Background: In South Africa, uptake of HIV oral pre-exposure prophylaxis (PrEP) has been slow among women, who account for 60% of new HIV diagnoses. A gender-enhanced (GE) online group workshop, Masibambane (“Let Us Work Together”) (N = 50), demonstrated greater increases in PrEP stage of change versus providing participants with individual access (IA) to online PrEP educational and motivational materials (N = 50). However, participants began the study at different stages, and it was unclear which women may have benefited most from the intervention. We explored how an underused analytic method could offer greater insight into women’s change trajectories. Methods: Participants completed questionnaires at baseline (“pre-intervention”), post-intervention, and three months after baseline (“follow-up”) and documented readiness through a 5-point stage-of-change (SOC) score based on the transtheoretical model. We used Markov transition matrices to calculate probabilities of different trajectories. Results: Participants who reported 3 (“would like to speak to a counselor”) were most likely to transition to 5 (“ready to take PrEP”) at post-intervention in the GE arm (P post, pre (5|3) = 0.60) but not the IA arm (P post, pre (5|3) = 0.17). Those who scored 2 (“uncertain”) at pre-intervention also exhibited greater probabilities of upward movement in the GE arm. Discussion: Compared to IA, GE women who expressed uncertainty or a desire for counseling at baseline were more likely to shift into a state of readiness, driving the observed difference across study arms. This analysis demonstrates how Markov modeling can provide greater understanding of population change dynamics than mean values alone.

HIV pre-exposure prophylaxis (PrEP) is underutilized in the United States. Emergency Departments (EDs) can be strategic locations for initiating PrEP; however, knowledge concerning patients' receptivity to ED PrEP programs is limited. This study explores ED patients' perspectives on PrEP service delivery and their preferences for implementation. Semi-structured qualitative interviews were conducted with 15 potentially PrEP-eligible ED patients to examine their receptiveness to PrEP services, preferences for delivery methods, and logistical considerations. Most participants were open to learning about PrEP in the ED, provided it did not delay care, occur during distress, or compromise privacy. Universal PrEP education was viewed as reducing stigma and increasing awareness, while targeted screening was seen as efficient. Participants strongly preferred receiving information in person rather than via videos or pamphlets. Concerns included ensuring ED staff expertise and maintaining privacy during PrEP-related discussions. Regarding same-day PrEP versus prescriptions or referrals, opinions varied, with participants valuing flexibility and linkage to care. This first qualitative study of ED patients' perspectives on PrEP services highlights general receptiveness, with key concerns about privacy, expertise, and wait times. Patient-centered approaches, including integrating PrEP services into ED workflows, offering flexible initiation options, and providing privacy, can support the feasibility of ED-based PrEP programs.

ABSTRACT:Offering preexposure prophylaxis (PrEP) in nontraditional settings, such as emergency departments (EDs), may be an opportunity to connect HIV-vulnerable people with PrEP. Our study aimed to identify the perspectives of N = 10 ED leaders on initiating PrEP in EDs in New York City. Leaders completed 30-min, audio-recorded, in-depth interviews through Zoom, covering challenges/benefits to offering PrEP in EDs, and how potential programs could be set up and managed. From interviews, we formed three key discussion points for designing and implementing PrEP in EDs: (a) ED leadership views PrEP as important, but resource/contextual barriers pose an implementation challenge, (b) interventions must leverage familiar clinical pathways for implementation and minimize burden to provider time/ED resources, (c) using telehealth and patient navigators to implement PrEP in ED interventions could overcome the challenges but may not be available everywhere. Building on relationships with referral partners could be a viable alternative in resource constrained settings.

Oral pre-exposure prophylaxis (PrEP) has been available to adolescent girls and young women (AGYW) in the South African public sector since 2019, yet uptake has lagged below targets. In this pilot trial focused on early PrEP cascade steps, a WhatsApp®-based small-group interactive intervention with a gender-empowerment component— “gender enhanced” (GE)—was compared to a control condition providing website links to PrEP information/motivation that women accessed individually (“individual access”, IA). PrEP was not offered as part of the trial. Eligible participants were 18–25 years, heterosexually active in the past six months, but not pre-screened for PrEP eligibility. Primary outcome was undergoing individual PrEP counselling; secondary outcomes were HIV testing and self-reported PrEP initiation. Fifty women enrolled in each condition (N = 100). Retention, feasibility and acceptability were high. Fifty-six percent underwent PrEP counseling in each condition; PrEP was initiated by 8 women in GE and 5 in IA. Stage of change (readiness) for PrEP increased more in GE than IA women post-intervention (b = 0.68 [95

Background:Pre-exposure prophylaxis (PrEP) usage has slowly increased in the United States, but significant disparities persist across race, ethnicity, sex, gender, age, and geography. Determinants of PrEP inequities include stigma and medical mistrust, lack of patient-centered services, lack of access to clinical care, and organizational resistance to change-within a health care system that neglects these barriers.Methods:We describe 5 implementation strategies to providing PrEP in nontraditional settings to underserved populations, using an equity-based approach to address key structural determinants. The alternative settings used in these Ending the HIV Epidemic projects (community-based organizations, telePrEP, mobile clinics, pharmacies, emergency departments) were chosen for the setting characteristics and their serving structurally underserved populations.Results:Community-based organizations have earned trust within communities and can serve as hubs for comprehensive sexual health services, including PrEP. Telehealth, which expanded significantly because of COVID-19, can help overcome transportation and scheduling barriers to PrEP access. Mobile clinics can also broaden PrEP delivery by bringing tailored services directly to communities, often providing shorter wait times and extended hours. Pharmacists can prescribe PrEP in certain states through legislation or collaborative practice agreements, offering a convenient, community-based option. Emergency departments provide an alternative site for PrEP delivery, with the potential to reach individuals not currently engaged in regular care.Conclusion:These alternative PrEP approaches can expand options for accessing PrEP and alleviate key barriers to care in traditional settings, although they may not eliminate all inequities. Offering more choices increases the likelihood that a broader population will be reached, thereby enhancing overall access to PrEP.

HIV pre-exposure prophylaxis (PrEP) is underutilized in the United States. Emergency departments (EDs) can be strategic locations for initiating PrEP; however, knowledge concerning patients' receptivity to ED PrEP programs is limited. This study explores ED patients' perspectives on PrEP service delivery and their preferences for implementation. Semi-structured qualitative interviews were conducted with 15 potentially PrEP-eligible ED patients to examine their receptiveness to PrEP services, preferences for delivery methods, and logistical considerations. Most participants were open to learning about PrEP in the ED, provided it did not delay care, occur during distress, or compromise privacy. Universal PrEP education was viewed as reducing stigma and increasing awareness, while targeted screening was considered efficient. Participants strongly preferred receiving information in person rather than via videos or pamphlets. Concerns included ensuring ED staff expertise and maintaining privacy during PrEP-related discussions. Opinions on initiating same-day PrEP versus prescriptions or referrals varied, with participants valuing flexibility and linkage to care. This first qualitative study of ED patients' perspectives on PrEP services highlights general receptiveness, with key concerns about privacy, expertise, and wait times. Patient-centered approaches, such as integrating services into ED workflows, offering flexible initiation options, and providing privacy, can address barriers and enhance the feasibility of ED-based PrEP programs.

Expanding women’s awareness of and access to HIV pre-exposure prophylaxis (PrEP) is key to enhancing its uptake, yet young women face difficulties in deciding whether to initiate any form of PrEP. Understanding factors that shape decision-making to initiate PrEP can support uptake and continuation. The Masibambane (“Let us work together”) pilot in eThekwini (Durban), South Africa, compared a gender-enhanced (GE) online group workshop (N = 50) to an “individual access” (IA) control condition (N = 50) for women (ages 18–25 years). Both conditions aimed to increase knowledge and motivation to initiate oral PrEP. This study used 3-month follow-up qualitative interviews from 40 women (20 per condition). The Transtheoretical Model of Health Behavior Change guided interviews and a framework analysis was used to understand stages of and influences on PrEP decision-making. Underscoring that PrEP uptake is not a straightforward or singular decision, most respondents, regardless of condition, conveyed shades of contemplation for initiating PrEP; only a few stated they currently were using or were uninterested in PrEP. Many viewed PrEP as an effective woman-controlled method and believed their partners placed them at risk of HIV. Other considerations included relationship status, pill modality, daily adherence, and side effects. For those who prepared to use PrEP, logistical barriers were frequent. Peers were perceived as sources of encouragement for adopting PrEP. Given these findings, HIV prevention efforts need to include interventions to support PrEP decision-making, recognizing that the process is continuous, multifaceted, and changes over time. This study elucidated relevant factors for supporting young women’s PrEP decision-making in South Africa.

BACKGROUND:For research on sensitive topics like HIV, it is critical to understand the capacity of adolescents to provide informed consent, as parental consent has been identified as the greatest barrier to adolescent participation in biomedical research. In many countries including low-and middle-income countries, where 90% of adolescents live, adolescents can consent to sexual and reproductive healthcare but require parent/guardian permission to participate in research before age 18 - leading to adolescent underrepresentation and systematic exclusion from biomedical and behavioral studies. Among adults, research has identified effective biomedical HIV prevention tools such as pre-exposure prophylaxis (PrEP) that have successfully decreased HIV transmission. Youth in East and Southern Africa have the highest HIV incidence in the world, yet less than 1% of biomedical HIV prevention trials include minor adolescents. Thus, developmentally tailored HIV prevention and care research for adolescents and young adults is urgently needed. METHODS:Improving understanding of Capacity to consent to sensitive biomedical Research among adolescents in Rakai Uganda (ICARE) will leverage The Rakai Community Cohort Study (RCCS) to test adolescent capacity to consent to biomedical research, identify differences in developmental decision-making, characterize eligibility for, beliefs about and interest in oral and injectable pre-exposure prophylaxis (PrEP), and construct a digital toolkit for including adolescents in biomedical research. The RCCS presents a unique opportunity to compare cognitive capacity to consent for biomedical research among adolescents with and without prior research experience at three developmental stages - early (10-14 years), middle (15-17 years), and late (18-19 years) - with the cognitive capacity of their parents/guardians. DISCUSSION:Limited data are available on adolescents' actual capacity to consent, particularly in low-and middle-income countries and low resource, high HIV prevalence settings. Findings will contribute to addressing a major barrier to research participation through an examination of the capacity of adolescents to comprehend risks, benefits, and the other elements of informed consent and, therefore, to provide informed consent to biomedical research. ICARE has the potential to offer guidance for ethical boards seeking to harmonize adolescent treatment and prevention with research procedures, thus addressing a major barrier to adolescent research participation.

Background Oral preexposure prophylaxis (PrEP) effectively prevents HIV but is underutilized in the United States, particularly among populations with higher incidence of HIV. Emergency departments (EDs), which often care for medically underserved individuals, could play a key role in expanding PrEP access. However, integrating PrEP into ED workflows presents challenges. Methods This qualitative study involved interviews with 22 stakeholders from 15 EDs and 4 sexual health clinics across the United States. Participants included ED leaders, providers, and navigators. The data were analyzed using a PrEP care cascade model, focusing on provider buy-in, patient identification, education, PrEP initiation, and linkage to care. Results Key barriers included limited provider knowledge, ED priorities focused on acute care, and the reliance on grant funding without long-term plans for sustainability. Successful programs relied on ED champions to advocate for PrEP and improve staff engagement. Some EDs offered same-day PrEP prescriptions or starter packs, which improved uptake, but most relied on referrals and had low follow-up rates. Patient identification strategies, such as using navigators or risk scores, varied across sites. Education was often led by ancillary staff, as ED providers had limited time and training. Sustainability remained a major challenge, as most programs were dependent on short-term funding. Conclusions To expand PrEP access in EDs, it is essential to address systemic barriers, improve provider training and establish sustainable funding models. Streamlined workflows, dedicated staff, and targeted interventions can help EDs play a more active role in HIV prevention.

