Publications

INTRODUCTION: Tobacco consumption is a significant public health problem in Nepal, accounting for 39200 deaths each year, accounting for 23.7% of all deaths. While Nepal has taken several policy measures to strengthen tobacco control, the persistent burden of tobacco and the associated health risks highlight the need for continuous monitoring and evaluation. Therefore, this study assessed the trend in age-specific and sex-specific mortality and disability attributable to different forms of tobacco use (smoking, chewing tobacco) in Nepal from 1990 to 2021. METHODS: This observational study used publicly available data from Nepal’s Global Burden of Disease (GBD) 2021 estimations. The age-standardized and age-specific summary exposure value (SEV), mortality, and disability-adjusted life years (DALYs) were extracted to measure the burden and trend of tobacco use. The data are presented as percentages or rates per 100000 population. RESULTS: From 1991 to 2021, the age-standardized SEV of tobacco consumption for both sexes at all ages decreased from 44.1% to 28.2%. The age-standardized deaths attributable to tobacco use, including all forms of tobacco products, decreased by (46.7%) from 262.9 (95% UI: 193.5–344.3) per 100000 in 1990 to 140.2 (95% UI: 101.1–181.9) per 100000 in 2021. CONCLUSIONS: Despite declines in SEV, and DALYs from 1990 to 2021, tobacco use remains a major public health concern. Strengthening smoking cessation programs, enforcing stricter tobacco control policies, raising taxes on tobacco products, and expanding public awareness campaigns are essential to reducing its burden.

Objectives: Africans who migrate to the US are initially leaner than US-born Black Americans of the same age. However, over time, they become affected by obesity, possibly due to exposure to the obesogenic food environment and sedentary lifestyle in the US. We aimed to understand barriers and facilitators to healthy diet and physical activity among African immigrants in the US. Methods: Using qualitative methods, we conducted eight focus groups remotely with 31 African immigrants (BMI ≥ 27 kg/m2) living in the US. We recruited African immigrants born in Ghana, Nigeria, Kenya, Uganda, Botswana, Ethiopia, South Africa, Sudan, and Zimbabwe. Participants completed a 5-minute screening survey to assess their eligibility. In focus groups, participants were queried about barriers and facilitators to the consumption of vegetable, lean proteins, and less sugary beverage consumption, physical activity. Data were recorded and fully transcribed. We analyzed the data using inductive qualitative content analysis, achieving inter-rater reliability of 81.8%. Results: We identified 11 barriers to a healthy diet, including differences in the taste of fruits and vegetables in the US compared to their home African countries, difficulty finding traditional African fruits and vegetables in the US, and not being accustomed to consuming raw vegetables. We identified 5 healthy diet facilitators, including making smoothies to obtain fruit servings and buying in bulk. We identified 4 barriers to physical activity, including a lack of time and paying for gym memberships. We also identified 5 physical activity facilitators, including weight gain and having friends and family with whom to exercise. Conclusions: African immigrants share similar barriers and facilitators to healthy diet and physical activity as others but also have unique barriers and facilitators that need to be addressed in tailored lifestyle interventions. Incorporating these in future lifestyle interventions may enhance relevance, engagement, and more sustainable behavior change.

Sexual and gender minority (SGM) populations experience disproportionately high rates of depression, anxiety, stress, and suicidal thoughts and behaviors (STBs). Ecological momentary assessment (EMA) offers a promising method for capturing real-time fluctuations in these psychological states. This systematic review evaluated the feasibility, acceptability, and predictive utility of EMA for assessing mental health in SGM. We searched PubMed, PsycINFO, Scopus, CINAHL, and Cochrane Library databases and identified 11 studies from 815 records. Most studies reported high feasibility and moderate-to-high acceptability, although concerns about participant burden and privacy were noted. Studies identified dynamic predictors of poor mental health, such as discrimination, affective instability, and interpersonal conflict, as well as protective factors, including social support and gender affirmation. Three studies used predictive modeling, and two incorporated EMA into just-in-time adaptive interventions (JITAIs). These findings suggest that EMA is feasible, with untapped potential for delivering responsive mental health care to SGM individuals.

Objective: To evaluate the feasibility and acceptability of daily oral emtricitabine/tenofovir alafenamide fumarate (FTC/TAF) as HIV pre-exposure prophylaxis (PrEP) among people who inject drugs with opioid use disorder (OUD). Methods: In this single-arm, open-label observational study, 100 people who inject drugs (PWID) were enrolled to receive daily oral FTC/TAF for HIV prevention through a community-based syringe services programme. Participants were referred for laboratory testing following enrolment and received a 90-day supply of FTC/TAF at baseline, 3-month and 6-month visits. Behavioural and biomedical data were collected at each follow-up visit. Feasibility was assessed by tracking the number of individuals screened, enrolled and retained in the study. Acceptability was measured at 3 and 6 months using an adapted 10-item acceptability rating profile. Adherence, uptake and side effects were assessed via self-report, and exit interviews were conducted at follow-up visits to provide qualitative context. Results: Participants had a median age of 43.5 years (IQR: 38–53), 63% were male, 52% non-Hispanic white, 37% injected daily, 67% reported condomless sex and 21% reported prior PrEP use. Although all participants were prescribed FTC/TAF, only 60 collected PrEP at least once during the study; of these, 42 collected it only once, 16 two times and two at all three time points (baseline, 3-month and 6-month). Among those on PrEP, self-reported adherence increased from 68.14% (±34.76) over 3 months to 88.37% (±21.52) over 6 months. Acceptability was high (range: 1–4): 3 months (3.20 (±0.35)) and 6 months (3.10 (±0.17)). The most frequently reported side effects were fatigue (18.4%) and nausea (17.2%). There were no HIV seroconversions. Conclusion: FTC/TAF PrEP was acceptable among PWID with OUD. However, feasibility challenges were due to low uptake and continuation, with only two participants completing PrEP pick-up at all follow-up visits, despite higher self-reported adherence among those retained at 6 months.

Background: Chemsex, a form of sexualized drug use, is a growing public health concern among men who have sex with men (MSM) in Malaysia. It is associated with an increased likelihood of HIV transmission and other adverse health outcomes, such as overdose. Although harm-reduction services are proven to be efficacious in mitigating these outcomes, they often remain inaccessible because of stigma, criminalization, and limited availability of the service. This study examines the barriers MSM face in such services and explores how a mobile smartphone app with tailored features could help overcome these barriers. Methods: From February to August 2022, six virtual focus groups were conducted with 22 MSM participants who had engaged in chemsex in the past six months. Participants were recruited through geosocial networking (GSN) applications and Facebook advertisements. The focus group sessions were recorded, transcribed, translated into English, and analyzed using thematic analysis. Results: Participants described multiple barriers to practicing chemsex harm reduction, including limited knowledge of safer drug use, peer pressure, fear of legal consequences, and stigma from healthcare providers. They emphasized the need for a mobile app that provides reliable educational resources, peer support groups, discreet ordering of harm-reduction supplies (e.g., condoms, lubricants, sterile injection equipment), and access to emergency assistance during adverse events. Privacy protection and a simple, familiar user interface were identified as essential for building trust and encouraging sustained use of the mobile app and uptake of harm reduction services among MSM. Conclusions: This study underscores the persistent structural and social barriers to harm reduction among MSM who engage in chemsex in Malaysia. A mobile app tailored to their lived experiences and privacy needs may offer a confidential pathway to harm-reduction information, community support, and linkage to services that MSM trust.

Although antiretroviral therapy (ART) has been highly effective in controlling HIV, many people with HIV (PWH) continue to experience poor quality of life (QoL), especially in resource-limited settings. This secondary analysis of a randomized clinical trial examined the impact of sequenced multilevel interventions on QoL among 940 men living with HIV who use alcohol in Mumbai, India. Participants were assigned to one of three intervention sequences—individual counseling (IC), group intervention (GI), and collective advocacy (CA) across three sites, a pilot site receiving all three interventions simultaneously, or a control site receiving standard care. QoL was measured using the EQ-5D-3 L instrument at baseline, 9, 18, and 24 months. Linear mixed models were used to assess the effect of intervention sequences on QoL over time, adjusting for sociodemographic and clinical covariates. The GI–CA–IC sequence significantly improved QoL compared to the control group (β = 0.04, 95% CI 0.02 to 0.06, p < 0.001). Conversely, the IC–GI–CA sequence showed a significant decline in QoL(β = − 0.02, 95% CI − 0.04 to − 0.01, p = 0.009). Pairwise comparisons confirmed the advantage of the GI–CA–IC sequence. Initiating with group sessions, followed by collective advocacy, and concluding with individual counseling may lead to greater improvements in QoL than other sequences. These results have significant implications for tailoring multilevel HIV interventions to optimize outcomes in local contexts. However, further research is needed to confirm these findings and explore the mechanisms underlying sequence effects.

Drug use disorders (DUDs) are emerging global public health challenges. Here we investigated the global and regional estimates of the prevalence and burden of DUDs, including amphetamine, cannabis, cocaine and opioid use disorders, from 1990 to 2023 for 204 countries and territories by using the Global Burden of Disease Study 2023. Overall, trends in global age-standardized disability-adjusted life-years of DUDs increased from 169.3 (95% uncertainty interval (95% UI), 134.4–203.9) per 100,000 people in 1990 to 212.0 (95% UI, 179.2–245.6) in 2023. In 2023, both prevalence and burden of DUDs were higher in high-income countries, particularly in the USA. The most prevalent DUDs in 2023 were cannabis use disorder (age-standardized prevalence, 270.8 (95% UI, 201.7–350.0) per 100,000 people) and opioid use disorder (205.9 (95% UI, 178.7–235.0)). Particularly, opioid use disorder showed a nearly twofold increase in prevalence and burden between 1990 and 2023. In 2023, compared with countries where cannabis use was illegal, countries permitting both recreational and medical cannabis use had higher prevalence rates for all types of DUDs. Proactive and effective policies are essential to mitigate the increasing global burden of DUDs.

Purpose: This study aimed to test the efficacy of the 4-week Bio-behavioral Community-Friendly Health Recovery Program (CHRP-BB) at improving HIV prevention outcomes among individuals receiving medication for opioid use disorder (MOUD) and to examine the extent to which cognitive dysfunction impacts outcomes. Patients and Methods: This randomized controlled trial included 237 individuals receiving MOUD and Pre-Exposure Prophylaxis (PrEP) in New Haven, CT. We conducted a longitudinal regression analysis to evaluate the impact of the intervention on HIV risk behaviors and PrEP-related outcomes over time. We estimated the effect of treatment on the outcome variables that include PrEP knowledge and adherence skills, HIV risk behavior, Syringe cleaning skills, and Condom skills using a difference-in-differences framework across four time periods (Post-intervention, and 3-, 6-, and 9-month follow-ups). Results: The CHRP-BB intervention exerted a positive effect on experimental group participants across a range of key outcomes, particularly among shorter term IDUs. Improvements that were the most pronounced included PrEP outcomes (knowledge and adherence skills) and syringe cleaning skills. Most outcomes were not significantly disrupted by cognitive dysfunction. Conclusion: Outcomes from this trial highlight the efficacy of the CHRP-BB intervention, including the use of cognitive dysfunction compensatory strategies, to significantly improve HIV prevention efforts among individuals on MOUD. We suggest that future efforts focus on refining and testing additional strategies that can further optimize intervention effects across a broader range of outcomes and MOUD patients.

Background and objectives: Anxiety and depressive symptoms among gay, bisexual, and other men who have sex with men (GBMSM) are growing public health concerns. Despite extensive global research on these issues among GBMSM, they are understudied in low- and middle-income settings like Nepal. Therefore, the present study focused on assessing the prevalence and associated factors of anxiety and depressive symptoms among GBMSM in Nepal. Methods: A nationwide cross-sectional online survey was conducted among 842 GBMSM in Nepal between March and May 2024. Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 were employed to assess anxiety and depressive symptoms, respectively. Bivariate and multivariable logistic regression analyses were utilized to examine the relationships between the outcome variables (i.e., anxiety and depressive symptoms). Results: Participants showed a concerning prevalence of anxiety and depressive symptoms. Engagement in transactional sex and substance use was associated with increased anxiety and depressive symptoms. Participants who had engaged in chemsex were also more likely to have depressive symptoms. Conversely, single participants were less likely to experience depressive symptoms. Conclusion: Our study revealed a noteworthy prevalence of anxiety and depressive symptoms among GBMSM in Nepal. These findings underscore the critical need for targeted mental health interventions to address the unique needs of GBMSM engaged in substance use and chemsex.

Early diagnosis and treatment of hypertension are critical strategies to minimize preventable deaths and suffering. Nepal has been a part of the global mass blood pressure screening initiative ‘May Measurement Month’ (MMM) since 2017. Although MMM was not executed globally due to the COVID-19 pandemic in 2020, Nepal has continued its legacy, building on the success of MMM in the past years. We used an opportunistic screening campaign for blood pressure measurement among individuals aged ≥ 18 in Nepal by following standard COVID-19 preventive measures. Of the three measurements, the second and third measurements were used to estimate the mean systolic and diastolic blood pressure (BP). Hypertension was defined as a systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, or in those who use antihypertensive medication. A total of 11,348 participants, aged between 18 and 90 years, were screened during the month of May and June in 2020, of which 56.7% were female. The mean age of the participants was 45.1 years (SD ± 17.0). The mean systolic and diastolic BP were 126.6 mmHg (SD ± 18.0) and 81.7 mmHg (SD ± 10.5). Hypertension was present in 31.5% of participants. Among the hypertensive participants, only 38% were aware of their elevated blood pressure, and 31.8% reported that they were currently taking antihypertensive medication. Furthermore, only 46.1% of the participants with hypertension had controlled BP. The low rates of awareness, treatment, and control of BP suggest the need to develop locally feasible and sustainable strategies for controlling blood pressure.

Objectives: This study aims to assess the cumulative incidence and rate of loss to follow-up (LTFU) among people living with HIV (PLHIV) in Nepal who begin antiretroviral therapy (ART) early, as well as to identify factors associated with LTFU in the context of the universal test and treat approach. Study design: Retrospective cohort study. Methods: We retrospectively analysed nationally representative routine programme data for all PLHIV initiated on ART from February 19, 2017, to February 18, 2020, and followed up until May 10, 2022. LTFU was defined as a client not returning to the HIV clinic for at least 3 months from the date of their last scheduled appointment. We calculated cumulative incidence rate (IR) and used a multivariable Cox proportional hazards regression model to identify factors associated with LTFU, reporting corresponding 95% confidence intervals (CI). Results: Of the 8192 clients included in our sample, 6797 (82.9 %) started ART within seven days following their HIV diagnosis. The overall IR of LTFU was 4.22 (95 % CI = 3.95–4.51) per 100 person years of observation. The cumulative incidence of LTFU increased over time on ART, from 3.81 % (95 % CI = 3.40–4.26) at 6 months, 6.51 % (95 % CI = 5.97–7.09) at 12 months to 13.41 % (95 % CI = 12.51–14.37) at 48 months. In the multivariable model, factors associated with higher odds of LTFU included initiating treatment within 7 days of diagnosis, younger age, being unmarried, belonging to the Dalit caste, having WHO clinical stage 1 at baseline, and initiation on a non-nucleoside reverse transcriptase inhibitors (NNRTI)-based regimen. Among key populations, sex workers, their clients, men who have sex with men and transgender, people who inject drugs were at higher risk of dropout compared to migrants. Conclusions: In this nationwide cohort, the risk of LTFU increased with time on ART. To optimize the test-and-treat strategy in Nepal, it is crucial to address the unique needs of youth and certain key populations and manage any early adverse drug reactions.

Introduction: Quality of life (QoL) encompasses an individual’s perception of their physical, psychological and social well-being, considering their goals, expectations, standards and concerns. This cross-sectional study aimed to assess the QoL of undergraduate students in Kathmandu, Nepal, and determine the associations between QoL domains and various sociodemographic characteristics. Methods: A web-based cross-sectional survey was conducted between February and March 2021 among 370 undergraduate health science and non-health sciences students at different colleges affiliated with four major universities in Kathmandu, Nepal. Health-related QoL was measured using the 24-item WHO Quality of Life Brief Version. Multivariable linear regression analysis assessed the factors associated with the different domains of QoL. Results: This study included 370 participants with a mean age (±SD) of 21.7 (±1.73) years. Among them, more than half were female (57.3%), residing in urban areas (52.4%) and from non-health science faculties (55.1%). The highest mean QoL score was observed in the psychological health domain (12.79±2.46), while the lowest was observed in physical health (12.49±3.31). Faculty of education (b=−0.71; 95% CI −1.39 to –0.03) and self-perceived illness status (b=−0.97; 95% CI −1.88 to –0.06) were significantly associated with the physical health domain of QoL; likewise, exercise habits (b=−0.53; 95% CI −1.04 to –0.02) were significantly associated with psychological health. Monthly family income (b=−0.77; 95% CI −1.51 to –0.03) and education faculty (b=−0.79; 95% CI −1.47 to –0.11) were significantly associated with the participants’ environmental domain of QoL. Conclusions: Nepali university students reported the highest QoL scores in the psychological health domain and the lowest in the physical health domain. Sociodemographic, academic, health-related and behavioural factors significantly predicted QoL. Practical measures to enhance physical health and initiatives to improve social interactions, particularly for health-science students, are recommended to improve overall QoL.

In Nepal, men who have sex with men (MSM) encounter significant social stigma, which exacerbates their vulnerability to mental health issues. The interplay of these factors increases the likelihood of engaging in risky sexual behaviors, ultimately resulting in adverse health outcomes. This study assessed the prevalence of human immunodeficiency virus (HIV) and syphilis and factors associated with syphilis infection and condomless sex in the past 6 months among MSM in Nepal. We calculated HIV and syphilis prevalence and used bivariate and multivariate analyses to identify factors associated with syphilis infection and sexual risk. Among 250 participants, the weighted HIV prevalence was 2.6% (95% confidence interval [CI]: 0.6–4.6), and the syphilis prevalence was 13.1% (95% CI: 8.8–17.2). The practice of condomless sex was found to be in 71.4% (95% CI: 65.7–76.9) of the participants. Condomless sex in the past 6 months (respondent-driven sampling [RDS] weighted adjusted odds ratio [aOR]: 4.5; 95% CI: 1.1–18) and reported employment denial due to being MSM (RDS weighted aOR: 4.1; 95% CI: 1.5–10.8) were significantly associated with higher odds of syphilis infection. MSM who were single (RDS weighted aOR: 2.2; 95% CI: 1.1–4.4) and gay (RDS weighted aOR: 2.2; 95% CI 1.2–4.1) had a higher likelihood of having condomless sex in the past 6 months. These findings highlight the need for targeted interventions at multiple levels to address the specific needs of marginalized populations, such as MSM, to lower their risk of sexually transmitted infections and reduce unsafe sexual behaviors, notably unprotected sex.

Introduction: Globally, gay, bisexual, and other men who have sex with men (GBMSM) experience disproportionate levels of stigma, and Nepal is no exception. Unfortunately, a standardized and cross-culturally validated scale is unavailable to measure the multidimensional stigma among GBMSM in Nepal. Therefore, the present study aimed to validate and evaluate the psychometric properties of the Nepali version of Neiland’s sexual stigma scale (NNSSS) among GBMSM in Nepal. Methods: A cross-sectional survey was conducted among 842 GBMSM in Nepal. Participants completed the NNSSS, patient health questionnaire-9, generalized anxiety disorder scale-7, and the sleep quality scale. The NNSSS was analyzed in three stages: exploratory factor analysis (EFA) to discover underlying variables, confirmatory factor analysis (CFA) to evaluate model fit, and concurrent validity to determine how well it aligns with standardized measures. Results: Participants’ mean age was 27.6 years (SD 7.1). The EFA results yielded a two-factor structure of the NNSSS, including perceived and enacted stigma. The internal reliability of the scale and subscales was satisfactory (total scale alpha coefficient: 0.87, perceived sub-scale: 0.76, and enacted sub-scale: 0.87). The CFA results further validated the two-factor structure. The NNSSS demonstrated strong internal consistency and adequate concurrent validity. It showed greater correlations with anxiety, depressive symptoms, and sleep quality. Conclusion: The present study found that the NNSSS is a psychometrically sound and effective measure of perceived and enacted stigma among GBMSM in Nepal. Given the severe stigma attached to GBMSM in Nepal, this scale is critical for developing effective stigma-reduction interventions.

Background: Human Immunodeficiency Virus (HIV) is a significant global health challenge that impacts the quality of life (QoL) of people living with HIV and AIDS (PLWHA) worldwide, including Nepal. QoL reflects overall well-being and is essential in HIV care, especially with antiretroviral therapy (ART). Method: We conducted a hospital-based cross-sectional study between December 2023 and January 2024 at the ART clinic of Lumbini Provincial Hospital, involving 246 PLWHA undergoing ART. The hospital was selected purposively and patients were recruited using a non-probability convenience sampling technique. QoL was assessed using the World Health Organization Quality of Life HIV BREF questionnaire (WHOQOL-HIV BREF), which consists of 31 items, with 29 items covering six domains rated on a five-point Likert scale. Domain scores ranged from 4 to 20, with higher score denoting a higher QoL. Data was entered in EpiData version 3.1 and analyzed in SPSS version 20 using descriptive and inferential statistics. Ethical approval was obtained from Institutional Review Committee of Chitwan Medical College and Lumbini Provincial Hospital, and written informed consent from all the participants. Result: A total of 246 patients were enrolled in the study with a median (IQR) age of 45(18) years. More than half of participants were female, married and belonged to Hindu religion, whereas nearly half belonged to Janajati ethnic groups. QoL was higher in the domains of physical health, level of independence and social relationship with a median score of 12(3), 12(2) and 12(3). Conversely, QoL were markedly lower in spiritual health with a median score of 10(4). Age, marital status, education, living status, occupation, regular intake of medicines and co-morbidity significantly influenced the QoL scores. Conclusion: This study highlights significant differences in QoL domains among PLWHA, particularly noting lower spiritual and psychological health scores. These findings suggest a need for targeted psycho-social interventions to improve psychological well-being, social functioning and spiritual health by addressing emotional, social, and spiritual needs.

Migrant women workers in Vietnam face significant barriers in accessing subsidized sexual and reproductive health services, as these are frequently linked to their official residence status. This lack of access increases their vulnerability to unintended pregnancies and unsafe induced abortions due to limited availability of contraception. This study examined the prevalence of induced abortion and associated factors among sexually active women migrant workers working in the industrial zones (IZs) in Vietnam. A cross-sectional study was conducted from January 2019 to November 2020 among 512 sexually active female migrant workers aged 18 to 29 living in rent clusters and dormitories in Thang Long Industrial Park, Hanoi, Vietnam. The primary outcome was self-reported induced abortion. Multivariable logistic regression identified factors associated with induced abortion. Participants had a mean age of 24.8 years; 42.0% were single, and 85.4% lived in rent clusters. Among 512 sexually active female migrant workers, 10.5% reported having had an induced abortion. Compared to single women, married women had significantly higher odds of abortion (adjusted odds ratio [aOR] = 8.13, 95% confidence interval [CI]: 2.44–27.05). Longer duration since first sexual intercourse (aOR = 1.30, 95% CI: 1.12–1.52), and lower monthly income (aOR = 0.994, 95% CI: 0.99–1.00) were also associated with abortion. In addition, belonging to a non-Kinh ethnic group was associated with lower odds of abortion (aOR = 0.32, 95% CI: 0.16–0.62). This study reveals significant reproductive health challenges, including a high prevalence of abortion, among sexually active women migrant workers in a Vietnamese IZ, particularly for married women. These findings underscore the urgent need for targeted interventions such as accessible contraception, extending service hours into evenings or weekends, offering mobile sexual and reproductive health services near IZs, culturally sensitive comprehensive education, and programs addressing gender inequities to reduce unintended pregnancies and lower abortion rates. For routine practice, prioritize accessible contraception and culturally sensitive sexuality education in Vietnamese IZs. In addition, stronger monitoring and enforcement of regulations for private clinics are needed to ensure the safety and quality of abortion services. Future research should investigate contraceptive use, cohabitation dynamics, and unsafe abortion rates within this population to inform more effective interventions.

People who use opioids (PWUO) face a higher risk of overdose, often resulting in significant morbidity and mortality within this population. Understanding the factors that contribute to non-fatal overdose among PWUO is essential for developing effective prevention strategies. Thus, the present study aimed to report on the history of and factors associated with non-fatal opioid overdose among PWUO. From April to June 2024, 199 adults with a recent history of opioid use were enrolled in a cross-sectional study to evaluate past experiences of non-fatal overdose. Participants self-reported their socio-demographic characteristics, experiences with overall overdose, history of opioid use, alcohol consumption, and mental health symptoms. Bivariate and multivariate logistic regression analyses were conducted to assess the correlations between the outcome variables. The mean age of participants was 44.2 years (SD = 10.2). Approximately 49.2% of participants had experienced an opioid overdose at some point. Opioid dependence, alcohol use disorder, and depressive symptoms were reported by 83.9%, 65.8%, and 58.3% of participants, respectively. Older participants were less likely to experience an overdose (aOR: 0.9, 95% CI: 0.9–0.9). On the other hand, participants who were opioid-dependent (aOR: 4.4, 95% CI: 1.7–11.7) and those experiencing suicidal ideation (aOR: 1.8, 95% CI: 1.0-3.5) were more likely to have ever experienced an opioid overdose. Our study demonstrated high rates of non-fatal opioid overdose among PWUO. This finding highlights the need for targeted harm reduction interventions and cross-sector collaboration to address opioid dependency and suicidal ideation, aiming to prevent overdoses in this population.

Background: Stigma is multifaceted and widely prevalent among gay, bisexual and other men who have sex with men (GBMSM). Although perceived and enacted stigma are mostly common and negatively impact GBMSM’s well-being, there is limited research in Nepal to guide comprehensive interventions for effective solutions. Thus, the present study aimed to evaluate perceived and enacted stigma related to sexual behavior, as well as the associated factors, among GBMSM in Nepal. Methods: A nationwide cross-sectional study was conducted online among 842 participants between April and May 2024. Neiland’s Sexual Stigma Scale was used to assess perceived and enacted stigma related to sexual behavior. The Patient Health Questionnaire-9 and the Sleep Quality Scale were also utilized. Exploratory factor analysis, and bivariate and multivariate linear regression analysis were used in the present study. Results: The mean age of the participants was 27.6 years (s.d. 7.1 years). Over half of the participants (54−76%) experienced perceived stigma, and nearly half (35−57%) experienced enacted stigma. Participants who were older (β = 0.06, P-value <0.01), had previously tested for HIV (β = 0.06, P-value 0.047), engaged in anal sex in the past 12 months (β = 0.2, P-value <0.01) or had depressive symptoms (β = 0.3, P-value <0.01) had higher perceived stigma. Participants who had been to sex parties or enganged in group sex in the past 12 months had lower perceived stigma (β = −0.09, P-value = 0.021) and higher enacted stigma (β = 0.08, P-value = 0.009). In addition, participants who had concealed their sexual orientation (β = 0.1, P-value = 0.004), had ever engaged in chemsex (β = 0.07, P-value = 0.024), had reported transactional sex (β = 0.08, P-value = 0.009) in the past 12 months or reported depressive symptoms (β = 0.3, P-value <0.01) had higher enacted stigma. Conversely, participants with adequate sleep (β = −0.1, P-value = 0.027) had a lower enacted stigma. Conclusion: Our study showed a substantial presence of perceived and enacted stigma among GBMSM in Nepal. Our findings underscore the need for stigma reduction initiatives and supportive care for GBMSM in Nepal, especially for older individuals and GBMSM who engaged in chemsex or group sex or suffer from depression, to promote an LGBT-friendly community.

Excessive daytime sleepiness (EDS) is a notable public health concern that needs comprehensive screening and effective care to mitigate potential adverse consequences. However, our understanding about EDS among men who have sex with men (MSM), particularly in low- and middle-income countries, remains limited or inadequate. Therefore, this study aims to assess the prevalence of EDS and identify the factors associated with EDS among MSM in Nepal. In Kathmandu, Nepal, a respondent-driven cross-sectional survey was carried out among 250 MSM, aged ≥ 18 years old. EDS, depressive symptoms, and social support were measured using the Epworth Sleepiness Scale (ESS-8), Patient Health Questionnaire (PHQ-9), and Oslo Social Support (OSS-3) scale, respectively. Multivariable logistic regression analysis was performed to identify potential factors associated with the outcome variable. The adjusted odds ratio (aOR) was calculated with a 95% confidence interval (CI). The prevalence of EDS among the study participants was 11.9%. MSM with moderate to severe depressive symptoms (aOR: 6.9; 95% CI: 2.5–18.7), strong social support (aOR: 4.9; 95% CI: 1.1–21.8) and disclosed sexual orientation to health care providers (aOR: 3.9; 95% CI: 1.4–11.5) had higher odds of having EDS. This study highlights preliminary evidence of a moderate prevalence of EDS among Nepalese MSM. Notably, depressive symptoms have been identified as a significant risk factor for higher scores on the ESS. This study should serve as a groundwork for future research on sleep-related disorders among MSM in Nepal.

The HIV care continuum is a framework that describes gaps in care engagement for people with HIV (PWH) who know their HIV status, are on antiretroviral therapy, and are virally suppressed. Despite the United Nations’ 95 - 95 - 95 targets, significant gaps remain in the United States, driven by PWH who are not engaged in care. To evaluate a Data-to-Care strategy to re-engage PWH who recently fell out of care, the Centers for Disease Control and Prevention funded a randomized, controlled trial called the Cooperative Re-Engagement Controlled Trial (CoRECT) was conducted in Connecticut, Massachusetts, and Pennsylvania between 2014 and 2018. Three Disease Intervention Specialists (DIS) were trained to provide a public health intervention that adapted the Anti-Retroviral Treatment and Access to Services (ARTAS) model for re-engaging PWH in care. In this secondary analysis, we examined the implementation processes and field experiences of DIS in Connecticut using an explanatory sequential mixed methods design. Data sources included DIS field notes, an internal database, and in-depth interviews with two DIS. We found that the fidelity to the adapted ARTAS (ARTAS+) varied considerably, barriers to care assessments were completed consistently (95%), and structured interactive sessions were completed less frequently (35%). Qualitative interviews with DIS highlighted the importance of flexibility and rapport-building in re-engagement efforts. Re-engagement efforts were negatively impacted by psychiatric and substance use disorders and homelessness, while patient-reported barriers included time mismanagement, inconvenient clinic operational hours, or not perceiving themselves as sick. The study provides a roadmap for future Data-to-Care implementation efforts and underscores the importance of patient-centered approaches for re-engaging PWH in care.

Men who have sex with men (MSM) have an elevated risk of adverse health outcomes associated with alcohol use and smoking. Although substantial studies have been conducted globally, little is known about alcohol use and smoking among MSM in Nepal. Therefore, the present study aimed to examine the prevalence and patterns of alcohol use and daily smoking among MSM in Nepal. A cross-sectional respondent-driven survey was conducted among MSM in Kathmandu, Nepal, between October and December 2022. Bivariate and multivariate logistic regression analyses were used to evaluate independent correlates of alcohol use in the past 12 months and daily smoking. Among 250 participants (mean age 27.6 ± 8.9 years), 71.6% had consumed alcohol in the past 12 months, and 42% smoked daily in the last 30 days. MSM who had an income of less than NRs 20,000 (aOR: 2.1; 95% CI: 1.1–3.8), were single (aOR: 2.0; 95% CI: 1.1–3.8), employed (aOR: 2.1; 95% CI: 1.1–4.1), engaged in sex work (aOR: 3.5; 95% CI: 1.1–11.1), ever smoked (aOR: 5.1; 95% CI: 2.6–9.7), and who did not engage in condomless sex (aOR: 2.1; 95% CI: 1.1–4.5) were more likely to use alcohol in the past 12 months. Similarly, participants who were born in Bagmati province (aOR: 3.7; 95% CI: 1.8–7.6), and had a history of drug use (aOR: 2.8; 95% CI: 1.3–5.7), and police detention (aOR: 3.2; 95% CI: 1.3–9.2) were more likely to be involved in daily smoking. The findings underscore the necessity of MSM-specific alcohol and smoking cessation programs in Nepal.

HIV continues to be a global public health issue. Urban slums in Bangladesh are at high risk for the HIV epidemic, but little is known about how slum people perceive their risk and deal with alcohol use. Therefore, the focus of the study was to explore the HIV risk perception, problematic alcohol use and the associated factors within urban slum settings. We conducted a cross-sectional study between March and May 2023 among 739 urban slum residents in Bangladesh. Data analysis involved bivariate and multivariate linear regression analyses. The participants’ mean age was 29.7 (SD 7.3) years. The mean of HIV risk perception and problematic alcohol use was 27.4 (SD 3.6) and 1.3 (SD 2.2), respectively. Higher HIV risk perception was associated with longer slum residency (β: 0.2, p-value: < 0.01), secondary education (β: 0.1, p: 0.001) and unemployment (β: 0.1, p: 0.003). Problematic alcohol use was associated with a smoking habit (β:0.1, p: < 0.01), a history of sexually transmitted infections (STIs) (β:0.3, p: < 0.01) and poor mental health (β:0.1, p: 0.001). The present study revealed a moderate presence of HIV risk perception and problematic alcohol use in urban slum residents. These findings underscore the need for a tailored approach to increase HIV perception and decrease alcohol use.

The increase in the chemsex phenomenon among gay, bisexual, and other men who have sex with men (GBMSM) is alarming, as it is associated with risky sexual behaviors, including condomless sex and multiple sex partners. Despite increasing concerns, there is nonexistent research on chemsex among GBMSM in Nepal. Therefore, our study aimed to identify the prevalence and factors associated with engagement in chemsex among GBMSM in Nepal. A cross-sectional online survey of 842 Nepali GBMSM was conducted between March and May 2024. Multivariable logistic regression was used to identify factors associated with chemsex engagement within the past 12 months. Among 842 participants (mean age 27.6 ± 7.1 years), 24.7% reported ever engaging in chemsex, and 19.1% did so in the past 12 months. GBMSM who had completed high school were less likely to have engaged in chemsex in the past 12 months (aOR: 0.5; 95% CI: 0.3–0.8). However, GBMSM who reported having multiple sex partners (aOR: 9.6; 95% CI: 1.3–71.4), being involved in party/group sex in the past 12 months (aOR: 2.5; 95% CI: 1.5–3.9), and with depressive symptoms (aOR: 2.0; 95% CI: 1.3–3.0) were more likely to have engaged in chemsex in the past 12 months. An integrated approach is urgently needed, encompassing awareness raising, safe drug use support, sexual health services, and mental health care.

Background: The opioid crisis in the United States has led to climbing overdose rates, alongside HIV outbreaks among people who inject drugs (PWID). One area of the pre-exposure prophylaxis (PrEP) cascade that has received little attention is the persistence of PrEP, especially among PWID. To address this gap, this study examined the receipt, persistence, and factors associated with PrEP persistence among opioid-dependent PWID. Methods: Between December 2020 and July 2022, we enrolled 100 opioid-dependent PWID. Eligible participants received a 90-day PrEP prescription from a community-based syringe services program and were followed up at 3 and 6 months. We assessed sociodemographic characteristics, PrEP use, and behaviors related to sex and drug use. We evaluated persistence on PrEP by calculating how many times each participant continued to pick up their PrEP prescription. To identify factors associated with persistence on PrEP, we used a multivariable ordinal logistic regression. Results: On average, participants were in their early 40s (mean age: 44.5, SD: 10.0 years), male (63.0 %), and unemployed (89.0 %). The majority (64.0 %) reported injecting drugs at least once per week in the past month, and 79.0 % had never used PrEP before. A total of 60 participants picked-up PrEP at least once during the 6-month follow-up period, with 42 (70.0 %) retrieving it only once, 16 (26.7 %) twice, and 2 (3.3 %) picking it up three times. In the multivariable model, unemployment (aOR = 7.819; 95 % CI: 1.538–39.751) and prior PrEP use (aOR = 3.381; 95 % CI: 1.210–9.443) were associated with higher persistence on PrEP, whereas participants who injected drugs once a week or less (aOR = 0.039; 95 % CI: 0.008–0.182) or more than once a week in the past month (aOR = 0.098; 95 % CI: 0.029–0.329) were less likely to consistently retrieve PrEP. Conclusions: Despite a high willingness to use PrEP among opioid-dependent, PrEP-naïve PWID in general, the adoption and persistence of PrEP were low in this study. Given that PWID represent a marginalized group at significant risk for HIV, these findings highlight the urgent need for comprehensive strategies to enhance the PrEP continuum of care by addressing the unique and diverse needs of this subgroup.

Men who have sex with men (MSM) are disproportionately affected by HIV. Individuals who accessed sexual health clinic services for sexually transmitted infections (STIs) and pre-exposure prophylaxis (PrEP) were less likely to engage in high-risk sexual behaviors such as transactional sex and condomless sex and exhibited greater perceived importance of HIV testing. HIV testing is considered the gateway to both prevention and treatment of HIV, enabling timely intervention in HIV transmission. Therefore, this study aimed to measure and determine factors associated with never testing for HIV among MSM in Nepal. We conducted the population-based HIV bio-behavioral surveillance study between October and December 2022 using the respondent-driven sampling (RDS) method. We computed estimates for never testing HIV and conducted bivariate and multivariate analyses to explore the correlation between participant characteristics and never testing HIV. Among the 250 participants, over half of the participants (52.5%) had never tested for HIV in their lifetime, and only 11.7% had tested for HIV in the last 12 months. MSM who had not engaged in transactional sex (aOR:4.5; 95% CI: 1.2-17.3), had no daily internet access (aOR: 5.4; 95% CI: 1.4-21.3), had no prior diagnosis of sexually transmitted infection in their lifetime (aOR: 8.4; 95% CI: 2.8-25.2), had never heard of HIV self-testing (aOR:6.7; 95% CI: 2.8-16.0), and were unaware that someone taking PrEP (aOR:44.9; 95% CI: 10.5-191.6) had higher odds of never having been tested for HIV. Conversely, MSM who were single (aOR:0.3; 95% CI: 0.1-0.8) had lower odds of never being tested for HIV. This study highlights a significant gap in HIV testing among MSM in Nepal, particularly among those who were unaware of an HIV self-testing kit. The findings underscore the need for targeted interventions to address multi-level barriers to increase HIV testing rates among Nepali MSM.

Background Tuberculosis preventive therapy (TPT) effectively reduces TB incidence among people living with HIV, but implementation remains suboptimal and data on community knowledge of TPT is needed. We sought to understand community members’ knowledge of TB and TPT to facilitate implementation of TPT. Methods In rural Msinga, KwaZulu Natal, South Africa, a cross-sectional study was conducted at community events during an HIV and TB testing initiative. Participants ≥ 18 years old who were residents of Msinga were anonymously surveyed. We evaluated Knowledge of TB and TPT, generating separate scores for each domain. Descriptive statistics, chi-square testing, Kruskal-Wallis, linear regression, and exploratory factor analysis (EFA) were performed. Results Among 104 respondents, median age was 32.5 years, 65% were female, and 23% completed secondary school. EFA identified two factors for TB knowledge: cultural beliefs of TB’s origin and transmission and understanding TB as a disease. Overall, TB knowledge was poor (median 10, IQR 8-12.5). Over one-third (N = 39, 37.5%) were unaware of TPT. Those who had heard of TPT had good knowledge of TPT, with a median score of 4 (IQR 4–4) out of 4. Factors associated with higher TPT knowledge on multivariate linear regression included being motivated to stay healthy to care for one’s family and knowing that TB can be avoided. Conclusions Rural South African community members demonstrated poor TB knowledge. Community members with good knowledge of TB were also aware of TPT. Greater community-level public health education and individual-level counseling efforts are needed to facilitate TPT expansion and implementation.

Background: Cognitive profiles of individuals with opioid use disorder (OUD) limit patients’ ability to learn, retain, and recall HIV prevention information. It also limits adherence to medications, such as pre-exposure prophylaxis (PrEP). Cognitive dysfunction accommodation strategies have shown promise at reducing HIV-related risk behaviors among individuals with OUD and increasing adherence to PrEP. This study investigated the feasibility, acceptability, and preliminary efficacy of integrating accommodation strategies into a behavioral HIV prevention intervention. Methods: This 2-arm single blind study provided 50 people who inject drugs (PWID) with OUD linkage to PrEP services and randomized them to a 4-week HIV prevention intervention condition. The active control condition received the HIV prevention intervention as treatment per usual, while the experimental condition received the enhanced HIV prevention intervention with added accommodation strategies. Participants completed acceptability ratings of intervention content and accommodation strategies post-intervention; feasibility was measured via participant recruitment and retention. HIV risk reduction information, motivation, and behavior (IMB) assessments and HIV risk reduction skills assessments were completed pre/post-intervention. Participants also completed weekly PrEP adherence assessments. Results: The intervention content received a high acceptability rating (89 %). Intervention feasibility was deemed acceptable, with 80 % of participants completing all study protocols. The accommodation strategies integrated into the HIV prevention sessions were also endorsed by 92 % of participants. Participants in the experimental condition had significant increases in retention and recall of how to perform HIV risk reduction skills including how to properly clean a syringe (p = 0.048) and how to accurately apply a female condom (p = 0.025), compared to the control condition. Weekly PrEP adherence was reported by the three (7.5 %) participants who indicated taking PrEP throughout the study. All three participants reported missing doses throughout each of the 4 weeks. Conclusions: Results from this study highlight the potential for integrating accommodation strategies into behavioral HIV prevention interventions to reduce the risk of HIV among PWID. Future research is needed to evaluate the use of such strategies by larger and diverse samples of PWID, as well as whether accommodation strategies enable the retention and recall of HIV prevention information and HIV prevention skills over longer periods of time.

In sub-Saharan Africa, accessing HIV testing services is a significant challenge for men who have sex with men (MSM) and transgender women (TGW). In this qualitative evidence synthesis, our aim is to understand social and structural barriers and how they hinder MSM’s and TGW’s access to HIV testing services in sub-Saharan African countries. We searched four selective databases (PubMed, Web of Science and CINAHL complemented with Google Scholar) for qualitative studies, published in English between January 2005 and December 2023, generated 1507 articles, of which 22 were included. Thematic synthesis was conducted for data synthesis. This led to five barriers that hinder HIV test uptake among MSM and TGW, which included: non-availability of tailored HIV testing services, stigma, lack of trust among service providers, sexual and physical violence, and criminalization of same sex relationship. To navigate these social and structural barriers and cope with fears of discrimination and criminalization, MSM and TGW engaged into riskier behaviors, including avoiding HIV testing, non-disclosure, or relying on informal or alternative sources of HIV testing. Decriminalization of same-sex relationship and peer-led HIV testing services were noted to address structural barriers, including stigma and poor access, and subsequently increase the participation in HIV testing services.

Introduction: Pre-exposure prophylaxis (PrEP) is an effective method for prevention of HIV transmission. Female sex workers (FSW) in Malaysia are at substantially increased risk of acquiring HIV compared to the general female population, yet little is known about this population’s current HIV prevention practices or acceptance of PrEP. This study aims to inform the culturally relevant implementation of PrEP through the qualitative exploration of (1) the potential need for PrEP in this population and (2) the factors that determine FSW willingness to use oral PrEP. Methods: In-depth, semi-structured interviews (n = 30) were conducted with FSW in English, Malay, or Tamil. Transcribed and translated interviews were analyzed using a grounded theory approach. Results: FSW express positive interest in PrEP but prefer it as a supplement to condoms, not a replacement. Perceived challenges to PrEP use include cost, adherence, and side effects. Conclusion: The findings suggest that in combination with condom use, PrEP may be an acceptable method of HIV prevention. Effective PrEP rollout may also include condom promotion using a peer-driven model, cost subsidies, and sex work harm reduction and empowerment components.

Evidence indicates that regular assessment of antiretroviral therapy (ART) adherence is necessary to promote adherence and achieve viral suppression. Self-reported adherence using a visual analog scale (VAS) has been used extensively to measure ART adherence. However, less is known about the accuracy of the VAS for measuring ART adherence among opioid-dependent people living with HIV. In this study, we aimed to evaluate the accuracy of the VAS in measuring ART adherence in opioid-dependent people living with HIV who are enrolled in a methadone maintenance program (MMP). This study was conducted within a larger randomized controlled trial among opioid-dependent people living with HIV (N = 109) who were enrolled in an inner-city MMP. Self-reported VAS ART adherence data were compared to pharmacy refill data, which is a more objective measure. Self-reported VAS ratings and pharmacy refill behavior were significantly correlated at the 6-month post-intervention mark (r = 0.349, p = 0.006) but not at any other time point (i.e., pre-intervention, post-intervention, 3-months, and 9-months post-intervention). Based on the pharmacy refill data, participants did not consistently adhere to their ART medication but self-reported high adherence on the VAS. The self-report VAS may not be an accurate measure for assessing ART adherence among opioid-dependent persons living with HIV and enrolled in a MMP. Based on our findings, it may be more accurate to use pharmacy refill information or other objective measures to quantify ART adherence over extended periods for this patient population.

Few evidence-based interventions have been widely adopted in common clinical settings, particularly for opioid-dependent people with HIV (PWH) seeking drug treatment. We developed a brief evidence-based intervention, Holistic Health for HIV (3H+), specifically for ease of implementation and integration within drug treatment settings. In this study, we compared 3H+ to the gold standard, Holistic Health Recovery Program (HHRP+) using a non-inferiority trial. Between 2012 and 2017, 106 participants were randomly assigned to either the brief 3H+ intervention or the gold standard HHRP+. HIV treatment (ART adherence, viral suppression) and risk behaviors (sharing injection equipment, condom use) were compared between the two arms at baseline, end-of-intervention (EOI-12 weeks) and at follow-up (24 weeks). Average treatment effect was calculated based on the difference-in-difference (DID) estimator and a non-parametric bootstrap was used to assess non-inferiority. At the 12-week EOI point, 3H+ was found to be non-inferior to HHRP+ with respect to multiple outcomes: percent sharing syringes and needles (DID:1.4, 95%CI [-18.6,21.5], p<0.01) and attainment of high ART adherence (DID: 9.7, 95%CI: [-13.1, 32.2], p = 0.04). At the 24-week EOI point, 3H+ was found to be non-inferior to HHRP+ with respect to percent sharing syringes and needles (DID: 8.9, [-10.1, 28.30], p = 0.04) and attainment of viral suppression (DID: 18.9, 95% CI:[-7.1, 42.0], p = 0.01). For other indicators, such as consistent condom use, the hypothesis test for non-inferiority was inconclusive at the 12-week EOI (DID: -20.2, 95%CI [-48.9–10.7], p = 0.51). For HIV treatment as prevention to be effective, PWH need to achieve viral suppression. In the absence of this success, they must reduce HIV risk behaviors. The finding that 3H+ was non-inferior to HHRP+ suggests that brief behavioral interventions can be deployed in real world settings to help more efficiently achieve Ending the HIV Epidemic goals.

Recent estimates report a high incidence and prevalence of HIV among men who have sex with men (MSM) in Malaysia. Mobile apps are a promising and cost-effective intervention modality to reach stigmatized and hard-to-reach populations to link them to HIV prevention services (e.g., HIV testing, pre-exposure prophylaxis, PrEP). This study assessed attitudes and preferences toward the format, content, and features of a mobile app designed to increase HIV testing and PrEP uptake among Malaysian MSM. We conducted six online focus groups between August and September 2021 with 20 MSM and 16 stakeholders (e.g., doctors, nurses, pharmacists, and NGO staff) to query. Transcripts were analyzed in Dedoose software to identify thematic content. Key themes in terms of app functions related to stylistic preferences (e.g., design, user interface), engagement strategies (e.g., reward systems, reminders), recommendations for new functions (e.g., enhanced communication options via chat, discussion forum), cost of services (e.g., PrEP), and legal considerations concerning certain features (e.g., telehealth, patient identification), minimizing privacy and confidentiality risks. Our data suggest that a tailored HIV prevention app would be acceptable among MSM in Malaysia. The findings further provide detailed recommendations for successfully developing a mobile app to improve access to HIV prevention services (e.g., HIV testing, PrEP) for optimal use among MSM in Malaysia.

Background: HIV continues to have a disproportionate impact on specific populations in Malaysia, particularly men who have sex with men (MSM). HIV self-testing (HIVST) is a strategy that has been shown to scale up HIV testing rates. However, it faces shortcomings because of concerns about self-efficacy, result interpretation, and lack of counseling and linkage to care. This underscores the need for an innovative approach that integrates HIVST with timely counseling, expert guidance, and referrals to enhance engagement in relevant HIV prevention or treatment. Objective: This study aims to describe the protocol used in developing and testing a web-based platform (ie, CINTAI) providing an HIVST kit and real-time e-counseling to support online-to-offline linkage to HIV care services for MSM in Malaysia. Methods: The methods are reported according to the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 guidelines. In phase I, we will adapt existing HIVST web-based platforms to create a new online-to-offline HIVST and counseling platform called “CINTAI” for Malaysian MSM. In phase II, we will use a type 1 hybrid implementation trial design to determine the feasibility, acceptability, and preliminary efficacy of “CINTAI” compared with treatment as usual among Malaysian MSM, with assessments conducted over 6 months. Multilevel implementation factors will also be collected to guide future adoption and scale-up. We will enroll 78 MSM in the pilot randomized controlled trial. Baseline characteristics will be tested for homogeneity between groups using appropriate statistical tests. A generalized linear mixed model with random subject effects will account for within-subject correlation. Treatment assignment, time, interaction, and confounders will be included. The proportion of MSM tested for HIV over 6 months and other outcomes (pre-exposure prophylaxis for HIV or antiretroviral therapy linkage, HIV risk behaviors, and chemsex harm reduction) will be compared using linear contrasts. Results: We completed phase I of the proposed study in April 2024 and started phase II in May 2024, with 15 participants recruited (7 in the CINTAI and 8 in the treatment-as-usual groups). On the basis of a series of formative works completed during phase I, we developed a fully functional, web-based platform that provides a digital platform for MSM in Malaysia to order HIVST kits for free and to receive HIV counseling, followed by offline linkage to HIV prevention services (if HIV negative) or HIV treatment services (if HIV positive). Conclusions: Despite being at high risk for HIV transmission, MSM in Malaysia have alarmingly low testing and linkage to HIV care services, prompting the need for innovative approaches to support HIV prevention efforts. If found to be feasible and acceptable, CINTAI 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 prevalence of gestational diabetes mellitus (GDM) is increasing, particularly in low- and middle-income countries (LMICs) like Nepal. GDM self-management, including intensive dietary and lifestyle modifications and blood glucose monitoring, is critical to maintain glycemic control and prevent adverse outcomes. However, in resource-limited settings, several barriers hinder optimal self-management. Mobile health (mHealth) technology holds promise as a strategy to augment GDM treatment by promoting healthy behaviors and supporting self-management, but this approach has not yet been tested in any LMIC. Objective: This report describes the protocol to develop a culturally tailored mHealth app that supports self-management and treatment of GDM (GDM–Dhulikhel Hospital [GDM-DH] app, phase 1) and test its usability and preliminary efficacy (phase 2) among patients with GDM in a periurban hospital setting in Nepal. Methods: The study will be conducted at Dhulikhel Hospital in Dhulikhel, Nepal. In the development phase (phase 1), a prototype of the GDM-DH app will be developed based on expert reviews and a user-centered design approach. To understand facilitators and barriers to GDM self-management and to gather feedback on the prototype, focus groups and in-depth interviews will be conducted with patients with GDM (n=12), health care providers (n=5), and family members (n=3), with plans to recruit further if saturation is not achieved. Feedback will be used to build a minimum viable product, which will undergo user testing with 18 patients with GDM using a think-aloud protocol. The final GDM-DH app will be developed based on user feedback and following an iterative product design and user testing process. In the randomized controlled trial phase (phase 2), newly diagnosed patients with GDM (n=120) will be recruited and randomized to either standard care alone or standard care plus the GDM-DH app from 24-30 weeks gestation until delivery. In this proof-of-concept trial, feasibility outcomes will be app usage, self-monitoring adherence, and app usability and acceptability. Exploratory treatment outcomes will be maternal glycemic control at 6 weeks post partum, birth weight, and rates of labor induction and cesarean delivery. Qualitative data obtained from phase 1 will be analyzed using thematic analysis. In phase 2, independent 2-tailed t tests or chi-square analyses will examine differences in outcomes between the 2 treatment conditions. Results: As of July 2024, we have completed phase 1. Phase 2 is underway. The first participant was enrolled in October 2021, with 99 participants enrolled as of July 2024. We anticipate completing recruitment by December 2024 and disseminating findings by December 2025. Conclusions: App-based lifestyle interventions for GDM management are not common in LMICs, where GDM prevalence is rapidly increasing. This proof-of-concept trial will provide valuable insights into the potential of leveraging mHealth app–based platforms for GDM self-management in LMICs.

Background: Transactional sex, which involves the exchange of sex for money, goods or other items of value, has been associated with adverse health outcomes, such as HIV and other sexually transmitted infections, mental health challenges, and substance use. Although transactional sex has been extensively studied globally among cisgender and transgender women, there is a lack of comprehensive understanding regarding its prevalence and correlates among gay, bisexual and other men who have sex with men (GBMSM), particularly in Nepal. Thus, this study aimed to examine the prevalence of transactional sex and its associated factors among GBMSM in Nepal.

Methods: A cross-sectional survey was conducted among GBMSM in Kathmandu Valley, Nepal, between October and December 2022 (N = 250). We collected information on participants’ sociodemographic characteristics, sexual and other behavioural characteristics, and their engagement in transactional sex. Bivariate and multivariate logistic regression analyses were performed to determine the factors associated with transactional sex.

Results: The average age of participants was 27.5 years (s.d. 8.9). Overall, 16.4% reported engaging in transactional sex within the past 6 months. Participants with more financial dependants (aOR: 1.2, 95% CI: 1.0–1.5) and those who had experienced police detention (aOR: 4.8, 95% CI: 1.1–19.6) were more likely to engage in transactional sex. In contrast, GBMSM who reported engaging in condomless sex were less likely to engage in transactional sex (aOR: 0.02, 95% CI: 0.06–0.1).

Conclusions: TThe study findings underscore a noteworthy prevalence of transactional sex and associated socioeconomic and behavioural factors among GBMSM in Nepal. These results underscore the need for targeted interventions addressing both economic vulnerabilities and legal interactions to reduce transactional sex and its associated risks in this high-risk group.

Introduction: While research has examined the connections between sleep quality, smartphone addiction, and depressive symptoms in general, no studies focused on undergraduate medical students in Nepal have specifically tested the complex relationship between these factors. Therefore, this study aimed to investigate the interaction between smartphone addiction, sleep quality, and depressive symptoms among undergraduate medical students of Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.

Methods: A cross-sectional study was conducted among 212 undergraduate medical students at Maharajgunj Medical Campus, Tribhuvan University, Nepal. Sleep quality, smartphone addiction, and depressive symptoms were assessed using the Pittsburgh Sleep Quality Index, Smartphone Addiction Scale Short Version, and Patient Health Questionnaire-9. Data were analyzed using IBM SPSS version 26 via the bootstrap model approach.

Results: Out of the total participants, 67.9% were male. Males showed higher scores in smartphone addiction and depressive symptoms than females (b = 5.3, Bca 95% CI:1.2, 9.1, p < 0.05). The unadjusted model indicated that the presence of smartphone addiction explained 36.5% of the indirect impact of sleep quality on depressive symptoms. However, in the adjusted model, after introducing socio-demographic, behavioral, and educational variables as covariates, this percentage decreased to 33.02%.

Conclusions: This study highlights the significant role of both smartphone addiction and sleep quality in mediating the indirect effect on depressive symptoms among undergraduate medical students. Smartphone addiction emerged as a key mediator of depressive symptoms, indicating a potentially important factor in mental health. Investigating this relationship further through longitudinal studies will be crucial for developing effective preventative and therapeutic approaches.

Chemsex is a form of sexualized drug use commonly practiced among MSM with psychoactive substances, such as methamphetamine. While this phenomenon has gained global attention in the past two decades, there is a dearth of empirical data to inform culturally competent interventions. The current work investigates the socio-contextual factors related to chemsex and harm reduction practices among Malaysian MSM. Between February and August 2022, we conducted six online focus group sessions with Malaysian MSM who had engaged in chemsex during the previous 6 months (N = 22). We queried participants about perceived benefits and harms, harm reduction practices, and informational needs. Most participants’ first chemsex experience occurred in a casual sexual encounter, often facilitated by mobile technology. Participants reported engaging in harm reduction practices before (e.g. medication reminders), during (e.g. peer support), and after (e.g. rest) chemsex. These findings have implications for future efforts to develop and implement tailored interventions to address the specific and acute needs of Malaysian MSM engaging in chemsex.

Background: Globally, transgender women have been disproportionately affected by the HIV epidemic, including in Malaysia, where an estimated 11% of transgender women are living with HIV. Available interventions designed specifically to meet transgender women’s needs for HIV prevention are limited. Mobile health, particularly smartphone mobile apps, is an innovative and cost-effective strategy for reaching transgender women and delivering interventions to reduce HIV vulnerability. Objective: This study aims to adapt a theory-based mobile health HIV prevention smartphone app, HealthMindr, to meet the unique needs of transgender women in Malaysia. We conducted theater testing of the HealthMindr app with transgender women and key stakeholders and explored barriers to transgender women’s uptake of HIV pre-exposure prophylaxis (PrEP). Methods: From February to April 2022, a total of 6 focus group (FG) sessions were conducted with 29 participants: 4 FG sessions with transgender women (n=18, 62%) and 2 FG sessions with stakeholders (n=11, 38%) providing HIV prevention services to transgender women in Malaysia. Barriers to PrEP uptake and gender-affirming care services among transgender women in Malaysia were explored. Participants were then introduced to the HealthMindr app and provided a comprehensive tour of the app’s features and functions. Participants provided feedback on the app and on how existing features should be adapted to meet the needs of transgender women, as well as any features that should be removed or added. Each FG was digitally recorded and transcribed. Transcripts were coded inductively using Dedoose software (version 9.0.54; SocioCultural Research Consultants, LLC) and analyzed to identify and interpret emerging themes. Results: Six subthemes related to PrEP barriers were found: stigma and discrimination, limited PrEP knowledge, high PrEP cost, accessibility concerns, alternative prevention methods, and perceived adverse effects. Participants suggested several recommendations regarding the attributes and app features that would be the most useful for transgender women in Malaysia. Adaptation and refinement of the app were related to the attributes of the app (user interface, security, customizable colors, themes, and avatars), feedback, and requests for additional mobile app functional (appointment booking, e-consultation, e-pharmacy, medicine tracker, mood tracker, resources, and service site locator) and communication (peer support group, live chat, and discussion forum) features. Conclusions: The results reveal that multifaceted barriers hinder PrEP uptake and use among transgender women in Malaysia. The findings also provide detailed recommendations for successfully adapting the HealthMindr app to the context of Malaysian transgender women, with a potential solution for delivering tailored HIV prevention, including PrEP, and increasing accessibility to gender-affirming care services.

Limited health literacy is linked to unhealthy behaviors, adverse health outcomes, poor quality of life and financial burdens on society. However, little is known about the level of health literacy, especially among school-going children. This cross-sectional study assesses health literacy levels and their determinants in 354 school children from Kathmandu Metropolitan City, utilizing a multi-stage cluster sampling method. The 10-item Health Literacy for School-Aged Children was used to measure the student’s literacy levels. Bivariate analysis and multivariable logistic regression at the significance level of 0.05 were performed to determine factors associated with limited health literacy. The majority of participants (76.6%) had moderate health literacy, while 13.8% had a high level and 9.6% had a low level of health literacy. Students from nuclear families had lower odds [adjusted odds ratio (aOR): 0.4; 95% CI: 0.2–0.8] of having limited health literacy. Students whose mother education was up to secondary school (aOR: 10.1; 95% CI: 1.3–78.9), students with pre-existing mental health conditions (aOR: 3.7; 95% CI: 1.4–9.6) and students with unsatisfactory health status (aOR: 3.9; 95% CI: 1.5–10.5) had higher odds to have limited health literacy. These results suggest the importance of prioritizing school health promotion and education activities for students with pre-existing mental health conditions and mothers with low educational attainment. Implementing peer support group programs for children with mental illnesses, mobilizing school health professionals and introducing interventions such as vocational training of mothers can collectively improve health literacy among school-going children.

To evaluate the feasibility and acceptability of daily oral emtricitabine/tenofovir alafenamide fumarate (FTC/TAF) as HIV pre-exposure prophylaxis (PrEP) among people who inject drugs with opioid use disorder (OUD). In this single-arm, open-label observational study, 100 people who inject drugs (PWID) were enrolled to receive daily oral FTC/TAF for HIV prevention through a community-based syringe services programme. Participants were referred for laboratory testing following enrolment and received a 90-day supply of FTC/TAF at baseline, 3-month and 6-month visits. Behavioural and biomedical data were collected at each follow-up visit. Feasibility was assessed by tracking the number of individuals screened, enrolled and retained in the study. Acceptability was measured at 3 and 6 months using an adapted 10-item acceptability rating profile. Adherence, uptake and side effects were assessed via self-report, and exit interviews were conducted at follow-up visits to provide qualitative context. Participants had a median age of 43.5 years (IQR: 38–53), 63% were male, 52% non-Hispanic white, 37% injected daily, 67% reported condomless sex and 21% reported prior PrEP use. Although all participants were prescribed FTC/TAF, only 60 collected PrEP at least once during the study; of these, 42 collected it only once, 16 two times and two at all three time points (baseline, 3-month and 6-month). Among those on PrEP, self-reported adherence increased from 68.14% (±34.76) over 3 months to 88.37% (±21.52) over 6 months. Acceptability was high (range: 1–4): 3 months (3.20 (±0.35)) and 6 months (3.10 (±0.17)). The most frequently reported side effects were fatigue (18.4%) and nausea (17.2%). There were no HIV seroconversions. FTC/TAF PrEP was acceptable among PWID with OUD. However, feasibility challenges were due to low uptake and continuation, with only two participants completing PrEP pick-up at all follow-up visits, despite higher self-reported adherence among those retained at 6 months.

Background: Mobile technology growth in Nepal offers promising opportunities for using mobile health (mHealth) interventions to facilitate HIV prevention efforts. However, little is known about access and utilization of communication technology and their willingness to use mHealth for HIV prevention services in Nepal.

Methods: We conducted a cross-sectional respondent-driven sampling survey of 250 MSM in Kathmandu Valley of Nepal from October to December 2022. We collected information on participant characteristics, HIV risk-related behaviors, ownership, or access to and frequency of use of communication technology (phones, tablets, laptops, and computers), and willingness to use mHealth to access HIV prevention services. Descriptive, bivariate, and multivariate linear regression analyses were performed.

Results: Almost all participants had smartphones with the internet (231/250, 92.4%) and accessed the internet daily (219/250, 87.6%) on the smartphone (236/250, 94.4%). The median score for willingness to use mHealth for HIV prevention was 10 (IQR: 3 to 17). Willingness to use mHealth was higher among those participants with a high school or above education (β = 0.223, p = < 0.001), had experienced violence (β = 0.231, p = 0.006), and had moderate to severe depressive symptoms (β = 0.223, p = < 0.001). However, monthly income above NPR 20,000 (USD 150) (β= -0.153, p = 0.008), disclosure of their sexual orientation to anyone (β= -0.159, p = < 0.007), and worry about being negatively judged by health care workers (β= -0.136, p = 0.023) were less willing to use mHealth strategies.

Conclusions: The findings from this study suggest that there is a high willingness for utilizing mHealth interventions for HIV prevention in MSM population who are at higher risk of HIV acquisition.

Background: Previous studies have indicated the association between stigma and depressive symptoms among frequently stigmatized groups, such as men who have sex with men (MSM). While this association has been suggested in the literature, there is a dearth of evidence that examines whether food insecurity statistically mediates the relationship between stigma and depressive symptoms.

Methods: This cross-sectional study conducted between October and December 2022 among a sample of 250 MSM in Kathmandu, Nepal, recruited through respondent-driven sampling. An unadjusted model including the exposure (stigma), mediator (food insecurity), and outcome variables (depressive symptoms) and an adjusted model that controlled for sociodemographic, behavioral, and health-related confounders were used. Bootstrapping was utilized to estimate the coefficients of these effects and the corresponding 95% confidence intervals. Via bootstrap approach, we find out the mediating role of food insecurity in the association between stigma and depressive symptoms.

Results: Depressive symptoms, stigma, and food insecurity were 19.6%, 24.4%, and 29.2%, respectively, among MSM. Food insecurity was associated with higher age (b = 0.094; 95% CI = 0.039, 0.150) and monthly income (b = -1.806; 95% CI = -2.622, -0.985). Depressive symptoms were associated with condom-less sex in past six months (b = -1.638; 95% CI = -3.041, -0.092). Stigma was associated with higher age (b = 0.196; 95% CI = 0.084, 0.323) and PrEP uptake (b = 2.905; 95% CI = 0.659. 5.248). Food insecurity statistically mediated 20.6% of the indirect effect of stigma in depressive symptoms.

Conclusions: Our findings show that food insecurity affects the relationship between stigma and depressive symptoms in this population. Reducing food insecurity and addressing the stigma surrounding sexual orientation should be a priority when addressing mental health concerns among MSM in Nepal and other resource-limited countries with similar socio-cultural settings.

Background: Pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention strategy that remarkably reduces HIV transmission risk. Although PrEP has been available in Nepal since 2019, very little is known about PrEP use among MSM in Nepal. This study aimed to examine PrEP awareness and its use among Nepali MSM and the factors influencing its adoption.

Methods: A cross-sectional survey was conducted among MSM in Nepal between October and December 2022 (N = 250). Bivariate analysis and logistic regression were performed to determine factors associated with awareness and use of PrEP.

Results: In the study population, 59.6% of participants were aware of PrEP, however, only 30.4% of them had utilized it. The odds of PrEP awareness were higher among participants who had completed high school or above (aOR = 4.1; 95% CI = 1.8-9.6), those with health insurance coverage (aOR = 6.9; 95% CI = 2.1-22.3) and had tested for HIV (aOR = 21.2; 95% CI = 8.3-53.9). Similarly, participants who identified as gay (aOR = 3.4; 95% CI = 1.4-8.4), had visited a doctor within the past 6 months (aOR = 2.9; 95% CI = 1.2-6.5), had previously tested for HIV (aOR = 12.3; 95% CI = 3.4-44.7), and had been diagnosed with sexually transmitted infections (aOR = 7.0; 95% CI = 2.5-19.5) were more likely to have used PrEP.

Conclusions: Our results highlight the critical importance of healthcare providers engaging in providing care for MSM, including facilitating as well as discussions about PrEP. In addition, there is a pressing need for innovative strategies (e.g., peer educators, social media, online facilitating technologies) to disseminate PrEP knowledge and reduce stigma surrounding PrEP.

Background: HIV testing uptake remains very low among men who have sex with men (MSM) in Malaysia, a subgroup still bearing a disproportionate HIV burden. Therefore, we sought to identify and measure factors associated with never-testing for HIV among Malaysian MSM to further characterize this subgroup and inform future public health interventions addressing low testing rates in the country.

Methods: We conducted a cross-sectional online survey among Malaysian MSM (August to September 2021). Participants completed questionnaires, including socio-demographic characteristics, HIV/STI testing practices, drug- and sex-related behaviors, and knowledge and attitudes toward HIV prevention services. Out of 1,799 completed surveys, 870 were included in the analysis after eliminating duplicates and incomplete surveys. We used logistic regression to determine factors associated with never-testing for HIV.

Results: Overall, one-third of the study participants (33.8%) reported having never tested for HIV. Of those who reported to have tested for HIV (n = 576), half reported that they had tested for HIV in the past 6 months (50.3%). In multivariable logistic regression, MSM with HIV sero-concordant partner (aOR = 3.44, 95% CI = 1.56–7.60), without a prior diagnosis of a sexually transmitted infection (aOR = 2.83, 95% CI = 1.46–5.49), unaware of pre-exposure prophylaxis (PrEP; aOR = 2.71, 95% CI = 1.74–4.21), unaware of someone taking PrEP (aOR = 1.64, 95% CI = 1.15–2.35), and unwilling to use PrEP (aOR = 2.48, 95% CI = 1.43–4.30) had higher odds of never been tested for HIV. In contrast, MSM who were older (aOR = 0.95, 95% CI = 0.93–0.97) and of the Malaya ethnic group (aOR = 0.59, 95% CI = 0.37–0.95) had lower odds of never testing for HIV.

Conclusions: Our findings shed light on the characteristics of HIV never-testers among MSM in Malaysia. The results indicate the need for innovative strategies to increase the uptake of HIV testing services among members of the MSM community.

Background: Men who have sex with men (MSM) are at increased risk for suicide, with a much higher prevalence of suicidality than the general population. While there is a growing interest in the identification of risk factors for suicidal behaviors globally, the understanding of the prevalence and risk factors for suicidal behaviors among MSM in the context of low- and middle-income countries is almost non-existent. Therefore, the current study aimed to investigate suicidal ideation, plan, and attempts, and related factors among MSM in Nepal.

Methods: A cross-sectional survey was conducted on 250 MSM between October and December 2022. Respondent-driven sampling method was used to recruit participants in this study. A structured questionnaire was used to investigate participants’ demographic, behavioral, health-related, and psychosocial characteristics. Bivariate and multivariable logistic regression was used to evaluate independent correlates of suicidal behaviors of MSM.

Results: Overall, the lifetime prevalence of suicidal ideation, plans, and attempts among MSM in this study were 42.4%, 31.2%, and 21.6%, respectively. Of the participants who reported experiencing suicidal ideation at some point in their lifetime (n=106), 22.6% thought about it multiple times in the past 12 months. MSM with depressive symptoms (aOR = 5.7, 95% CI = 2.4-14.1), advanced education (higher secondary and above; aOR = 2.9, 95% CI = 1.4-6.1), and smoking habit (aOR = 2.5, 95% CI = 1.2-5.3) were at increased risk for suicidal ideation. Similarly, those with depressive symptoms (aOR = 2.2, 95% CI = 1.1-4.8) and advanced education (aOR = 2.7, 95% CI = 1.2-5.7) were more likely to plan suicide, whereas young MSM were significantly more prone to attempting suicide (aOR = 2.7, 95% CI = 1.3-5.8). Interestingly, MSM with moderate to severe food insecurity were 2-3 times more likely to think about, plan, or attempt suicide (ideation: aOR = 3.5, 95% CI = 1.6-7.7; plan: aOR = 3.7, 95% CI = 1.6-8.3; attempt: aOR = 2.2, 95% CI = 1.1-4.6).

Conclusions: Our findings indicated an increased risk for suicidal behaviors among MSM in Nepal. The results suggest the importance of early assessment of suicidal behaviors among MSM and the need for tailored interventions to simultaneously address mental health problems and food insecurity to reduce suicide-related problems among Nepalese MSM.

The monkeypox virus (MPOX) poses a major threat to the health of people, particularly among men who have sex with men (MSM). However, the knowledge regarding MPOX among MSM in Nepal is poorly understood. Therefore, the present study aimed to assess the knowledge of human monkeypox among Nepalese MSM. A cross-sectional face-to-face survey was conducted among purposively selected 250 participants (mean age 27.6 ± 8.9 years) in Nepal between October and December 2022. The questionnaire consisted of informed consent along with questions covering age, education, and MPOX. The findings demonstrated that the majority of MSM in Nepal had poor knowledge of MPOX. Around 87% of participants had no idea whether MPOX is contagious or not. However, the results call for immediate action to improve knowledge of MSM through health education programs and appropriate interventions to spread awareness of MPOX.

Men who have sex with men (MSM) in Malaysia are disproportionately affected by HIV. As pre-exposure prophylaxis (PrEP) is being introduced, we assessed population-based PrEP delivery preferences among MSM in Malaysia. We conducted a discrete choice experiment through an online survey among 718 MSM. The survey included 14 choice tasks presenting experimentally varied combinations of five attributes related to PrEP delivery (i.e., cost, dosing strategy, clinician interaction strategy, dispensing venue, and burden of visits to start PrEP). We used latent class analysis and Hierarchical Bayesian modeling to generate the relative importance of each attribute and preference across six possible PrEP delivery programs. PrEP dosing, followed by cost, was the most important attribute. The participants were clustered into five preference groups. Two groups (n = 290) most commonly preferred on-demand, while the other three preferred injectable PrEP. One group (n = 188) almost exclusively considered cost in their decision-making, and the smallest group (n = 86) was substantially less interested in PrEP for reasons unrelated to access. In simulated scenarios, PrEP initiation rates varied by the type of program available to 55·0% of MSM. Successful PrEP uptake among Malaysian MSM requires expanding beyond daily oral PrEP to on-demand and long-acting injectable PrEP, especially at affordable cost.

Chemsex is a form of sexualized drug use commonly practiced among MSM with psychoactive substances, such as methamphetamine. While this phenomenon has gained global attention in the past two decades, there is a dearth of empirical data to inform culturally competent interventions. The current work investigates the socio-contextual factors related to chemsex and harm reduction practices among Malaysian MSM. Between February and August 2022, we conducted six online focus group sessions with Malaysian MSM who had engaged in chemsex during the previous 6 months (N = 22). We queried participants about perceived benefits and harms, harm reduction practices, and informational needs. Most participants’ first chemsex experience occurred in a casual sexual encounter, often facilitated by mobile technology. Participants reported engaging in harm reduction practices before (e.g. medication reminders), during (e.g. peer support), and after (e.g. rest) chemsex. These findings have implications for future efforts to develop and implement tailored interventions to address the specific and acute needs of Malaysian MSM engaging in chemsex.

Young migrant women workers frequently experience disparities in accessing health services, including sexual and reproductive health (SRH) services, especially in urban settings. This study assesses the barriers and utilization of SRH services and explores factors associated with the utilization of these services among young female migrant workers working in the industrial zone (IZ) in Vietnam. A cross-sectional survey was conducted among 1061 young women migrant workers working in an IZ in Hanoi, Vietnam. Multivariable logistic regression analysis was used to identify factors associated with utilization of SRH services. Nearly 35% of the participants reported using SRH services at least once since working in the IZ. Additionally, around 78% of the participants reported using a contraceptive method during their last sexual encounter. The study also found that older participants (25–29 years old) were nearly two times more likely to use SRH services than younger participants (18–24 years old) (OR = 1.91, 95% CI: 1.19–3.06). Married participants had nearly six times higher odds of using SRH services compared to single participants (OR = 5.98, 95% CI: 3.71–9.63), and participants with higher incomes were more likely to use SRH services (OR = 1.02, 95% CI: 1.01–1.04). The most commonly reported barriers to access SRH services were inconvenient hours of service operation (26.2%), followed by long distance from the service location (9.2%) and high service cost (5.2%). This study found a low level of SRH service utilization and identified several barriers to accessing these services among the study participants. The study findings provide important evidence insights for policymakers and program managers to develop and implement policies that help reduce barriers and enhance the provision of SRH services tailored to the needs of IZ married and unmarried women migrant workers in the IZ in rapidly developing and urbanizing countries like Vietnam and other low- and middle-income countries with similar contexts.

Introduction: People who inject drugs (PWID) have remained a contributor to the consistent HIV incidence rates in the US for decades. Pre-exposure prophylaxis (PrEP) is a promising biomedical intervention for HIV prevention among individuals at risk for HIV infection, including PWID. However, PWID report the lowest rates of PrEP uptake and adherence among at-risk groups. Tailored HIV prevention interventions must include strategies that compensate for cognitive dysfunction among PWID.

Methods and Analysis: Using the multiphase optimisation strategy, we will be conducting a 16-condition factorial experiment to investigate the effects of four different accommodation strategy components to compensate for cognitive dysfunction among 256 PWID on medication for opioid use disorder. This innovative approach will inform optimisation of a highly effective intervention to enhance PWID’s ability to process and utilise HIV prevention content to improve PrEP adherence and HIV risk reduction in a drug treatment setting.

Ethics and Dissemination: The institutional review board at the University of Connecticut approved this protocol (H22-0122) with an institutional reliance agreement with APT Foundation Inc. All participants are required to sign an informed consent form prior to engaging in any study protocols. The results of this study will be disseminated on national and international platforms through presentations at major conferences and journals

Background: Men who have sex with men (MSM) in Malaysia are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is an evidence-based HIV prevention strategy; yet, uptake remains low among Malaysian MSM, who have a limited understanding of barriers to PrEP.

Methods: We employed the nominal group technique (NGT), a structured mixed-methods strategy to understand the barriers and facilitators to PrEP use among Malaysian MSM, combined with a qualitative focus group. Six virtual focus group sessions, three among MSM (n = 20) and three among stakeholders (n = 16), were conducted using a video-conferencing platform. Rank-ordering of barriers from NGT was recorded, and thematic analysis was conducted for content.

Results: Similar barriers were reported by MSM and community stakeholders, with aggregated costs associated with PrEP care (e.g., consultation with a clinician, medication, laboratory testing) being the greatest barrier, followed by limited knowledge and awareness of PrEP. Additionally, the lack of access to PrEP providers, the complex clinical protocol for PrEP initiation and follow-up, and social stigma undermined PrEP delivery. Qualitative discussions identified potential new strategies to overcome these barriers, including expanded outreach efforts to reach hard-to-reach MSM, a ‘one-stop’ delivery model for PrEP services, a patient-centered decision aid to guide PrEP uptake, and easy access to LGBT-friendly PrEP providers.

Conclusions: Current barriers may be overcome through governmental subsidy for PrEP and evidence-informed shared decision aids to support both MSM and PrEP providers.

Heavy alcohol use is negatively affecting antiretroviral therapy adherence, mental health and health-related quality of life among people living with HIV (PLWH). This paper aims to test the mediation model examining whether changes in depression symptoms mediate in the relationship between health-related quality of life and alcohol use among male PLWH who consume alcohol in India. The study is guided by the stress-coping model, which posits that individuals facing stress may turn to maladaptive coping mechanisms such as alcohol use to alleviate their distress, which includes depression and a low health-related quality of life due to various physical, psychological, and social factors associated with the HIV infection. This study used the data from a randomized controlled clinical trial entitled ‘Alcohol and ART adherence: Assessment, Intervention, and Modeling in India’. Participants completed surveys assessing demographic characteristics, health-related quality of life, depressive symptoms, and alcohol use. Multiple simple mediation models were investigated to examine whether changes in depression symptoms mediated the association between the changes in health-related quality of life and alcohol use after a 9-month follow-up. A total of 940 male PLWH were recruited and interviewed, with 564 participants in the intervention group and 376 participants in the control group. After a 9-month intervention, the mediation results showed that, among intervention participants, a decrease in depressiove symptoms mediated the relationship between improved health-related quality of life and lower alcohol use. However, among control participants, changes in depressive symptoms did not mediate the relationship between changes in health-related quality of life and alcohol use. The study findings have practical and theoretical implications. From a practical perspective, the results suggest that interventions aimed at simultaneously improving HRQoL and depressive symptoms among male PLWH with alcohol use may help reduce alcohol consumption. Therefore, interventions that address depressive symptoms in addition to improving HRQoL may have an even greater impact on reducing alcohol use among this population. Theoretically, the study supports the use of the stress-coping theory in understanding the association between HRQoL, mental health, and alcohol use among male PLWH, contributing to existing literature on a gap in our understanding of the interactions among these factors among PLWH.

Background: Chemsex—the use of psychoactive drugs to enhance the sexual experience—is an increasing phenomenon globally. Despite the increasing burden and associated harms of chemsex, evidence-based interventions (ie, behavioral and pharmacological) for chemsex users are nonexistent.

Objective: In this study, we assessed the usability and acceptability of a mobile health (mHealth)–delivered safer chemsex package (“PartyPack”) as a sexual harm reduction strategy among men who have sex with men in Malaysia—a setting where chemsex is becoming increasingly prevalent.

Methods: This study is part of a larger smartphone app-based intervention (ie, JomPrEP; University of Connecticut) designed to improve access to HIV prevention services among Malaysian men who have sex with men. A total of 50 participants were recruited from the Greater Kuala Lumpur region of Malaysia to use the JomPrEP app, which included a feature allowing participants to order PartyPack, for 30 days (March-April 2022). The usability and acceptability of the PartyPack were assessed using self-report, app analytics, and exit interviews (n=20).

Results: Overall, 8% (4/50) of participants reported having engaged in chemsex in the past 6 months; however, engagement in condomless sex (34/50, 68%) and group sex (9/50, 18%) was much higher. A total of 43 (86%) participants ordered PartyPack, of which 27 (63%) made multiple orders during the 30 days. Most participants (41/43, 95%) reported being satisfied with the PartyPack order feature in the app, with 91% (39/43) indicating the order and tracking process was easy. Thematic data exploration further revealed important information for understanding (eg, items included in the package, use of mHealth platform to order package, and discreetness of the PartyPack box and order and delivery) and refining the logistical preferences (eg, using branded items and allowing customization during order).

Conclusions: Our findings provide strong evidence of the usability and acceptability of a mHealth-delivered safer chemsex package as a potential sexual harm reduction tool among this underserved population. Replication in a study with a larger sample size to test the efficacy of the PartyPack is warranted.

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.

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: TB preventative therapy (TPT) is crucial for reducing the burden of TB in endemic settings. We assessed stigma associated with TPT and the social groups from whom stigma was anticipated.

Methods: We conducted an anonymous cross-sectional survey of community-dwelling adults in rural South Africa. Descriptive statistics, exploratory factor analysis, χ2 tests, Kruskal–Wallis tests, and Poisson regression were used to identify factors associated with TPT stigma.

Results: The mean age of the 104 participants was 35 years, 65% were female, and 26% had completed secondary school. The vast majority perceived stigma associated with TPT (71%; mean score 1.7, SD ± 1.4). Factor analysis identified a two-factor solution that explained 61.9% of the variance. Being single (P < 0.001), previously screened for TB (P = 0.04), worried about being infected by TB (P = 0.006), and interested in taking TPT (P = 0.01) were associated with higher perceived stigma scores. TPT stigma was perceived among 8%, 16%, and 66% of their family, friends, and other community members, respectively.

Conclusion: The prevalence of TPT-related stigma in a rural South African community was high. Community members anticipated less stigma from family members compared to other social groups. Global expansion and implementation of TPT will require novel interventions, such as engaging patients´ families to support uptake and promote adherence.

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: 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: 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.

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: 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: 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.

Background: Background: The growth in mobile technology access, utilization, and services holds great promise to facilitate HIV prevention efforts in Malaysia. Despite these promising trends, there is a dearth of evidence on the use of mHealth platforms to address HIV prevention needs of Malaysian gay, bisexual, and other men who have sex with men (GBMSM).

Objective: The goal of this study was to gain insights into: a) access and utilization of communication technology (e.g., landline phone, internet, cell phone); b) acceptability of mHealth-based interventions for HIV prevention services; and c) preferences regarding the format and frequency of mHealth interventions among Malaysian GBMSM.

Methods: A cross-sectional survey of 376 Malaysian GBMSM was conducted between July 2018 and March 2020. Participants were recruited using respondent-driven sampling (RDS) in the Greater Kuala Lumpur region, Malaysia. Participants completed a self-administered assessment of participant demographics, HIV risk-related behaviors, access to and frequency of use of communication technology, and acceptability of mHealth for HIV prevention.

Results: Almost all participants owned or had access to a smartphone with Internet access (97.9%) and accessed the Internet daily (99.2%), mainly on a smartphone (88.8%). Using a 5-point scale, participants on average used smartphones primarily for social networking (M=4.5; SD=0.8), followed by sending or receiving emails (M=4.0; SD=1.0) and searching for health-related information (M=3.5; SD=0.9). Further, the results indicated high acceptance of mHealth for HIV prevention (M=4.1; SD=1.5), including: receiving HIV prevention information (91.8%); receiving medication reminders (89.4%); screening and monitoring sexual activity (81.4%) and illicit drug use (74.7%); and monitoring drug cravings (74.5%). Participants overwhelmingly preferred a smartphone app over other modalities (e.g., text, phone call, email) for engaging in mHealth HIV prevention tools. Acceptance of mHealth was higher for those who were university graduates, living in a relationship with a partner, engaged in sexualized drug use, and engaged in receptive anal sex.

Conclusions: Findings from this study provide support for developing and deploying mHealth strategies for HIV prevention in GBMSM using a smartphone app, crucial for a key population with suboptimal engagement in HIV prevention and treatment.

Background: Background: Neurocognitive dysfunction is common among individuals with opioid use disorders (OUD) and can impede a range of treatment outcomes. We developed the 57-item Brief Inventory of Neuro-cognitive Impairment (BINI) to help detect and monitor neurocognitive dysfunction in the context of drug treatment settings. To date, no study has examined the possible presence of BINI subgroups among OUD patients, which could enhance our ability to tailor intervention strategies to meet individual treatment needs. The purpose of this study was to conduct a latent profile analysis to identify BINI subgroups that differ in terms of their reported and objective neurocognitive dysfunction. We hypothesized that subgroups would emerge, suggesting the potential benefit of implementing tailored strategies for optimal treatment outcomes.

Methods: Latent profile analyses included data from opioid-dependent patients (N = 177) enrolled in a methadone maintenance treatment program between July 2018 and October 2019.

Results: We found three profiles of self-reported neurocognitive symptoms, including those with 1) minimal concerns 2) moderate concerns, and 3) many concerns across multiple domains.

Conclusions: If these results are confirmed, the BINI may be used to rapidly identify persons who require specific accommodation strategies to improve their drug treatment outcomes.

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.

Introduction: Scaling up vaccination against COVID-19 is central to controlling the COVID-19 epidemic in the United States. Several vaccines are now approved for the prevention of COVID-19, but public concerns over safety and efficacy have heightened distrust and vaccine hesitancy. This is particularly concerning among people with HIV (PWH) who may be vulnerable to more severe COVID-19 disease. Here, we aimed to identify and understand COVID-19 vaccine hesitancy in a sample of PWH in the U.S./p>

Methods: We conducted a cross-sectional online survey among PWH in the U.S. between 6 December 2020 and 8 January 2021. Measures included demographics, participants’ HIV and health-related attributes, COVID-19 history and experiences, COVID-19 vaccine-related concerns, and standardized measures of attitudes towards COVID-19 vaccines. Multivariate linear regression was used to identify factors associated with vaccine hesitancy in this sample.

Results: Among the 1030 respondents, most were male (89.7%), White (66.0%), and identified as gay or lesbian (84.5%). Participants’ mean time living with HIV was 17.0 years (standard deviation (SD) = 11.1). The mean score for vaccine hesitancy was 1.5 (SD = 0.5; range: 1–5); 935 participants (90.8%) had a score greater than 1.0, indicating most participants had some degree of vaccine hesitancy. The final multivariate linear regression showed that greater vaccine hesitancy was associated with being Black (b = 0.149, p = 0.005), single (b = 0.070, p = 0.018), politically conservative (b = 0.157, p = 0.010), “anti-vaxxer” (b = 1.791, p < 0.001), concern about side effects (b = 0.226, p < 0.001), concern about safety (b = 0.260, p < 0.001), and being worried that the vaccine will not be effective (b = 0.169, p = 0.008) and they were being experimented on (b = 0.287, p < 0.001). Participants who were male White (b = −0.093, p = 0.008) and university graduates (b = −0.093, p < 0.001) and had a CD4 count of 200 cells/mm3 (b = −0.082, p = 0.048) and a liberal political orientation (b = −0.131, p < 0.001) were associated with lower vaccine hesitancy.

Conclusions: Our findings provide important insights regarding COVID-19 vaccine hesitancy among PWH. Further efforts are required to understand how various social, political, and psychological factors contribute to COVID-19 vaccine hesitancy among key populations.

Background: HIV incidence in Eastern Europe and Central Asia (EECA) continues to increase, primarily among people who inject drugs (PWID) and people in prisons. In Kyrgyzstan, an estimated 35% of people in prison are PWID, and 10% have been diagnosed with HIV. In 2008, Kyrgyzstan became the first country in EECA to provide free and voluntary methadone in prisons. We examine the impact of this national program on methadone within prison as well as linkage to and retention in treatment upon release to the community./p>

Methods: Administrative data from a national methadone registry with de-identified information were assessed retrospectively. We examined the delivery of methadone services, including the duration of treatment both within prison and after release, for all prisoners who were prescribed methadone in Kyrgyz prisons from 2008 to 2018. Reasons for discontinuing methadone, HIV status and methadone dose are also analyzed.

Results: Between 2008 and 2018, nine of Kyrgyzstan’s 16 prisons offered methadone, and 982 incarcerated people initiated methadone within prison. Prisoners prescribed methadone were mostly male (96.2%), in their mid-30s (mean=34.9 years), and had been incarcerated for a relatively long time (mean = 44.1 months); their mean treatment duration in prison was 12.5 months, and 31.6% had HIV. A subsample (N = 645; 65.7%) of these were released to the community. Of these 645 people, 356 (55.2%) were not taking methadone at the time of release, 128 (19.8%) were on methadone and continued it after release, and the remainder (N=161, 25.0%) were on methadone at the time of release, but subsequently discontinued it, most within the first 7 days after release. Among those continuing methadone, 14.8% (N=19) remained on treatment ≥ 12 months. Independent correlates of linkage to methadone after release included positive HIV status (adjusted hazard ratio (aHR)=1.55; p = 0.033), receipt of methadone before their incarceration (aHR=2.01; p = 0.039), and receipt of methadone at the time of release (aHR = 20.81; p<0.001).

Conclusions: This is the first evaluation of within-prison methadone treatment in EECA. Uptake of methadone within prison and retention in treatment after release were both low. Continuous maintenance of treatment throughout incarceration is an opportunity to optimize HIV prevention and link patients to methadone post-release.

Objective: Vaccination against coronavirus disease 2019 (COVID-19) is a promising avenue for arresting the COVID-19 pandemic, yet suboptimal rates of vaccine uptake in at-risk groups may hinder efficacy and worsen existing health disparities. People with opioid use disorder (OUD) are likely to face increased vulnerability to COVID-19 due to a confluence of biological and social risk factors. We sought to assess factors associated with willingness to vaccinate against COVID-19 in people with OUD.

Methods: Phone surveys were conducted from May to October 2020 with participants enrolled in an urban methadone maintenance program (MMP). Participants were adults who met DSM-5 criteria for OUD and reported injection drug use or sexual risk behavior. Participants were asked about their willingness to receive a highly or partially effective vaccine. Provider trust was assessed using the Trust in Physician scale. Multinomial regression was used to assess demographic and psychosocial factors related to vaccination willingness.

Results: We surveyed 109 people with OUD enrolled in a MMP (M = 47 years; 56% women; 59% White, 23% Black/African American, 14.4% Hispanic/Latinx; 1.8% other). Participants who identified as Black or African American were significantly less likely to endorse willingness to use a partially effective COVID-19 vaccine (adjusted odds ratio [aOR] = .10; 95% confidence interval (CI) [.02, .61], p = .012), although not necessarily less willing to receive a highly effective vaccine (aOR = .40; 95% CI [.09, 1.73], p = .219; n.s.). Trust in physician was positively associated with willingness to use a partially effective vaccine (aOR = 1.12; 95% CI [1.02, 1.23], p = .017), but was not significantly associated with willingness to receive a highly effective vaccine (aOR = 1.07; 95% CI [.98, 1.16], p = .162, n.s).

Conclusions: Proactive outreach from trustworthy sources will be needed to counter vaccine hesitancy in people with OUD, especially among Black Americans with OUD.

Background: The use of mobile health (mHealth), including 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, the mHealth platform has the potential to open new frontiers for HIV prevention efforts. However, little guidance is available to inform researchers about privacy and confidentiality concerns unique to the development and implementation of app-based HIV prevention programs.

Objective: Given the lack of empirical data in this area, we aim to understand the privacy and confidentiality concerns associated with participation in a hypothetical app-based research study for HIV prevention efforts.

Methods: A cross-sectional, web-based survey was conducted between June and July 2020 among 355 Malaysian MSM. The survey included demographic and sexual health questions and a series of short videos describing a hypothetical app-based HIV prevention program, followed by questions related to privacy and confidentiality concerns in each step of the app-based program (ie, recruitment, clinical interaction, risk assessment, and weekly reminder). Multivariable logistic regression models were used to identify the correlates of willingness to use such an app-based program.

Results: Most of the participants (266/355, 74.9%) indicated their willingness to participate in a hypothetical mHealth app-based HIV prevention program. Participants expressed concerns about privacy, confidentiality, data security, and risks and benefits of participating in all stages of the app-based HIV research process. Multivariate analyses indicated that participants who had a higher degree of perceived participation benefits (adjusted odds ratio [aOR] 1.873; 95% CI 1.274-2.755; P=.001) were more willing to participate. In contrast, participants who had increased concerns about app-based clinical interaction and e-prescription (aOR 0.610; 95% CI 0.445-0.838; P=.002) and those who had a higher degree of perceived risks of participating (aOR 0.731; 95% CI 0.594-0.899; P=.003) were less willing to participate.

Conclusions: Overall, our results indicate that mHealth app-based HIV prevention programs are acceptable for future research on Malaysian MSM. The findings further highlighted the role of privacy and confidentiality, as well as the associated risks and benefits associated with participation in such a program. Given the ever-evolving nature of such technological platforms and the complex ethical-legal landscape, such platforms must be safe and secure to ensure widespread public trust and uptake.

Background: COVID-19 is disproportionately affecting disadvantaged populations, including persons with opioid use disorder (OUD). Persons with OUD are at greater risk for direct (e.g., COVID-19 diagnosis, severe symptoms) and indirect consequences (relapse, overdose) of COVID-19. Given stay at home orders, at-home testing options may serve as a viable tool to curb the increase in COVID-19 transmission and adverse effects of COVID-19.

Methods: From May to September 2020, we surveyed 110 persons in treatment for OUD about their willingness to use various self-administered at-home COVID-19 testing measures. Participants were stratified by age, gender, and racial-ethnic identity to observe differences in willingness to use COVID-19 tests. The three COVID-19 tests included a throat swab sample, a saliva-based sample, and a blood prick test.

Results: A high willingness to use at-home COVID-19 tests was observed in patients in treatment for OUD. A greater proportion of females were willing to use a saliva-based test; greater proportions of White participants were willing to use a saliva based COVID-19 test compared to racial-ethnic minorities. Older aged participants (≥45 years old) reported greater rates of willingness to use a self-administered at home blood prick test for COVID-19.

Conclusions: At-home testing measures for COVID-19 appear highly acceptable among people with OUD.

The current study examined the association between subjective cognitive dysfunction and objective test performance in persons enrolled in drug treatment and stabilized on methadone maintenance therapy (MMT). A total of 177 participants completed the self-reported brief inventory of neurocognitive impairment (BINI) and NIH Toolbox test battery. In participants with neurocognitive dysfunction, scores on all BINI subscales were negatively associated with objective performance on the NIH Toolbox (BINI Global r = −0.26, p = 0.01; BINI Subscales ranging −0.22 to −0.32, all p’s < 0.03). Using cutoff scores, results showed participants who scored above the cutoff on the BINI Learning subscale demonstrated significant evidence of objective neurocognitive dysfunction on the NIH Toolbox (65% vs. 35%; χ2 = 6.57, p = 0.02), suggesting possible clinical utility. Future studies are needed to determine the feasibility of using the BINI to inform the accommodation of patients with specific neurocognitive profiles to optimize treatment outcomes.

The impact of pre-exposure prophylaxis (PrEP) uptake on sexual and injection-related behaviors among women who inject drugs (WWID) is poorly understood. Over 24-weeks, PrEP uptake among WWID was associated with increased sharing of injection equipment but not syringes and no changes in condomless sex, providing limited evidence of risk compensation in this vulnerable population.

Objective: The COVID-19 pandemic has exacerbated health disparities, particularly among at-risk people with opioid use disorder (OUD). We sought to characterize the direct and indirect impacts of COVID-19 on this group to understand how the pandemic has affected this group, this group’s public health response to COVID-19, and whether there were differences by race/ethnicity.

Methods: This study recruited its sample from a drug treatment setting in the northeast region of the United States. We surveyed 110 individuals on methadone as treatment for OUD and assessed COVID-19-related impacts on their health behaviors and other indices of social, physical, and mental well-being, including sexual health behaviors, substance use, mental health status, health care access, income, and employment.

Results: Our findings highlight overall increases in depression, anxiety, loneliness, and frustration among the sample of people with OUD; the study also observed decreases in financial stability. Significant differences between groups indicated a greater financial burden among racial-ethnic minorities; this subgroup also reported greater direct adverse effects of COVID-19, including being more concerned about contracting COVID-19, not being able to get a COVID-19 test, and knowing someone who had died from COVID-19. A greater proportion of Whites indicated increases in alcohol consumption and non–prescription drug use than did racial-ethnic minorities.

Conclusions: Treatment providers must be vigilant in managing direct and indirect outcomes of COVID-19 among people with OUD. Findings highlight the need to develop culturally competent, differentiated interventions in partnership with community-based organizations to meet the unique challenges that the COVID-19 pandemic presents for people in treatment for OUD.

In the Bangkok Tenofovir Study of oral pre-exposure prophylaxis (PrEP; TDF/FTC), adherence was poor. Long-acting injectable pre-exposure prophylaxis (LAI-PrEP) for HIV prevention may help overcome adherence challenges and is currently being tested in clinical trials, but not in people who use drugs (PWUD), an important key population that remains highly vulnerable to HIV. Since PWUD are not currently included in trials of LAI-PrEP, we sought to examine awareness about LAI-PrEP and factors associated with willingness to use LAI-PrEP in this understudied population. Participants included 234 HIV-negative people with opioid use disorder and self-reported HIV–risk behaviors recruited from Connecticut’s largest addiction treatment program. We analyzed data from a standardized assessment using audio computer-assisted self-interview (ACASI) to assess the independent factors associated with willingness to use LAI-PrEP. While only 25.6% of participants were aware of LAI-PrEP (67.1% had heard of oral PrEP), after being given a description of it, 73.5% were willing to use it, if it were available. Participants were most commonly concerned about long-term side effects (76.9%) of LAI-PrEP. Independent correlates of willingness to use LAI-PrEP were female sex (aOR = 2.181, p = 0.018), recent visit to healthcare provider (aOR = 2.9, p = 0.023), high perceived risk of acquiring HIV (aOR = 3.3, p = 0.007), and having previously taken oral PrEP (aOR = 3.284, p = 0.017). Findings suggest that PWUD are highly interested in PrEP, especially in LAI-PrEP formulations. Our results indicate the potential for LAI-PrEP, as an alternative to oral daily PrEP, to be implemented into existing evidence-based HIV-based HIV prevention efforts that target high-risk PWUD.

Treatment for opioid use disorder (OUD) is often in the context of biobehavioural interventions, consisting of medication for OUD (for example, methadone and buprenorphine), which is accompanied by psychoeducation and/or behavioural therapies. Patients with OUD often display weaknesses in cognitive function that may impact the efficacy of such behavioural interventions. A review of the literature was conducted to: (1) describe common cognitive dysfunction profiles among patients with OUD, (2) outline intervention approaches for patients with OUD, (3) consider the cognitive demands that interventions place on patients with OUD and (4) identify potential accommodation strategies that may be used to optimise treatment outcomes. Cognitive profiles of patients with OUD often include weaknesses in executive function, attention, memory and information processing. Behavioural interventions require the patients’ ability to learn, understand and remember information (placing specific cognitive demands on patients). Accommodation strategies are, therefore, needed for patients with challenges in one or more of these areas. Research on accommodation strategies for patients with OUD is very limited. We applied research from populations with similar cognitive profiles to form a comprehensive collection of potential strategies to compensate for cognitive dysfunction among patients with OUD. The cognitive profiles and accommodation strategies included in this review are intended to inform future intervention research aimed at improving outcomes among patients with OUD.

Background: Cognitive dysfunction is common in persons seeking medication for opioid use disorder (MOUD) and may hinder many addiction-related services. Brief but accurate screening measures are needed to efficiently assess cognitive dysfunction in these resource-limited settings. The study aimed to develop a brief predictive risk score tailored for use among patients in drug treatment.

Methods: The present study examined predictors of mild cognitive impairment (MCI), objectively assessed via the NIH Toolbox, among 173 patients receiving methadone as MOUD at an urban New England drug treatment facility. Predictors of MCI were identified in one subsample using demographic characteristics, medical chart data, and selected items from the Brief Inventory of Neuro-Cognitive Impairment (BINI). Predictors were cross-validated in a second subsample using logistic regression. Receiver operating curve (ROC) analyses determined an optimal cut-off score for detecting MCI.

Results: A cognitive dysfunction risk score (CDRS) was calculated from patient demographics (age 50+, non-White ethnicity, less than high school education), medical and substance use chart data (history of head injury, overdose, psychiatric diagnosis, past year polysubstance use), and selected self-report items (BINI). The CDRS discriminated acceptably well, with a ROC curve area of 70.6 %, and correctly identified 78 % of MCI cases (sensitivity = 87.5 %; specificity = 55.6 %).

Conclusions: The CDRS identified patients with cognitive challenges at a level likely to impede treatment engagement and/or key outcomes. The CDRS may assist in efficiently identifying patients with cognitive dysfunction while requiring minimal training and resources. Larger validation studies are needed in other clinical settings.

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.

Introduction: In recent years, opioid-related mortality has increased steadily in the United States. Fentanyl, a synthetic opioid, has been a primary driver of the current wave of overdose-related deaths. Little is known, however, about fentanyl use among opioid-dependent people who inject drugs (PWID). We, therefore, sought to characterize purposeful fentanyl use among PWID.

Methods: A cross-sectional survey was administrated to 104 opioid-dependent PWID on methadone who self-reported drug- or sex-related risk behaviors. Participants were recruited between July 2018 and October 2019 from a methadone clinic in New Haven, Connecticut. Multivariable logistic regressions were used to identify independent correlates of purposeful fentanyl use.

Results: Overall, 43.2% and 22.1% of the participants reported any (lifetime) or recent (past 30 days) purposeful fentanyl use, respectively. Independent correlates of any purposeful fentanyl use were younger age (aOR= 0.94; p = 0.021), recent daily injection (aOR= 3.52; p = 0.047), recent cocaine use (aOR= 3.54; p = 0.041), and moderate/severe depression (aOR= 3.82; p = 0.028). Independent correlates of recent purposeful fentanyl use were moderate/severe depression (aOR= 10.94; p = 0.031), recently sharing injection equipment (aOR= 2.96; p = 0.044), and recently engaging in transactional sex (aOR= 3.60; p = 0.026).

Conclusions: These findings indicate that opioid-dependent PWID on methadone remain at increased risk for overdose given the high prevalence of ongoing purposeful fentanyl exposure. Interventions to reduce the harms associated with fentanyl use should target young PWID and active fentanyl users, with an emphasis on achieving adequate methadone dosage and screening and treating depression in methadone-maintained patients who preferentially seek fentanyl.

The COVID-19 pandemic has necessitated restrictive orders and programmatic changes that may be associated with disruptions in services, including those for opioid-dependent people who inject drugs (PWID). This study aims to assess the impact of COVID-19 pandemic on access to and utilization of various HIV prevention services among PWID with opioid use disorder (OUD). We interviewed 110 PWID enrolled in medication for opioid use disorder (MOUD) treatment (e.g., methadone) between May and October, 2020 to identify if this sample experienced changed in access to the following services due to the COVID-19 pandemic: (a) HIV or sexually transmitted infection (STI) testing, (b) pre-exposure prophylaxis (PrEP) services, (c) HIV counselor or doctor appointments, and (d) clean injection equipment. A majority of the sample reported that COVID-19 had not changed their access to HIV testing or access to STI testing. Almost half of the sample reported that getting an appointment with a doctor decreased due to COVID-19. Participants reported that access to a lab or blood testing, access to injection equipment, and sessions with a case manager or counselor decreased. One-fourth of the 32 participants who were taking PrEP before the onset of COVID-19 reported that they had trouble getting their PrEP prescription due to COVID-19, and some reported that they had difficulty getting the PrEP prescription filled at their pharmacy. Our results indicate that PWID did not experience reduced access to HIV or STI testing, but difficulties in obtaining appointments with HIV counselors or doctors and limited access to PrEP were presented. Innovative strategies are needed to reduce the adverse effects of COVID-19 on HIV prevention among PWID.

Scale-up of pre-exposure prophylaxis (PrEP) in people who inject drugs (PWID) remains suboptimal. Patient-level factors are often complex and may contribute to scale-up. Using cross-sectional data from 234 opioid-dependent patients on methadone who met eligibility criteria for PrEP, we conducted logistic regression analyses to assess potential moderators associated with being on PrEP (n = 60). Mean provider trust was significantly higher among Blacks vs Whites (39.4 vs 34.9; p = 0.002) and non-homeless vs homeless participants (37.5 vs 34.8; p = 0.008). Though race/ethnicity was not a significant moderator on provider trust and PrEP use, increased provider trust was marginally associated with increased PrEP use among Blacks (p = 0.058). Additionally, homelessness significantly moderated provider trust and PrEP use (p = 0.024). Provider trust among non-homeless participants was positively correlated with PrEP use (p = 0.013) but not among homeless participants. Strategies that promote provider trust in Blacks and non-homeless PWID on methadone may improve PrEP scale-up.

Background: People who use drugs (PWUD) continue to experience a disproportionate HIV burden due to drug- and sex-related risk behaviors. Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV infection, but very little is known about PrEP use among PWUD and their willingness to initiate PrEP.

Methods: We conducted a cross-sectional survey among 234 HIV-negative, opioid-dependent individuals recruited from an urban methadone clinic. Participants were assessed using an audio-computer assisted self-interview technique. Bivariate and multiple logistic regressions were used to explore independent correlates of actual PrEP use and willingness to initiate PrEP.

Results: One-fourth (25.6 %) of participants had previously used PrEP. Over two-thirds (67.1 %) of participants had previously heard of PrEP, and 65.0 % were willing to take it. In multivariable logistic regression analyses, the number of times participants engaged in HIV testing (aOR = 1.66, p < 0.01) and whether they visited a healthcare provider (aOR=20.81, p = 0.02) were associated with a higher likelihood of PrEP use, while perceived HIV risk (aOR=2.71, p < 0.01) and previous use of PrEP (aOR=3.57, p < 0.01) were significantly associated with willingness to initiate PrEP.

Conclusion: PrEP use was low among PWUD, but their willingness to initiate PrEP was moderate, which indicated a significant discrepancy between actual PrEP use and willingness to use it. Our findings highlight the importance of healthcare providers engaging opioid-dependent individuals in discussions about PrEP and the need for innovative strategies to increase their awareness of PrEP and modify their perceptions of HIV risk.

Introduction: Transgender women (TW) face one of the highest HIV burdens worldwide. In Malaysia, 12.4% of TW are HIV infected, ∼30-fold higher than in the Malaysian adult population. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy, however, little is known about TW’s willingness to use PrEP or their preferences for receiving PrEP. This study examined the correlates of Malaysian TW’s willingness to use PrEP and their attitudes and preferences related to delivery of PrEP and PrEP-related care.

Methods: Between June and August 2017, 361 TW in Malaysia completed an online survey about their knowledge of and willingness to use PrEP for HIV prevention.

Results: Only 20.2% of participants had ever previously heard of PrEP and none were currently taking PrEP. The majority (82.5%) expressed high willingness to take PrEP and most participants met the World Health Organization (WHO) indication for PrEP (82.3%). In the multivariate model, lifetime hormone use, prior postexposure prophylaxis use, and having completed a high school education were associated with higher willingness to use PrEP, while injection drug use, older age, and Chinese ethnicity were associated with lower PrEP willingness.

Conclusion: TW in Malaysia are highly willing to use PrEP for HIV prevention. Differences in willingness to use PrEP identified by education, ethnicity, substance abuse, and age suggest different strategies may be needed to scale-up PrEP for this diverse community of TW.

The COVID-19 outbreak in China was devastating and spread throughout the country before being contained. Stringent physical distancing recommendations and shelter-in-place were first introduced in the hardest-hit provinces, and by March, these recommendations were uniform throughout the country. In the presence of an evolving and deadly pandemic, we sought to investigate the impact of this pandemic on individual well-being and prevention practices among Chinese urban residents. From March 2–11, 2020, 4607 individuals were recruited from 11 provinces with varying numbers of COVID-19 cases using the social networking app WeChat to complete a brief, anonymous, online survey. The analytical sample was restricted to 2551 urban residents. Standardized scales measured generalized anxiety disorder (GAD), the primary outcome. Multiple logistic regression was conducted to identify correlates of GAD alongside assessment of community practices in response to the COVID-19 pandemic. We found that during the COVID-19 pandemic, the recommended public health practices significantly (p < 0.001) increased, including wearing facial mask, practicing physical distancing, handwashing, decreased public spitting, and going outside in urban communities. Overall, 40.3% of participants met screening criteria for GAD and 49.3%, 62.6%, and 55.4% reported that their work, social life, and family life were interrupted by anxious feelings, respectively. Independent correlates of having anxiety symptoms included being a healthcare provider (aOR = 1.58, p < 0.01), living in regions with a higher density of COVID-19 cases (aOR = 2.13, p < 0.01), having completed college (aOR = 1.38, p = 0.03), meeting screening criteria for depression (aOR = 6.03, p < 0.01), and poorer perceived health status (aOR = 1.54, p < 0.01). COVID-19 had a profound impact on the health of urban dwellers throughout China. Not only did they markedly increase their self- and community-protective behaviors, but they also experienced high levels of anxiety associated with a heightened vulnerability like depression, having poor perceived health, and the potential of increased exposure to COVID-19 such as living closer to the epicenter of the pandemic.

Background: HIV self-testing (HIVST) has the potential to improve HIV testing uptake and frequency for key populations like MSM who experience multiple barriers accessing clinic-based HIV testing. In the absence of HIVST in Malaysia, there is no guidance to inform HIVST delivery. This study investigated the acceptability of HIVST and preferences about the HIVST service delivery approaches using a standardized stated preference method.

Methods: A cross-sectional online survey conducted between January and April 2019 assessed the interest in HIVST in 544 MSM in Malaysia. Participants ranked eight hypothetical HIVST service delivery program elements with varied combinations of six, two-level HIVST service delivery program attributes (cost, privacy, accuracy, kit collection site, kit type, and testing support). SPSS conjoint procedure was used to estimate the relative importance of each attribute and preference across eight possible HIVST service delivery programs.

Results: Overall, 70.4% had previously tested for HIV, and of those, 64.0% had done so in the past 6 months (45.0% of all participants). Of all the participants, 25.2% reported having used HIVST previously. The acceptability for HIVST service delivery models ranged from 44.9 to 77.1%, with mean acceptability of 56.2% across the eight hypothetical HIVST distribution scenarios. The HIVST service delivery scenario with the highest acceptability had the following attributes: no cost (free), anonymity (name not required), 99–100% accuracy, home-delivered, fingerstick, and testing support using telephone hotline or texting. HIVST cost was the most important attribute (relative importance score: RIS = 19.30) associated with acceptability, followed by anonymity (RIS = 18.41), accuracy (RIS = 17.33), kit delivery (RIS = 16.99), fingerstick kit (RIS = 15.86), and support (RIS = 12.08).

Conclusions: Acceptability for HIVST in Malaysian MSM was high but differed markedly by a number of HIVST delivery scenarios and attributes. These findings could be relevant as the Malaysian Ministry of Health is in the process of developing a regulatory framework for ensuring the quality of kits, as well as policies supporting safe use while broader implementation under national AIDS programs.

The current study examined the association between subjective cognitive dysfunction and objective test performance in persons enrolled in drug treatment and stabilized on methadone maintenance therapy (MMT). A total of 177 participants completed the self-reported brief inventory of neurocognitive impairment (BINI) and NIH Toolbox test battery. In participants with neurocognitive dysfunction, scores on all BINI subscales were negatively associated with objective performance on the NIH Toolbox (BINI Global r = −0.26, p = 0.01; BINI Subscales ranging −0.22 to −0.32, all p’s < 0.03). Using cutoff scores, results showed participants who scored above the cutoff on the BINI Learning subscale demonstrated significant evidence of objective neurocognitive dysfunction on the NIH Toolbox (65% vs. 35%; χ2 = 6.57, p = 0.02), suggesting possible clinical utility. Future studies are needed to determine the feasibility of using the BINI to inform the accommodation of patients with specific neurocognitive profiles to optimize treatment outcomes.

The evolving opioid epidemic in the United States has increased drug-related overdose rates exponentially. Fentanyl, a synthetic opioid, has recently fueled the epidemic, increasing overdose death rates. Harm reduction strategies (drug checking, naloxone administration, etc.) are at the forefront of preventing opioid-related overdoses in high-risk populations. Little is known, however, about how people who inject drugs (PWID) may modify their drug use behaviors after suspected fentanyl contamination in their drugs. We conducted a cross-sectional survey among 105 opioid-dependent PWID enrolled in a methadone maintenance program. We assessed their willingness to engage in various harm reduction methods (i.e., slowing down drug use, not using drugs, carrying naloxone, using with someone who has naloxone) after suspected fentanyl contamination of their drugs. In a multivariable analysis, participants who were white, low-income, polysubstance users, and had previously experienced an overdose or had previously administered naloxone were more likely to report a willingness to engage in harm reduction measures. These findings provide an evidence-based understanding of PWID’s engagement in harm reduction behaviors after suspecting potential fentanyl exposure as well as a basis for tailoring intervention strategies in the context of fentanyl-adulterated markets.

Background: While global research on the implementation of HIV self-testing (HIVST) has increased exponentially, few studies have assessed information on HIVST uptake factors (i.e., willingness, preferences) in transgender women (TW) and none in the Malaysian context. We therefore sought to assess willingness to use HIVST among this understudied key population.

Methods: A cross-sectional survey was conducted among 361 HIV-negative Malaysian TW in 2017. Participants were recruited using flyers, announcements through social media, and direct referral from staff members of the community-based organizations serving the TW communities. Multivariable logistic regression was used to identify correlates of willingness to use HIVST.

Results: Nearly half of the participants (47.6%) reported that they would be willing to use HIVST. Multivariable analysis showed that willingness to use HIVST was positively associated with having experienced sexual assault in childhood (adjusted odds ratio [aOR]=3.239, p<0.001), having ever used mobile phone or apps to find sex work clients (aOR=1.677, p=0.040), and having engaged in condomless sex in the past 6 months (aOR=1.886, p=0.018). In contrast, living in Kuala Lumpur (aOR=0.559, p=0.032), having higher number of sex work clients per day (aOR=0.927, p=0.004), and current depressive symptoms (aOR=0.576, p=0.026) were negatively associated with willingness to use HIVST.

Conclusions: Findings in this study suggest that TW in our sample were moderately willing to use HIVST. Especially important here is the increased interest in HIVST among TW who are at higher risk for HIV infection. Overall, our findings underscore the need for additional research on how to most effectively implement HIVST for key populations, including TW, such that uptake and retention in regular HIV screening is sustained.

Injection drug use is a key risk factor for the transmission of HIV. Prevention strategies, such as the use of pre-exposure prophylaxis (PrEP), are effective at reducing the risk of HIV transmission in people who inject drugs (PWID). Following PRISMA guidelines, a literature search was conducted to identify the current state of the PrEP care cascade in PWID. Twenty-three articles were evaluated in this systematic review. A decline in engagement throughout the stages of the PrEP care cascade was found. High awareness and willingness to use PrEP was found, yet PrEP uptake was relatively low (0–3%). There is a lack of research on interventions to increase engagement of PrEP across all levels of the care cascade in PWID. Implications from the interventions that have been published provide insight into practice and public policy on efficacious strategies to reduce HIV incidence in PWID. Our findings suggest that more efforts are needed to identify and screen PWID for PrEP eligibility and to link and maintain them with appropriate PrEP care.

Cognitive impairment is common in persons with opioid use disorder and associated with poor treatment outcomes, including elevated risk for relapse. Much less is known about the underlying structure of these deficits and the possible presence of cognitive phenotypes. A total of 177 adults (average 42.2 years of age, 52.0% male, 65.5% Caucasian) enrolled in a methadone maintenance treatment program completed the NIH Toolbox as part of a larger project. Cluster analyses revealed a 2-cluster solution–persons with intact cognitive function in all domains (n = 93; Intact) and those with impairments on tests of attention and executive function (n = 83; Impaired). Follow-up analyses revealed that the Impaired group was slightly older, more likely to self-identify as a racial/ethnic minority, and less likely to report consuming alcohol four or more times per week. These findings suggest the existence of distinct cognitive profiles in persons with opioid use disorder and encourage further examination, particularly studies to examine the possible benefits of routine screening for cognitive impairment as part of substance use treatment.

People who use drugs (PWUD) remain at high risk for acquiring human immunodeficiency virus (HIV), both from injection and from sexual risk-taking. In 2016, 9% of 39,782 new HIV diagnoses occurred among people who inject drugs in the United States. Reaching PWUD with accurate information about and motivation for initiating pre-exposure prophylaxis (PrEP) remains challenging and remains the first crucial step in the knowledge-attitude-behavior change continuum. This study seeks to contribute to closing this information gap by examining the HIV information-seeking behaviors among PWUD who are not on PrEP, so as to identify potential strategies to increase adoption of HIV prevention such as PrEP as part of overall health and related to risk-taking behaviors. A cross-sectional survey was conducted in 2016 among HIV-negative PWUD (n = 400), 57.3% of whom reported injecting at least once in a week, chronically maintained on methadone treatment (MMT) at a large addiction treatment program. The study found that the number of hours spent online by people who use drugs was comparable to the general population. Awareness about PrEP and the seeking of HIV-related information was low in this population. Looking for sex partners online, perception of risk, having multiple partners were associated with seeking HIV information. Although using injection drugs was related to high perception of risk of acquiring HIV, it was not associated with seeking HIV information online. It is imperative to further understand the online HIV information seeking behavior of this population and provide targeted information in order to increase awareness and knowledge about HIV-related risk and methods of prevention, including information about PrEP.

Introduction: There has been increasing interest in the use of mHealth technology in health care. To our knowledge, however, there is a lack of empirical evidence on the utilization of text messaging services (short message service; SMS) for HIV prevention among opioid-dependent people who use drugs (PWUD). As part of our formative work, we conducted an in-depth feasibility and acceptability study on the use of SMS reminders for HIV prevention in this risk group.

Methods: Forty HIV-negative, opioid-dependent PWUD who are currently taking pre-exposure prophylaxis (PrEP) were enrolled in the study. Participants received daily PrEP text reminders and weekly HIV risk reduction-related messages, which were developed using a user-centered approach. Participants were assessed at baseline and immediately post-intervention. Following the post-intervention assessment, participants completed an in-depth qualitative interview.

Results: Feasibility of text messaging service was high, as assessed by participants’ willingness to receive text messages (100%), retention (95%), and successful delivery of text messages (97%). Results further showed that participants were satisfied and perceived the use of daily PrEP reminder text messages as valuable and acceptable [mean: 75.0 (range 0–100)]. Whereas, acceptability for the weekly text messages on HIV risk reduction was 60.3 (±15.6), with 58.3% recommending them for future use. Thematic data exploration revealed important information for understanding and refining SMS content as well as logistical preferences.

Despite evidence from recent trials of the efficacy of pre-exposure prophylaxis (PrEP) in reducing the risk of contracting HIV, PrEP uptake has been slow due to a range of social, structural, and behavioral factors. In this systematic review, we examined the influence of stigma on the PrEP care continuum among men and transwomen who have sex with men (MTWSM). We conducted a literature search in the PubMed electronic database (2012–2018) that focused on the PrEP care continuum among high-risk MTWSM. We explored studies that specifically looked at the influence of stigma on the PrEP cascade among these socially disadvantaged populations. Our search yielded 161 articles, of which nine were ultimately included in our systematic review. The results showed a significant association between stigma and unwillingness to seek or use PrEP suggesting that stigma may negatively affect willingness and uptake of PrEP among these high-risk groups.

In settings where stigma and discrimination toward men who have sex with men (MSM) are high or illegal, like in Malaysia, innovative methods to anonymously reach them are urgently needed. The near ubiquitous availability of mobile technology, including smartphones, has the potential to open new frontiers (such as mHealth) to prevent HIV and other sexually transmitted infections (STIs). The extent to which MSM use mHealth tools for HIV and STI prevention in the Malaysia context, however, is unknown. A cross-sectional online survey in 622 Malaysian MSM was conducted between July and November 2017. Participants were recruited via advertisements on mobile apps frequently used by MSM. In addition to demographic, smartphone access and utilization, and other information were assessed using logistic regression to determine factors associated with the use of a smartphone to search for online sexual health information. Nearly all (99.2%) participants owned a smartphone, with 63% reported having used one to seek sexual health information, including HIV/STIs. Overall, 96% used smartphones to find sexual partners, with high levels of HIV risk behavior reported. