Author Archives: Roman Shresha

Background:Although research on HIV self-testing (HIVST) has rapidly increased, few studies have explored HIVST uptake in female sex workers (FSW), and none in Malaysia. Therefore, we endeavored to assess the willingness to use HIVST in this at-risk, vulnerable population. A cross-sectional survey study was conducted among 113 HIV-negative Malaysian FSW in 2017. Participants were recruited using advertisements on social media, flyers, and direct referrals from community-based organizations. Data were collected using self-administered surveys. Multivariable logistic regression was used to identify correlates of willingness to use HIVST. Nearly a third of participants (30.1%) reported they would be willing to use HIVST. Multivariable analyses adjusting for Malay ethnicity, stable housing, living in Kuala Lumpur (KL), years in sex work, age of first sex work, childhood sexual assault, history of HIV testing, and previously in prison indicated that living in KL (adjusted odds ratio [aOR]=5.214, p=0.0137) was associated with a greater willingness to use HIVST. In contrast, having stable housing (aOR=0.100, p=0.0064) was negatively associated with willingness to use HIVST. Our results indicate that HIVST may potentially enhance uptake of HIV testing among FSWs living in an urban environment and experiencing unstable housing, but overall willingness to use HIVST is low. These findings highlight the need for efforts to increase awareness of HIVST among FSWs and additional research on the effective implementation of HIVST for FSW.

Background: The use of smartphone apps can improve the HIV prevention cascade for key populations such as men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, mobile health app-based strategies have the potential to open new frontiers for HIV prevention. However, little guidance is available to inform researchers about the ethical concerns that are unique to the development and implementation of app-based HIV prevention programs.

Objective: This study aimed to fill this gap by characterizing the attitudes and concerns of Malaysian MSM regarding HIV prevention mobile apps, particularly regarding the ethical aspects surrounding their use.

Methods: We conducted web-based focus group discussions with 23 MSM between August and September 2021. Using in-depth semistructured interviews, participants were asked about the risks and ethical issues they perceived to be associated with using mobile apps for HIV prevention. Each session was digitally recorded and transcribed. Transcripts were inductively coded using the Dedoose software (SocioCultural Research Consultants) and analyzed to identify and interpret emerging themes.

Results: Although participants were highly willing to use app-based strategies for HIV prevention, they raised several ethical concerns related to their use. Prominent concerns raised by participants included privacy and confidentiality concerns, including fear of third-party access to personal health information (eg, friends or family and government agencies), issues around personal health data storage and management, equity and equitable access, informed consent, and regulation.

Conclusions: The study’s findings highlight the role of ethical concerns related to the use of app-based HIV prevention programs. Given the ever-growing nature of such technological platforms that are intermixed with a complex ethical-legal landscape, mobile health platforms must be safe and secure to minimize unintended harm, safeguard user privacy and confidentiality, and obtain public trust and uptake.

Background: HIV disproportionately affects men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, including in health care settings, mobile health (mHealth) platforms have the potential to open new frontiers in HIV prevention.

Objective: We developed an innovative, clinic-integrated smartphone app called JomPrEP, which provides a virtual platform for Malaysian MSM to engage in HIV prevention services. In collaboration with the local clinics in Malaysia, JomPrEP offers a range of HIV prevention (ie, HIV testing and pre-exposure prophylaxis [PrEP]) and other support services (eg, referral to mental health support) without having to interface face to face with clinicians. This study evaluated the usability and acceptability of JomPrEP to deliver HIV prevention services for MSM in Malaysia.

Methods: In total, 50 PrEP-naive MSM without HIV in Greater Kuala Lumpur, Malaysia, were recruited between March and April 2022. Participants used JomPrEP for a month and completed a postuse survey. The usability of the app and its features were assessed using self-report and objective measures (eg, app analytics, clinic dashboard). Acceptability was evaluated using the System Usability Scale (SUS).