Background:HIV acquisition among adolescents and young adults (AYA, 15-24 years) is influenced by individual factors, community factors, and public policies and programs. We explored the association of HIV incidence and prevalence with these factors over time among AYA in Rakai, Uganda. Methods:We examined trends over nine survey rounds (2005-2020) of the Rakai Community Cohort Study (RCCS), an open population-based surveillance cohort of individuals living in 30 continuously followed communities in south-central Uganda (n= 35,938 person rounds). We evaluated the associations between individual and community-level factors including HIV community viremia (CV, a measure of community-level ART use and HIV prevalence) and HIV incidence and prevalence. Logistic GEE, Poisson GLM and univariate models were run for HIV prevalence, HIV incidence, and predictors of interest, respectively. Findings:HIV incidence and prevalence declined over time after round 14 (2010-2011) by 66% among AYA men and after round 17 (2015-16) by 60% among young women. Between survey round 11 (2007-2008) and round 19 (2017-2019), the proportions reporting being sexually experienced declined from 58% to 38% in adolescent men (15-19) and from 65% to 35% among adolescent women. The prevalence of VMMC among adolescent men increased from 20% in round 11 to 79% in round 19. At the community-level, we found substantial increases in ART use among PLHIV ( 5% in round 11 and 86% in round 19) with corresponding declines in community viremia. In multivariable analyses, a combination of individual and community-level factors were found to predict HIV incidence and prevalence among AYA, notably VMMC among young men and community viremia among young women. Interpretation:Declines in HIV incidence and prevalence occurred first among AYA men and later among AYA women. These coincided with declines in sexual experience and with public policies that increased access to VMMC and ART. Combination HIV prevention with AYA needs to address risk factors at multiple levels. Funding:This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD, grants R01HD091003, RO1HD070769, R01HD050180, R01 HD074949, and P2CHD058486), the National Institute of Allergy and Infectious Diseases (grants R01AI143333, R01AI110324, U01AI100031, U01AI075115, R01AI110324, R01AI102939, and K01AI125086-01), the National Institute of Mental Health (grants R01MH115799, R01MH107275, R01 MH128232, F31MH134699), and the Division of Intramural Research of the National Institute for Allergy and Infectious Diseases. Author Contributions:SAG, JSS, ISC, TL, YW, ES, SH, AND PK conceived and designed the study. ISC, JT and YW oversaw data cleaning and statistical analysis and directly accessed and verified the underlying data reported in the manuscript. AK and DM accessed the data, created the figures for the resubmission and edited the text. AK and DTL, FN, DS, JK, MKG, MJW, LWC, FMS oversaw data collection. All authors had full access to the data in the study, participated in the interpretation of data and revising the manuscript, and had final responsibility for the decision to submit for publication. Research in context:Evidence before this study: Age-specific rates of HIV incidence are often highest among AYA and particularly young women. Risk factors for HIV infection among AYA include earlier sexual initiation, multiple partners, and inconsistent condom use. Combination prevention including community-wide uptake of ART and male medical circumcision has been associated with declines in HIV incidence in Rakai, Uganda in the overall population. 1,2 A 2019 review of HIV incidence among adolescent girls and young women from 10 high-prevalence African countries found that few studies have examined incidence over time, and among those that there was limited evidence of incidence declines. 3 Added value of this study: Using data from 2005-2020 and the Rakai Community Cohort Study (RCCS) in southcentral Uganda, we found evidence that community-level factors including community viremia and ART use, VMMC among young men, and declines in sexual experience were associated with lower risk of HIV acquisition and seroprevalent infection among AYA. Declining HIV incidence and prevalence over time among AYA coincided with policy changes expanding access to ART and VMMC.Implications of all the available evidence: Age of sexual initiation and community-level factors play critical roles in HIV transmission in Rakai and in declines over time in youth HIV incidence and prevalence. HIV prevention for AYA needs to address individual factors and public policies to improve access to ART and VMMC.

Background:Preventing HIV infections among adolescents and young adults (AYAs) is crucial for curtailing the epidemic. Oral pre-exposure prophylaxis (PrEP) is a highly effective prevention method increasingly available to this age group in sub-Saharan Africa but population-based data on awareness and use of PrEP among AYAs remains limited.Methods:Analyzing survey data from 2 rounds of the Rakai Community Cohort Study, an open, population-based cohort, we estimated prevalence ratios associating various sociodemographic characteristics with PrEP awareness and ever-use among 15- to 24-year-olds in south-central Uganda between 2018 and 2023.Results:Most (62.4%, N = 3308/5301) participants were aware of PrEP as an HIV prevention method but only 1.7% (N = 133/7999) of AYAs had ever used it. Among the 35.5% (N = 2838/7999) of participants meeting PrEP eligibility criteria, ever-use was similarly rare (2.6%, N = 75/2838). Compared with 20 to 24-year-olds, 15 to 19-year-olds were less likely to report awareness [fullyadjPR (prevalence ratio) = 0.82, 95%CI (confidence interval): 0.78, 0.86] or ever-use (fullyadjPR = 0.35, 95%CI: 0.21, 0.58). Participants from fishing communities were more likely to be PrEP-aware (fullyadjPR = 1.22, 95%CI: 1.16, 1.29) or have ever used the prevention method (fullyadjPR = 6.07, 95%CI: 4.10, 8.98) than those from non-fishing communities.Conclusions:In this cross-sectional study of AYAs in Uganda, awareness of PrEP was common but ever-use was rare, even among the third of respondents who were likely PrEP-eligible. This suggests that prevention policies and barriers besides unawareness of the method impede PrEP initiation. Efforts that target those barriers, particularly for adolescents, are critical for reducing HIV incidence among this priority population.

Risk perception, its relationship to preventive health behaviors and other factors (e.g., direct experience of a disease) are important for determining effective targets for disease prevention. Whether these relationships are the same for various diseases has not been well-researched. Drawing on a holistic model of risk perception, this study compares levels of perceived risk for COVID-19 and HIV in a rural Zambian community, examines hypothesized correlates of perceived risk, and evaluates whether higher perceived risk and/or its correlates are associated with practicing preventive behaviors for each disease. The sample included 118 adults participating in a larger study of families affected by HIV. Via surveys, information about risk perception, preventive behaviors, knowledge about, trust in information sources, direct experience and hearing about each disease, and prosociality, were collected. For each disease, perceived risk was not related to its preventive behaviors. Levels of perceived risk for COVID-19 and HIV differed significantly, as did their correlates. Having trusted sources of information about HIV was related to higher perceived risk of HIV. Direct experience of COVID-19 was related to higher perceived risk of COVID-19, but only at a level of interest. Although practicing preventive behaviors for each condition was related to higher levels of knowledge about each disease at a level of interest, willingness to engage in behavior beneficial to others (prosociality) was significantly related only to COVID-19 preventive behaviors. Different diseases provoke different levels of perceived risk and engagement with preventive behaviors and may be correlated with distinct factors. These differences may be due to history of experience with a disease, as well as cultural factors.

LGBTQ+ women have long been overlooked in sexual and reproductive health research. However, recent research has established that LGBTQ+ women have unique and specific needs that need to be addressed in order to improve effectiveness of sexual health education and practice with this historically and presently underserved population. Informed by a reproductive justice framework coupled with liberation psychology theory, this review discusses the current state of sexual and reproductive health and technologies among LGBTQ+ women. In particular, we focus on a range of HIV prevention and reproductive technologies and their use and promotion, including the internal condom, abortion, oral contraceptives, dapivirine ring, HIV pre-exposure prophylaxis, intrauterine device, and other less studied options, such as the contraceptive sponge. Grounded in an intersectional framing, this review acknowledges the intersecting systems of oppression that affect multiply marginalized women inequitably and disproportionately. A sociohistorical, critical lens is applied to acknowledge the well-documented racist origins of reproductive health technologies and ongoing coercive practices that have led to medical mistrust among marginalized and stigmatized communities, particularly racialized LGBTQ+ women, women with disabilities, and women who are poor or incarcerated. Moreover, we discuss the urgent need to center LGBTQ+ women in research and clinical care, community-engaged health promotion efforts, affirming non-heteronormative sexual health education, and health policies that prioritize autonomy and dismantle structural barriers for this population. We conclude with recommendations and future directions in this area to remedy entrenched disparities in health.

Peer-to-peer chain recruitment has been used for descriptive studies, but few intervention studies have employed it. We used this method to enroll sexually active women ages 18 to 25 into an online Pre-Exposure Prophylaxis (PrEP) information and motivation intervention pilot in eThekwini (Durban), South Africa. Seeds (N = 16) were recruited by study staff and randomized to Masibambane, Ladies Chat, a Gender-Enhanced group-based WhatsApp Workshop (GE), or Individual-Access (IA), a control condition that provided participants with online information/motivation materials only. Each seed could recruit up to three women to participate in the same study condition, with an incentive for each enrolled woman; participants in subsequent waves could choose to recruit or not. We evaluated if peer-to-peer recruitment was self-sustaining and resulted in enrolling women who, in subsequent waves, had less contact with the health care system and less knowledge about PrEP than the initial seeds. Over three recruitment waves beyond the seeds, 84 women were recruited. Almost 90% of women became recruiters, with each recruiting on average 1.90 women and 1.26 eligible enrolled women. The approach was successful at reaching women with less education but not women with less health system contact and PrEP knowledge across waves. IA participants had a slightly higher, though non-significantly different, percentage of individuals who became Peer Health Advocates (PHAs) than GE participants and, on average, they recruited slightly more women who enrolled. Our findings demonstrated that peer-to-peer recruitment is a feasible and self-sustaining way to recruit SA young women into a PrEP intervention study.

Background:In sub-Saharan Africa, pediatric and adult treatment programs have not met the needs of youth living with HIV (15-24 years), whose enrollment in antiretroviral treatment (ART) programs is much lower than that of adults. To inform targeted interventions, we analyzed factors associated with ART use among youth in Uganda.Methods:Data were from 42 communities between 2011 and 2020 (5 survey rounds) from the Rakai Community Cohort Study, an open, population-based cohort. Among youth, we assessed trends in ART use over time and demographic characteristics and sexual behaviors associated with ART use.Results:Youth (N = 1518) contributed 2101 person-visits. ART coverage increased over time with 8% of men and 11% of women on ART in 2011-2013 and 45% and 68%, respectively, on ART in 2018-2020 (AORwomen vs. men=2.57; 95% CI: 1.72 to 3.84). Youth with 2 or more sexual partners compared with youth with 0-1 sexual partner were less likely to be on ART (men AOR = 0.40; 0.19-0.82; women AOR = 0.54; 0.41-0.72). Youth who reported consistent condom use were more likely to be on ART (men AOR = 2.94; 95% CI: 1.14 to 7.57; women AOR = 1.70; 95% CI: 1.00 to 2.88).Conclusions:In this longitudinal study, ART use among youth increased over time, yet at 63% remained well below UNAIDS 95-95-95 goals, thus depriving many of lifesaving treatment. Those engaging in fewer protective sexual behaviors had lower ART use, thus further increasing risk of future HIV transmission. Targeted efforts are needed to ensure rapid initiation of ART and continued engagement among this vulnerable population.

Few studies have sought to untangle the influence of social determinants and pregnancy on adolescent marriage declines. Using longitudinal data from 15- to 17-year-old girls in the Rakai Community Cohort Survey, we assessed how education, socio-economic status, orphanhood and pregnancy contributed to trends in adolescent marriage. We examined descriptive trends and logistic regressions of the associations between social determinants and adolescent marriage, and conducted causal mediation analysis to assess the extent that pregnancy mediated the effect of education on marriage. Between 1999-2018, adolescent marriages and pregnancies dropped substantially (24%-6% and 28%-8%). Girls' secondary schooling was strongly associated with lower marriage risk (aOR marriage=0.09; 95%CI=0.07-0.12), accounting for time. Lower pregnancy rates partially explained the effect of secondary schooling on lower adolescent marriage (aOR indirect effect=0.55; 95%CI=0.421-0.721). Findings affirm the importance of education in preventing adolescent marriages but call attention to the role of pregnancies in influencing adolescent marriages.

BackgroundOral HIV preexposure prophylaxis (PrEP) is safe and effective but underutilized. Health care providers' beliefs about PrEP and attitudes toward people who could benefit may affect PrEP access.MethodsThis mixed-methods study (2016-2018) was conducted in 8 New York City public sexual health clinics that implemented a PrEP program. Data included 32 in-depth qualitative interviews with clinicians, quantitatively coded to reflect their PrEP beliefs; a provider questionnaire; and 6 months of medical record visit data for these providers. Among patients with a PrEP indication, we examined the odds of a patient being initiated on PrEP associated with providers' PrEP beliefs and demographic characteristics, and patient characteristics.ResultsProviders reported strong support for offering PrEP to eligible patients. The majority denied concerns about possible development of drug-resistant viral strains, giving PrEP to people who might not benefit, and PrEP toxicity. Nevertheless, about one-third agreed with each of these concerns, and 55% thought PrEP use might limit condom use. Of 2176 patients with a PrEP indication, 20% were initiated. Providers with more restrictive PrEP beliefs did not have lower odds of initiating patients on PrEP. Women as well as Black and Latinx patients were less likely to be initiated on PrEP.ConclusionsContrary to our hypotheses, providers' negative PrEP beliefs did not seem to reduce initiation of PrEP for eligible patients. This may be attributable to clear clinical protocols, strong staff support, and training on implementing PrEP in this setting. Racial and gender disparities in PrEP uptake urgently require attention.

PrEP is an HIV prevention option that could benefit substance-involved women, a high-risk population with low PrEP uptake. Little is known about their interest in PrEP. This qualitative study used in-depth interviews to examine PrEP willingness, barriers, and facilitators among 16 women in outpatient psychosocial substance use treatment, methadone, and/or harm reduction/syringe programs in NYC. All expressed willingness to use PrEP, but only during periods of perceived risk. Women perceived themselves to be at high risk for HIV when engaging in active substance use and/or transactional sex. They perceived themselves to be at low risk and therefore unmotivated to take PrEP when abstinent from these activities. Paradoxically, a major barrier to using PrEP was anticipated interference from substance use and transactional sex, the very same activities that create a perception of risk. Facilitators of PrEP use included perceptions of it as effortless (as opposed to barrier methods during sex) and effective, safe, and accessible. Other barriers included fear of stigma and doubts about adhering daily. Recommendations for best PrEP implementation practices for substance-involved women included tailored and venue-specific PrEP information and messaging, PrEP discussion with trusted medical providers, and on-site PrEP prescription in substance use treatment and harm reduction programs.

Objective: We aimed to elucidate the role of partnerships with older men in the HIV epidemic among adolescent girls and young women (AGYW) aged 15–24 years in sub-Saharan Africa. Design: Analysis of Population-based HIV Impact Assessments in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe. Methods: We examined associations between reported partner age and recent HIV infection among AGYW, incorporating male population-level HIV characteristics by age-band. Recent HIV infection was defined using the LAg avidity assay algorithm. Viremia was defined as a viral load of more than 1000 copies/ml, regardless of serostatus. Logistic regression compared recent infection in AGYW with older male partners to those reporting younger partners. Dyadic analysis examined cohabitating male partner age, HIV status, and viremia to assess associations with AGYW infection. Results: Among 17 813 AGYW, increasing partner age was associated with higher odds of recent infection, peaking for partners aged 35–44 (adjusted odds ratio = 8.94, 95% confidence interval: 2.63–30.37) compared with partners aged 15–24. Population-level viremia was highest in this male age-band. Dyadic analyses of 5432 partnerships confirmed the association between partner age-band and prevalent HIV infection (male spousal age 35–44-adjusted odds ratio = 3.82, 95% confidence interval: 2.17–6.75). Most new infections were in AGYW with partners aged 25–34, as most AGYW had partners in this age-band. Conclusion: These results provide evidence that men aged 25–34 drive most AGYW infections, but partners over 9 years older than AGYW in the 35–44 age-band confer greater risk. Population-level infectiousness and male age group should be incorporated into identifying high-risk typologies in AGYW.

Objective Since rapid population growth challenges longitudinal population-based HIV cohorts in Africa to maintain coverage of their target populations, this study evaluated whether the exclusion of some residents due to growing population size biases key HIV metrics like prevalence and population-level viremia. Design, setting and participants Data were obtained from the Rakai Community Cohort Study (RCCS) in south central Uganda, an open population-based cohort which began excluding some residents of newly constructed household structures within its surveillance boundaries in 2008. The study includes adults aged 15–49 years who were censused from 2019 to 2020. Measures We fit ensemble machine learning models to RCCS census and survey data to predict HIV seroprevalence and viremia (prevalence of those with viral load >1000 copies/mL) in the excluded population and evaluated whether their inclusion would change overall estimates. Results Of the 24 729 census-eligible residents, 2920 (12%) residents were excluded from the RCCS because they were living in new households. The predicted seroprevalence for these excluded residents was 10.8% (95% CI: 9.6% to 11.8%)—somewhat lower than 11.7% (95% CI: 11.2% to 12.3%) in the observed sample. Predicted seroprevalence for younger excluded residents aged 15–24 years was 4.9% (95% CI: 3.6% to 6.1%)—significantly higher than that in the observed sample for the same age group (2.6% (95% CI: 2.2% to 3.1%)), while predicted seroprevalence for older excluded residents aged 25–49 years was 15.0% (95% CI: 13.3% to 16.4%)—significantly lower than their counterparts in the observed sample (17.2% (95% CI: 16.4% to 18.1%)). Over all ages, the predicted prevalence of viremia in excluded residents (3.7% (95% CI: 3.0% to 4.5%)) was significantly higher than that in the observed sample (1.7% (95% CI: 1.5% to 1.9%)), resulting in a higher overall population-level viremia estimate of 2.1% (95% CI: 1.8% to 2.4%). Conclusions Exclusion of residents in new households may modestly bias HIV viremia estimates and some age-specific seroprevalence estimates in the RCCS. Overall, HIV seroprevalence estimates were not significantly affected.