrEP). The outcome of interest was PrEP adherence, defined as missing fewer than five pills in the past 30 days for Daily PrEP, and no missed doses for the Event-Driven PrEP regimen. Univariate and multivariate logistic regressions were conducted for data analyses. RESULTS:A total of 927 individuals started PrEP, with follow-up data available for 650 people (70%) after 3 months. There were 593 men with a median age of 30 years (range 21-61 years) in this study. Of those people, 341 reported taking Daily-PrEP, and 93% (317/341) reported missing fewer than five pills in the past 30 days. Among 252 participants who reported taking the Event-Driven PrEP regimen, 61.5% (155/252) reported full adherence. Daily-PrEP users were more likely to report good adherence than Event-Driven PrEP users (OR 7.28, P < 0.0001, 95% CI: 4.28-12.39). CONCLUSION:We observed a higher adherence to daily PrEP compared with Event-Driven PrEP among a sample of MSM in China. Further research is needed to examine long-term PrEP adherence among MSM in China.

Introduction Crowdsourcing engages the community to create and share solutions; this participatory method could be used to create effective pre-exposure prophylaxis (PrEP) promotions. We explored acceptability of using crowdsourcing to develop PrEP promotions among sexual minority men (SMM) and sexual health providers in Alabama. Methods We conducted focus group discussions (FGDs) with SMM and interviews with sexual health providers with guides grounded in the Theoretical Framework of Acceptability. We employed thematic analysis through deductive and inductive coding. Results Ten SMM (60% Black, 50% younger than 30 years) participated in FGDs, and six providers completed interviews. We found four themes: 1) Personal identity and background inform the participation and products of crowdsourcing, 2) SMM and providers are motivated to participate in crowdsourcing, 3) Crowdsourcing participants require resources to effectively engage, and 4) Logistic and social factors are barriers to crowdsourcing participation. Discussion Crowdsourcing as a strategy to create PrEP promotions in the Southern United states would be acceptable and feasible in the correct context. These formative, yet novel, findings demonstrate that SMM and sexual health providers would be willing to participate in crowdsourcing events and also provide key insight to design crowdsourcing events.

Social innovation in health provides solutions to address healthcare delivery gaps using community engagement as a strategy. This study aimed to assess and understand the extent to which social innovation in health projects in LMICs use community engagement approaches in their processes, and how these shape and influence the outcomes of these health projects. We used a sequential mixed methods approach. Semi-structured interviews with social innovators were followed by an online survey among social innovation researchers and implementers. Interviews were recorded, transcribed and analyzed using NVivo 11, and themes informed development of the survey tool. The survey data were analyzed using STATA version-14 and descriptive statistics were presented. A total of 27 social innovators participated in semi-structured interviews, with 66.7% from Africa. The survey respondents had a mean age of 38.6 years (SD ± 11.5) and most of them were males 141 (51.5%). Community engagement in social innovation health projects was mostly utilized during problem identification 167 (62.1%), intervention identification and design 179 (66.5%), and delivery of interventions 213 (79.2%). Half of the social innovations 135 (52.1%) had very high level of community engagement, described as collaborative or shared leadership. There was differential participation of community stakeholders at different stages of the social innovation projects. Community engagement resulted into intervention acceptance, community ownership, and improved sustainability of interventions. Key sustainability strategies employed in social innovation health projects included capacity building, integration with existing health systems, partnerships, and financial interventions. More than half of the social innovation health projects used community engagement strategies across the various stages of their work. However, there is still need to create strong governance structures, co-create interventions with communities, and have shared responsibilities with the communities in order to attain the desirable high level of community engagement and substantiality in social innovation health projects in LMICs.

Background Generosity is a critical yet understudied dimension of prosocial behavior in healthcare. Existing research has focused on individual traits or professional values, with limited attention to how generosity is shaped in everyday clinical contexts. This study examines how healthcare professionals in China understand and enact generosity in sexually transmitted infection (STI) services, and how it is shaped by relational and organizational conditions. Methods We conducted semi-structured interviews with 27 healthcare professionals and a focus group with four participants across five hospitals in Guangdong Province, China. Thematic analysis explored clinicians’ understandings and experiences of generosity. Crisp-set Qualitative Comparative Analysis (csQCA) examined configurations of relational and organizational conditions associated with reported generous practices. Data were analyzed using NVivo 12 and csQCA 4.0. Given uniform outcome presence, findings are interpreted as descriptive configurational patterns rather than causal effects. Results Participants described generosity as discretionary practices beyond formal duties, including emotional support, flexible scheduling, and financial accommodations. These practices were associated with patient trust and collegial support, but also with emotional strain and boundary tensions in resource-constrained settings. Generosity was more often described in accounts involving clinicians’ engagement with patients’ broader social circumstances and experiences of supportive team environments. Overall, generosity appeared as a context-dependent practice shaped by interacting relational and organizational conditions. Conclusion Generosity in STI care appears as a relationally embedded practice shaped by interactions among clinicians, patients, and organizational environments. It reflects the coupling of relational dynamics and institutional conditions that simultaneously enable and constrain discretionary care. Sustaining situated generosity therefore depends less on individual motivation than on organizational infrastructures that structure relational work in clinical settings.

Introduction Social innovation in health is a community-engaged process to stimulate creative solutions to local health challenges. Although it has expanded, little is known about core competencies required for training social innovation in health. This evidence synthesis included data from a global scoping review and crowdsourcing open call to identify core competencies in social innovation in health training. Methods We organized a scoping review and a crowdsourcing open call to identify existing studies on training practices in social innovation in health. The scoping review followed PRISMA 2020 guidelines, and the protocol was uploaded on the Open Science Framework (OSF). We extracted studies from 2007 and 2023 describing training on social innovation in health from nine databases. The purpose was to solicit training approaches for social innovation in health, focusing on low and middle-income country (LMIC) settings. Textual data describing social innovation learning competencies from the open call and studies from the scoping review were descriptively analysed. Results Six skills, six mindsets and four types of knowledge were categorized as core competencies from 20 scoping review studies and 38 eligible open call entries. Seven competencies were further addressed for their frequent presence in the social innovation in health training. Communication skill(12 studies and 18 entries) and collaborative mindset(15 studies and 19 entries) were highlighted in training to connect stakeholders and partners from local community; Community-engaged participatory methods(14 studies and 16 entries), and intersectional knowledge (9 studies and 13 entries)were considered crucial in understanding the health context and designing the solutions. Conclusion Our evidence synthesis identified core competencies in social innovation in health through a scoping review and crowdsourcing open call. These findings informed a co-created SIH training workshop series and consensus-building on the competencies list. Future training programs or health curricula could integrate these competencies to develop standardized SIH learning frameworks.

BACKGROUND:Sexuality is a key component of psycho-physical well-being among older adults. We aimed to understand sexual attitudes and conversations, and their correlates among older adults. METHODS:This study was based on a cross-sectional survey conducted from June 2020 to December 2022 in China. Community-dwelling heterosexual older adults aged ≥50 were recruited. Sexual attitudes included believing that sex is harmful to health and supporting sex education. The conversation was defined as talking about sex with a partner. Logistic regressions were used to assess the correlates of sexual attitude and conversation. RESULTS:A total of 3001 older adults (60.6% men, 39.4% women) were included. Of these, 13.3% believed sex is harmful to health, 53.2% supported sex education and 34.6% reported conversation. For men, age (60-69 years: aOR 0.57, 95% CI: 0.39-0.82), living in urban areas (aOR 2.78, 95% CI: 1.90-4.05), being employed (aOR 0.44, 95% CI: 0.29-0.66), higher annual incomes (aOR 0.42, 95% CI: 0.22-0.78) and being sexually active (aOR 0.54, 95% CI: 0.36-0.79) were associated with believing that sex is harmful. For women, higher educational levels (aOR 0.48, 95% CI: 0.29-0.79) and sexual knowledge acquisition (aOR 1.95, 95% CI: 1.24-3.05) were significantly associated with this negative belief. Notably, older adults who reported life satisfaction (men: aOR 1.70, 95% CI: 1.32-2.18; women: aOR 2.66, 95% CI: 1.90-3.72) and sexual knowledge acquisition (men: aOR 2.00, 95% CI: 1.53-2.43; women: aOR 1.56, 95% CI: 1.13-2.17) were more likely to talk about sex. CONCLUSION:A minority of older adults believed that sex was harmful to health, whereas over half supported sex education, and approximately one-third reported conversations with their partner about sex. Targeted interventions are needed to adjust sexual attitudes and facilitate sex-related conversations.

BACKGROUND:Secondary distribution of HIV self-testing can expand testing among men who have sex with men. A parent quasi-experimental trial found that sexual health influencers (SHIs) identified by a machine-learning model achieved greater peer uptake than those identified by an empirical scale, but the factors driving distribution effectiveness remain unclear. METHODS:We conducted a secondary analysis of the parent trial (ChiCTR2000039632) in five provinces in southern China. Participants were randomized to either the empirical scale or machine-learning identification arm, and SHIs were then selected within each arm. The current analysis included 196 SHIs with complete follow up. Effective distribution was defined as motivating at least one peer to test. Predictor variables captured sociodemographic, behavioral and network characteristics. Multivariable Poisson LASSO models with multiple imputation and cross-validation estimated adjusted incidence rate ratios (aIRRs). RESULTS:Among 196 SHIs (mean age 28 years), 46.9% achieved effective distribution. A total of 286 unique peers returned verified HIV self-testing results, of whom 118 (41.3%) were first-time testers. Peer HIV testing was associated with stronger awareness of peers' HIV status (aIRR 1.31; 95% CI 1.16-1.48) and more active sharing of HIV information (aIRR 1.28; 95% CI 1.10-1.50). SHIs who had been accompanied during their own HIV test recruited more newly tested peers (aIRR 1.94; 95% CI 1.12-3.37). CONCLUSIONS:Our data have implications for secondary distribution of HIV self-test kits and suggest the need for capacity strengthening related to peer engagement in HIV self-testing.

AIM:Many STI testing services are underfunded. Pay-it-forward is a strategy to support STI testing that asks participants to donate money to spur others to receive STI testing. To explore factors influencing monetary donations, we performed a secondary analysis of data from a randomized controlled trial that evaluated a pay-it-forward strategy to increase STI testing among men in China. METHODS:We used a convergent parallel mixed-methods design to analyze data from the RCT and semi-structured interviews. Correlates of monetary donations were identified using logistic regression. Interview responses were analyzed using thematic analysis using charitable triad theory to explore donor, recipient, and organizational factors influencing donation behavior. RESULTS:A total of 800 men received the pay-it-forward intervention. Overall, 139/718 (19%) made monetary donations, with a mean amount of 3.88 USD. The total value of all donations was 539.4 USD. At the donor level, donation behavior was associated with individual characteristics such as age, gender, and prior testing history. Donors who could identify with or visualize future recipients were also more likely to donate money. At the recipient level, income was not significantly associated with donation. At the organizational level, transparency and clear messaging enhanced trust and facilitated donations. An increased perceived risk of STI infection also motivated donations. CONCLUSION:Our findings highlight key factors driving donations in a pay-it-forward program. Transparent fund allocation and real-time donor feedback can enhance trust and participation. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov NCT05723263.

Background:Incentive-based intervention has been widely implemented for HIV prevention and care, necessitating an urgent evidence-based synthesis of the extensive new evidence. Methods:We conducted a global systematic review and meta-analysis (PROSPERO: CRD42022368634) of randomised controlled trials (RCTs) identified through MEDLINE, Web of Science, and Google Scholar, Embase, Scopus, and region-specific databases (inception to Sep 10, 2024). Two reviewers independently selected studies using the Covidence online tool. Eligible studies with money-type, non-money type, and lottery type of incentives reporting outcomes along HIV prevention and care continuum were included. Cochrane Risk-of -Bias Tool (ROB) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach were used to assess risk of bias and evidence grading. We pooled risk ratio (RR) using random-effects model versus standard care. Findings:We included 62 RCTs with 118,432 participants from 16 countries, over half of which were published in the recent five years. Compared to standard care, incentive-based intervention was associated with improvements from a 1.8 times increase in HIV testing uptakes (15 studies, 82,327 participants, RR 1.83 [95% CI: 1.31-2.54], I2 = 99%) to a 1.25 times increase in viral suppression (14 studies, 14,341 participants, RR 1.25 [1.14-1.38], I2 = 75%). When limited to monetary-type incentives, it is associated with 2.13 times of HIV testing uptakes (nine studies, 17,320 participants, [95% CI: 1.36-3.33], I2 = 98%). When limited to studies with 2-3 months implementation, it is associated with 2.82 times of HIV testing uptakes (four studies, 25,167 participants, [95% CI: 1.10-7.21], I2 = 98%) The effect of incentives varied across countries with different income levels, but consistent across different sexes. There were negative effects found in studies with outcomes of reducing HIV incidence, STI prevalence, and mortality. Interpretation:Incentive-based interventions are associated with improved outcomes across the HIV prevention and care continuum, with inconsistency between incentive types, implementation duration, income-levels of countries. The results of its implementation, including outcomes and sustainability, are required to maximize its effectiveness in practice. Funding:National Natural Science Foundation of China and Guangdong Province (Grant No. 82304201 and 2024A1515012123).

Introduction: International students as a high mobility cross-border migrant group can be expose to high risk of HIV infection, however limited HIV prevention resources has been allocated to this population and prevention strategies are unclear. This scoping review aimed to examine factors influencing the use of HIV prevention services among this population globally. Methods: We searched six electronic databases (MEDLINE, EMBASE, Scopus, CINAHL, PubMed, and Web of Science) and also screened the reference lists of included studies and relevant reviews for eligible articles. Studies were eligible if they reported data regarding barriers and facilitators to HIV prevention services among international students. Data were extracted and synthesised based on a social-ecological model. All searches were completed on 10 December 2025. Results: Of 4488 records identified, we included 16 studies (12 quantitative, 3 qualitative, and 1 mixed-methods). Most (88%, 14/16) were conducted in high-income settings. We found that international students lacked tailored information about HIV and were unfamiliar with destination-country health service pathways (n=6). They also reported low perceived risk of HIV (n=5), stigma related to sexuality and racism in healthcare settings (n=5), language barriers (n=4), and cultural barriers to open communication around HIV and sexual health (n=3), all of which hindered their use of HIV prevention services. International students could benefit from tailored communication strategies (4 studies), greater public funding (4 studies), and peer support networks (2 studies). Most existing HIV prevention strategies do not target international students. Conclusions: This review indicates that international students face multi-level challenges in using HIV prevention services. Collaborative efforts are needed to provide coordinated, culturally appropriate support to ensure international students’ equitable use of HIV prevention services.

Adolescents and young adults (AYA) in Nigeria with increased HIV risk, such as those who engage in multiple sexual partnerships (i.e., more than one sexual partner within a specified period), transactional sex (i.e., exchange of money or gifts for sex), or needle-sharing (i.e., needles or other injection equipment are shared by multiple people), are eligible for pre-exposure prophylaxis (PrEP). One strategy that has the potential to reach PrEP-eligible AYA is HIV self-testing, which can expand existing HIV testing services and support differentiated PrEP programs. However, little is known about HIV self-testing in these AYA populations. We examined associations between these three high-risk behaviors and HIV self-testing. We analyzed data from Innovative Tools to Expand Youth-friendly HIV Self-Testing (I-TEST), a stepped-wedge trial examining the impact of a combination intervention package on HIV self-testing among AYA aged 14-24 years in Nigeria. We fit generalized linear models, with an identity link and a binomial error distribution, using generalized estimating equations. We generalized trial estimates to all AYA in Nigeria using a two-stage weighted approach. Of 1,429 participants, the median age was 20 years (IQR: 18-22), 50.3% were female, and 69.4% reported secondary school as their highest education level completed. AYA who engaged in transactional sex had higher HIV self-testing uptake (8.1% [4.8, 11.5]) than AYA with no history of transactional sex. There were no statistically significant differences in recent HIV self-testing uptake among AYA by sexual partnerships or needle-sharing history. The trial estimates were similar in the adjusted models. The estimates for the trial and generalized samples were in the same direction, except for AYA with two recent sexual partners. There was a high level of HIV self-testing uptake across all categories of sexual partnerships, transactional sex, and needle-sharing, with significantly higher uptake among those who engaged in transactional sex, indicating that HIV self-testing strategies are reaching these various AYA populations and the need to sustain access for these groups.