Results: The participants’ mean age was 27.9 (SD 5.3) years. Participants used JomPrEP for an average of 8 (SD 5.0) times during 30 days of testing, with each session lasting an average of 28 (SD 38.9) minutes. Of the 50 participants, 42 (84%) ordered an HIV self-testing (HIVST) kit using the app, of whom 18 (42%) ordered an HIVST more than once. Almost all participants (46/50, 92%) initiated PrEP using the app (same-day PrEP initiation: 30/46, 65%); of these, 16/46 (35%) participants chose PrEP e-consultation via the app (vs in-person consultation). Regarding PrEP dispensing, 18/46 (39%) participants chose to receive their PrEP via mail delivery (vs pharmacy pickup). The app was rated as having high acceptability with a mean score of 73.8 (SD 10.1) on the SUS.

Conclusions: JomPrEP was found to be a highly feasible and acceptable tool for MSM in Malaysia to access HIV prevention services quickly and conveniently. A broader, randomized controlled trial is warranted to evaluate its efficacy on HIV prevention outcomes among MSM in Malaysia.

Abstract: The recent approval of long-acting injectable cabotegravir (CAB-LA) as PrEP for HIV prevention could be an attractive alternative for MSM, particularly among those who face barriers to adherence using the oral pill. This study reports on the awareness of long-acting injectable PrEP (LAI-PrEP) and factors associated with interest in LAI-PrEP use among a nationwide sample of MSM in Malaysia. An online cross-sectional survey was conducted between August and September 2021 to explore perspectives on PrEP modalities among Malaysian MSM (N = 870). Convenience sampling was used to recruit participants using ads on two platforms hornet and facebook. While only 9.1% of the study participants were aware of LAI-PrEP, the majority had heard of oral PrEP (80.9%). After giving a description of it, a large majority (86.6%) expressed interest in using it if made accessible. Those who had a prior history of HIV testing (aOR = 1.9; 95% CI = 1.2–3.2) were more likely to use LAI-PrEP. Interestingly, despite the concerns related to potential high cost (aOR = 3.4; 95% CI = 2.1–5.5) and long-term side effects (aOR = 1.9; 95% CI = 1.2–3.1), the majority of the participants were interested in using LAI-PrEP. Those who were afraid of (or disliked) syringes were less interested in using it (aOR = 0.2; 95% CI; 0.1–0.4). In the recent context that LAI-PrEP was shown to be safe and effective at preventing HIV, our results indicate its potential relevance as an additional PrEP option that could accelerate the uptake and scale-up of PrEP. However, it is crucial to conduct future research urgently to improve the understanding of strategies that could enhance the accessibility, acceptability, and affordability of LAI-PrEP for MSM in low- and middle-income countries, including Malaysia.

Background:Chemsex is the use of illicit drugs—particularly methamphetamine, gamma hydroxybutyrate (GHB), and gamma-butyrolactone (GBL)—to enhance sexual activity. Chemsex, which occurs primarily among communities of men who have sex with men (MSM), is associated with greater HIV risk behaviors, including multiple sex partners, group sex, condomless sex, and injection drug use. Despite evidence showing chemsex engagement among Malaysian MSM, there is a paucity of research on chemsex among MSM in Malaysia. .

Methods: This cross-sectional study was conducted through an online survey (August to September 2021) among 870 Malaysian MSM. Participants were recruited through targeted advertisements on social networks. We collected information regarding participants’ recent (<6 months) engagement in chemsex, demographic characteristics, psychosocial factors, pre-exposure prophylaxis (PrEP) knowledge and history, and recent sexual- and drug-related behavior. Multivariable logistic regression was used to identify factors associated with recent (<6 months) chemsex engagement.

Results: Just under 1 in 10 (9.0%) of participants reported having engaged in chemsex in the previous six months. More than two-thirds of participants (69.1%) had not disclosed their sexual orientation to anyone in their family and 35.2% reported moderate to severe depressive symptoms. Multivariable analysis found that recent injection drug use (adjusted odds ratio: aOR = 6.61; 95% confidence interval: CI, 2.30–19.03), having shared pre-exposure prophylaxis (PrEP) with someone else (aOR = 5.60; 95% CI, 1.76–17.77), higher perceived HIV risk (aOR = 3.15; 95% CI, 1.25–7.93), knowing someone using PrEP (aOR = 2.93; 95% CI, 1.62–5.31), recent engagement in transactional sex (aOR = 2.38; 95% CI, 1.06–5.39), having a recent STI diagnosis (aOR = 2.36; 95% CI, 1.25–4.44), recent engagement in anal sex (aOR = 2.21; 95% CI, 1.07–4.57), and recent sexual intercourse with an HIV-positive partner (aOR = 2.09; 95% CI, 1.07–4.08) were associated with recent engagement in chemsex.

Conclusions: Malaysian MSM who practice chemsex are vulnerable to several HIV risk factors, such as transactional sex, HIV-positive sexual partners, and injection drug use. There is an urgent need for programs that integrate drug, sexual health, and mental health services, with a focus on harm reduction (e.g., condoms, access to and utilization of HIV testing and PrEP services, drug knowledge, and safer drug use) tailored for MSM who practice chemsex.

Background: Men who have sex with men (MSM) are disproportionately affected by the HIV epidemic in Malaysia and globally. Cross-cutting prevention strategies such as mobile health (mHealth), particularly smartphone apps, hold great promise for HIV prevention efforts among Malaysian MSM, especially when linked to HIV testing and pre-exposure prophylaxis (PrEP).

Objective: This study aims to adapt an existing app to create and test a clinic-integrated app (JomPrEP), a virtual platform to deliver HIV testing and PrEP services for MSM in Malaysia.

Methods: The JomPrEP project involves developing and testing an app-based platform for HIV prevention among Malaysian MSM and will be conducted in 2 phases. In phase I (development phase), we will adapt an existing mHealth app (HealthMindr) to create a new clinic-integrated app called “JomPrEP” to deliver holistic HIV prevention services (eg, HIV testing, PrEP, support services for mental health and substance use) among MSM in Malaysia. During phase II (testing phase), we will use a type I hybrid implementation science trial design to test the efficacy of JomPrEP while gathering information on implementation factors to guide future scale-up in real-world settings.

Results: As of September 2022, we have completed phase I of the proposed study. Based on a series of formative work completed during phase I, we developed a fully functional, clinic-integrated JomPrEP app, which provides a virtual platform for MSM in Malaysia to facilitate their engagement in HIV prevention in a fast and convenient manner. Based on participant feedback provided during phase I, we are currently optimizing JomPrEP and the research protocols for a large-scale efficacy trial (phase II), which will commence in January 2023.

Conclusions: Scant HIV prevention resources coupled with entrenched stigma, discrimination, and criminalization of same-sex sexual behavior and substance use hamper access to HIV prevention services in Malaysia. If found efficacious, JomPrEP can be easily adapted for a range of health outcomes and health care delivery services for MSM, including adaptation to other low- and middle-income countries.

Background: The ongoing volatile opioid epidemic remains a significant public health concern, alongside continued outbreaks of HIV and hepatitis C virus among people who inject drugs. The limited access to and scale-up of medications for opioid use disorder (MOUD) among people who inject drugs, coupled with multilevel barriers to pre-exposure prophylaxis (PrEP) uptake, makes it imperative to integrate evidence-based risk reduction and HIV prevention strategies in innovative ways. To address this need, we developed an integrated rapid access to HIV prevention program for people who inject drugs (iRaPID) that incorporates same-day PrEP and MOUD for this population.

Objective: The primary objective of this pilot study is to assess the feasibility and acceptability of the program and evaluate its preliminary efficacy on PrEP and MOUD uptake for a future randomized controlled trial (RCT). We also aim to explore information on the implementation of the program in a real-world setting using a type I hybrid implementation trial design.

Methods: Using a type I hybrid implementation trial design, we are pilot testing the nurse practitioner-led iRaPID program while exploring information on its implementation in a real-world setting. Specifically, we will assess the feasibility and acceptability of the iRaPID program and evaluate its preliminary efficacy on PrEP and MOUD uptake in a pilot RCT. The enrolled 50 people who inject drugs will be randomized (1:1) to either iRaPID or treatment as usual (TAU). Behavioral assessments will occur at baseline, and at 1, 3, and 6 months. Additionally, we will conduct a process evaluation of the delivery and implementation of the iRaPID program to collect information for future implementation.

Results: Recruitment began in July 2021 and was completed in August 2022. Data collection is planned through February 2023. The Institutional Review Boards at Yale University and the University of Connecticut approved this study (2000028740).

Conclusions: This prospective pilot study will test a nurse practitioner-led, integrated HIV prevention program that incorporates same-day PrEP and MOUD for people who inject drugs. This low-threshold protocol delivers integrated prevention via one-stop shopping under the direction of nurse practitioners. iRaPID seeks to overcome barriers to delayed PrEP and MOUD initiation, which is crucial for people who inject drugs who have had minimal access to evidence-based prevention.

Background: Mobile technologies are being increasingly developed to support the practice of medicine, nursing, and public health, including HIV testing and prevention. Chatbots using artificial intelligence (AI) are novel mobile health strategies that can promote HIV testing and prevention among men who have sex with men (MSM) in Malaysia, a hard-to-reach population at elevated risk of HIV, yet little is known about the features that are important to this key population.

Methods: We conducted 5 structured web-based focus group interviews with 31 MSM in Malaysia between July 2021 and September 2021. The interviews were first recorded, transcribed, coded, and thematically analyzed using NVivo (version 9; QSR International). Subsequently, the unified theory of acceptance and use of technology was used to guide data analysis to map emerging themes related to the barriers to and facilitators of chatbot acceptance onto its 4 domains: performance expectancy, effort expectancy, facilitating conditions, and social influence.

Results: Multiple barriers and facilitators influencing MSM’s acceptance of an AI chatbot were identified for each domain. Performance expectancy (ie, the perceived usefulness of the AI chatbot) was influenced by MSM’s concerns about the AI chatbot’s ability to deliver accurate information, its effectiveness in information dissemination and problem-solving, and its ability to provide emotional support and raise health awareness. Convenience, cost, and technical errors influenced the AI chatbot’s effort expectancy (ie, the perceived ease of use). Efficient linkage to health care professionals and HIV self-testing was reported as a facilitating condition of MSM’s receptiveness to using an AI chatbot to access HIV testing. Participants stated that social influence (ie, sociopolitical climate) factors influencing the acceptance of mobile technology that addressed HIV in Malaysia included privacy concerns, pervasive stigma against homosexuality, and the criminalization of same-sex sexual behaviors. Key design strategies that could enhance MSM’s acceptance of an HIV prevention AI chatbot included an anonymous user setting; embedding the chatbot in MSM-friendly web-based platforms; and providing user-guiding questions and options related to HIV testing, prevention, and treatment.

Conclusions: This study provides important insights into key features and potential implementation strategies central to designing an AI chatbot as a culturally sensitive digital health tool to prevent stigmatized health conditions in vulnerable and systematically marginalized populations. Such features not only are crucial to designing effective user-centered and culturally situated mobile health interventions for MSM in Malaysia but also illuminate the importance of incorporating social stigma considerations into health technology implementation strategies.

Background: Preventing HIV transmission among people who inject drugs (PWID) is a key element of the US Ending the HIV Epidemic strategy and includes both pre-exposure prophylaxis (PrEP) and medications for opioid use disorder (MOUD). While both lead to decreases in HIV transmission, MOUD has other social and health benefits; meanwhile, PrEP has additional HIV prevention advantages from sexual risk and the injection of stimulants. However, these medications are often prescribed in different settings and require multiple visits before initiation. Strategies to integrate these services (i.e., co-prescription) and offer same-day prescriptions may reduce demands on patients who could benefit from them.

Methods: Nominal group technique, a consensus method that rapidly generates and ranks responses, was used to ascertain barriers and solutions for same-day delivery of PrEP and MOUD as an integrated approach among PWID (n = 14) and clinical (n = 9) stakeholders. The qualitative portion of the discussion generated themes for analysis, and the ranks of the proposed barriers and solutions to the program are presented.

Results: The top three barriers among PWID to getting a same-day prescription for both PrEP and MOUD were (1) instability of insurance (e.g., insurance lapses); (2) access to a local prescriber; and (3) client-level implementation factors, such as lack of personal motivation. Among clinical stakeholders, the three greatest challenges were (1) time constraints on providers; (2) logistics (e.g., coordination between providers and labs); and (3) availability of providers who can prescribe both medications. Potential solutions identified by both stakeholders included pharmacy delivery of the medications, coordinated care between providers and health care systems (e.g., case management), and efficiencies in clinical care (e.g., clinical checklists), among others.

Conclusions: Implementing and sustaining a combined PrEP and MOUD strategy will require co-training providers on both medications while creating efficiencies in systems of care and innovations that encourage and retain PWID in care. Pilot testing the co-prescribing of PrEP and MOUD with quality performance improvement is a step toward new practice models.

Background: The use of smartphone apps can improve the HIV prevention cascade for key populations such as men who have sex with men (MSM). In Malaysia, where stigma and discrimination toward MSM are high, app-based strategies have the potential to open new frontiers for HIV prevention efforts. However, little guidance is available to inform researchers about ethical concerns unique to the development and implementation of app-based HIV prevention programs.

Objective: This study aims to understand and characterize the attitudes and concerns of Malaysian MSM regarding HIV prevention mobile apps, particularly focusing on ethical aspects surrounding their use.

Methods: We conducted online focus group discussions with 23 MSM between August and September 2021. Using in-depth semi structured interviews, participants were asked about their perceived risks, benefits, and ethical issues associated with using mobile apps for HIV prevention. Each session was digitally recorded and transcribed. Transcripts were inductively coded using Dedoose software and analyzed to identify and interpret emerging themes.

Results: Overall, participants indicated a preference for using app-based strategies for HIV prevention efforts. Emerging themes on benefits related to app use for HIV prevention included convenience, anonymity (ability to remain anonymous while seeking care), less stigmatizing access to services (ability to avoid the burden and stigma of visiting an HIV clinic in person), readily accessible multimedia resources (eg, text, graphics, videos), and self-management portals (eg, medication adherence, appointment reminders). Prominent concerns raised by participants included privacy and confidentiality concerns, issues around personal health data storage and management, and fear of the Malaysian government accessing data.

Conclusions: The findings from this study indicate that app-based strategies for HIV prevention efforts are acceptable among Malaysian MSM. The results further highlighted the role of ethical concerns and the associated risks and benefits related to the use of app-based HIV prevention programs. Given the ever-evolving nature of such technological platforms and the complex ethical and legal landscape, such platforms must be safe and secure to ensure widespread public trust and uptake.

Background: Mobile technologies are increasingly deployed to support the practice of medicine, nursing, and public health, including HIV testing and prevention. Chatbots using artificial intelligence (AI) are novel mHealth strategies that can promote HIV testing and prevention among men who have sex with men (MSM) in Malaysia, a hard-to-reach population at elevated risk for HIV, yet little is known about features important to this key population.

Objective: To identify the barriers and facilitators of Malaysian MSM’s acceptance of an AI-chatbot designed to assist HIV testing, in relation to its perceived benefits, limitations, and preferred features among potential users.

Methods: We conducted five online focus group interviews with 31 MSM in Malaysia between July and September 2021. Interviews were first recorded, transcribed, coded, and thematically analyzed using NVIVO 9 (QSR International). The Unified Theory of Acceptance and Use of Technology (UTAUT) was used to guide data analysis to map emerging themes related to the barriers and facilitators of chatbot acceptance onto the four domains of UTAUT, specifically performance expectancy, effort expectancy, facilitating conditions, and social influence.

Results: Multiple barriers and facilitators influencing MSM’s acceptance of an AI-chatbot were identified for each domain. Performance expectancy (i.e., the perceived usefulness of the AI-chatbot) was influenced by MSM’s concerns about the AI-chatbot’s ability to deliver accurate information, its effectiveness in information dissemination and problem-solving, and its ability to provide emotional support and raise health awareness. Convenience, cost, and technical errors influenced the AI-chatbot’s effort expectancy (i.e., the perceived ease of use). Efficient linkage to healthcare professionals and HIV self-testing were reported as facilitating conditions of MSM’s receptiveness to using an AI-chatbot to access HIV testing. Social influence factors influencing acceptability of mobile technology addressing HIV in Malaysia included the socio-political climate in Malaysia, including privacy concerns, pervasive stigma against homosexuality, and the criminalization of same-sex sexual behaviors. Key design strategies that could enhance MSM’s acceptance of an HIV-prevention AI-chatbot included anonymous user setting, embedding the chatbot in MSM-friendly online platforms, and providing within-app guiding questions and options related to HIV testing, prevention, and treatment.

Conclusions: This study provides important insights into key features and potential implementation strategies central to designing an AI-chatbot as a culturally sensitive digital health tool to prevent stigmatized health conditions in vulnerable and systematically marginalized populations. Such features not only are crucial to designing effective user-centered and culturally situated mHealth intervention for MSM in Malaysia, but also illuminate the importance of incorporating social stigma considerations into health technology implementation strategies.

Purpose: Men who have sex with men (MSM) experience high levels of stigma and discrimination. Previous studies in Malaysia have demonstrated that discrimination toward MSM extends to clinical care settings, leading to MSM’s disengagement from healthcare, thus resulting in poor health outcomes. Minimizing stigma and discrimination against MSM is critical to fostering an inclusive environment for care and optimizing health outcomes. The purpose of this study was to explore the sociodemographic and stigma-related correlates of physicians’ intention to discriminate against MSM.

Methods: Physicians (N=568) from two university-affiliated hospitals in Kuala Lumpur, Malaysia, completed an online cross-sectional survey. Measures included sociodemographic characteristics, clinical background, intention to discriminate against MSM, and several stigma-related constructs. Bivariate and multivariate linear regressions were used to evaluate independent correlates of discrimination intent against MSM.

Results: On average, physicians disagreed that they intended to discriminate against MSM (M=1.9, SD=0.7), but 70.6% of physicians expressed some intention to discriminate. The multivariate model demonstrated that physicians who intended to discriminate against MSM expressed greater prejudice (B=0.27, p<0.01), had more internalized shame associated with treating MSM (B=0.25, p<0.01), and fear about MSM (B=0.35, p<0.01).

Conclusions: Stigma-related constructs including prejudice, internalized shame, and fear were positively related to physicians’ intention to discriminate against MSM. Physicians who had less favorable feelings toward people living with HIV also reported more discrimination intent toward MSM. Therefore, implementing interventions to reduce physicians’ stigma toward MSM and unfavorable feelings toward people living with HIV may promote equitable and stigma-free access to healthcare.

Background: The health risks associated with moderate alcohol consumption continue to be debated. Small amounts of alcohol might lower the risk of some health outcomes but increase the risk of others, suggesting that the overall risk depends, in part, on background disease rates, which vary by region, age, sex, and year.

Methods: For this analysis, we constructed burden-weighted dose–response relative risk curves across 22 health outcomes to estimate the theoretical minimum risk exposure level (TMREL) and non-drinker equivalence (NDE), the consumption level at which the health risk is equivalent to that of a non-drinker, using disease rates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020 for 21 regions, including 204 countries and territories, by 5-year age group, sex, and year for individuals aged 15–95 years and older from 1990 to 2020. Based on the NDE, we quantified the population consuming harmful amounts of alcohol.

Results: The burden-weighted relative risk curves for alcohol use varied by region and age. Among individuals aged 15–39 years in 2020, the TMREL varied between 0 (95% uncertainty interval 0–0) and 0·603 (0·400–1·00) standard drinks per day, and the NDE varied between 0·002 (0–0) and 1·75 (0·698–4·30) standard drinks per day. Among individuals aged 40 years and older, the burden-weighted relative risk curve was J-shaped for all regions, with a 2020 TMREL that ranged from 0·114 (0–0·403) to 1·87 (0·500–3·30) standard drinks per day and an NDE that ranged between 0·193 (0–0·900) and 6·94 (3·40–8·30) standard drinks per day. Among individuals consuming harmful amounts of alcohol in 2020, 59·1% (54·3–65·4) were aged 15–39 years and 76·9% (73·0–81·3) were male.

Interpretation: There is strong evidence to support recommendations on alcohol consumption varying by age and location. Stronger interventions, particularly those tailored towards younger individuals, are needed to reduce the substantial global health loss attributable to alcohol.

Background: Approximately 215 million Americans have been fully vaccinated for COVID-19, representing over 65% of the total population. People with HIV (PWH) may be more susceptible to COVID-19 infection or severe disease, elevating the importance of COVID-19 vaccination uptake in the population. We report results from a national survey of PWH to evaluate the likelihood of receiving a COVID-19 vaccine.

Methods: We conducted an online survey of 1,030 PWH living in the United States between December 6, 2020 and January 8, 2021 to evaluate likelihood of receiving a COVID-19 vaccine.

Results: Overall, participants were highly willing to be vaccinated, with 83.8% stating they “strongly agree” (65.7%) or “somewhat agree” (18.1%). Participants’ top vaccine-related concerns were side-effects (39.3%), safety (14.7%), and fair/equitable distribution of the vaccine to affected communities (13.6%). Participants were more willing to be vaccinated if they reported receiving an annual influenza vaccination (p < 0.001), had previously tested positive for (p = 0.043) COVID-19, had been hospitalized for (p = 0.027) COVID-19 infection, or had an undetectable HIV viral load (p = 0.002). Black (p < 0.001), politically conservative (p < 0.001), and participants with an annual income of ≤$19,999 (p = 0.005) were significantly less willing to be vaccinated for COVID-19.

Conclusions: The vast majority of PWH were willing to be vaccinated, though predominantly those who were already engaged in HIV care or directly affected by COVID-19. Findings from this large survey of PWH suggest intensive outreach efforts are needed to support engagement in vaccination programs, particularly among Black and politically conservative PWH.

Background: Pre-exposure prophylaxis (PrEP) is a valuable HIV prevention strategy, particularly among men who have sex with men (MSM); however, PrEP uptake is below the threshold needed to curb the HIV epidemic among this group, especially in settings like Malaysia, where same-sex sexual behavior is illegal.

Methods: A sample of 355 participants completed an online survey between June and July 2020, recruited through geosocial networking apps for MSM and social networking websites (e.g., Facebook). We used descriptive and multivariable analyses to examine correlates of PrEP use within this population.

Results: The sample was predominantly Malay (53.5%), had monthly incomes greater than RM 3,000 (USD 730) (52.7%), and a tertiary level of education (84.5%). About 80% of participants heard of PrEP prior to the survey, with significantly less (18.3%) having ever taken PrEP. In the adjusted multivariable logistic model, using drugs before or during sexual intercourse (“chemsex”) (AOR: 3.37; 95% CI: 1.44-7.89), being diagnosed with a sexually transmitted infection in the last 12 months (AOR: 2.08; 95% CI: 1.13-3.85), HIV testing in the previous six months (AOR: 3.23; 95% CI: 1.74-5.99), and disclosure of sexual orientation (AOR: 1.85; 95% CI: 1.02-3.34) were associated with having taken PrEP in the past.

Conclusions: This study revealed that PrEP use among Malaysian MSM is relatively low, despite high awareness, and is associated with healthcare engagement and high-risk behaviors. These results highlight the need to tailor outreach activities for individuals at increased risk for HIV and those disengaged with the health system.

The use of amphetamine-type stimulants (ATS) has been associated with increased sexual risk behaviors and HIV transmission, among other adverse health outcomes. However, ATS use among female sex workers (FSWs) in Malaysia has not yet been characterized. We examined the prevalence and correlates associated with ATS use among Malaysian FSW. Between February and December 2016, 492 FSWs, including cisgender (n=299) and transgender (n=193) women, were recruited using respondent-driven sampling in Greater Kuala Lumpur, Malaysia. A structured questionnaire was used to collect demographic characteristics, sexual behaviors, ATS and other substance use, behavioral health issues, involvement in criminal justice, and experience of physical and sexual trauma. Logistic regression analyses were conducted to determine factors associated with active ATS use, defined as ATS use in the last 30 days. Nearly one-third (32.3%) of participants reported active ATS use. In the multivariable model, ATS use was associated with drug use during sex work (aOR=17.10; 8.32-35.15), having moderate to severe level of substance use disorder (aOR=3.38; 1.48-7.70), and engaging in sex work with multiple clients per day (two clients: aOR=3.39; 1.36-8.46; three clients: aOR=5.06; 1.81-14.10). A high prevalence of ATS use was documented in our sample. The presence of moderate to severe substance use disorder, the use of drugs during sex work activity, and having multiple sex work clients per day were significantly associated with active ATS use. Given these findings, prevention and harm reduction strategies need to be tailored to address the increasing ATS use and the associated adverse health consequences among FSWs in Malaysia.

Background: Chewing tobacco and other types of smokeless tobacco use have had less attention from the global health community than smoked tobacco use. However, the practice is popular in many parts of the world and has been linked to several adverse health outcomes. Understanding trends in prevalence with age, over time, and by location and sex is important for policy setting and in relation to monitoring and assessing commitment to the WHO Framework Convention on Tobacco Control.

Methods: We estimated prevalence of chewing tobacco use as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 using a modelling strategy that used information on multiple types of smokeless tobacco products. We generated a time series of prevalence of chewing tobacco use among individuals aged 15 years and older from 1990 to 2019 in 204 countries and territories, including age-sex specific estimates. We also compared these trends to those of smoked tobacco over the same time period.

Results: In 2019, 273·9 million (95% uncertainty interval 258·5 to 290·9) people aged 15 years and older used chewing tobacco, and the global age-standardised prevalence of chewing tobacco use was 4·72% (4·46 to 5·01). 228·2 million (213·6 to 244·7; 83·29% [82·15 to 84·42]) chewing tobacco users lived in the south Asia region. Prevalence among young people aged 15–19 years was over 10% in seven locations in 2019. Although global age-standardised prevalence of smoking tobacco use decreased significantly between 1990 and 2019 (annualised rate of change: –1·21% [–1·26 to –1·16]), similar progress was not observed for chewing tobacco (0·46% [0·13 to 0·79]). Among the 12 highest prevalence countries (Bangladesh, Bhutan, Cambodia, India, Madagascar, Marshall Islands, Myanmar, Nepal, Pakistan, Palau, Sri Lanka, and Yemen), only Yemen had a significant decrease in the prevalence of chewing tobacco use, which was among males between 1990 and 2019 (−0·94% [–1·72 to –0·14]), compared with nine of 12 countries that had significant decreases in the prevalence of smoking tobacco. Among females, none of these 12 countries had significant decreases in prevalence of chewing tobacco use, whereas seven of 12 countries had a significant decrease in the prevalence of tobacco smoking use for the period.

Interpretation: Chewing tobacco remains a substantial public health problem in several regions of the world, and predominantly in south Asia. We found little change in the prevalence of chewing tobacco use between 1990 and 2019, and that control efforts have had much larger effects on the prevalence of smoking tobacco use than on chewing tobacco use in some countries. Mitigating the health effects of chewing tobacco requires stronger regulations and policies that specifically target use of chewing tobacco, especially in countries with high prevalence.

Background: Ending the global tobacco epidemic is a defining challenge in global health. Timely and comprehensive estimates of the prevalence of smoking tobacco use and attributable disease burden are needed to guide tobacco control efforts nationally and globally.

Methods: We estimated the prevalence of smoking tobacco use and attributable disease burden for 204 countries and territories, by age and sex, from 1990 to 2019 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We modelled multiple smoking-related indicators from 3625 nationally representative surveys. We completed systematic reviews and did Bayesian meta-regressions for 36 causally linked health outcomes to estimate non-linear dose-response risk curves for current and former smokers. We used a direct estimation approach to estimate attributable burden, providing more comprehensive estimates of the health effects of smoking than previously available.

Results: Globally in 2019, 1·14 billion (95% uncertainty interval 1·13–1·16) individuals were current smokers, who consumed 7·41 trillion (7·11–7·74) cigarette-equivalents of tobacco in 2019. Although prevalence of smoking had decreased significantly since 1990 among both males (27·5% [26·5–28·5] reduction) and females (37·7% [35·4–39·9] reduction) aged 15 years and older, population growth has led to a significant increase in the total number of smokers from 0·99 billion (0·98–1·00) in 1990. Globally in 2019, smoking tobacco use accounted for 7·69 million (7·16–8·20) deaths and 200 million (185–214) disability-adjusted life-years, and was the leading risk factor for death among males (20·2% [19·3–21·1] of male deaths). 6·68 million [86·9%] of 7·69 million deaths attributable to smoking tobacco use were among current smokers.

Interpretation: In the absence of intervention, the annual toll of 7·69 million deaths and 200 million disability-adjusted life-years attributable to smoking will increase over the coming decades. Substantial progress in reducing the prevalence of smoking tobacco use has been observed in countries from all regions and at all stages of development, but a large implementation gap remains for tobacco control. Countries have a clear and urgent opportunity to pass strong, evidence-based policies to accelerate reductions in the prevalence of smoking and reap massive health benefits for their citizens.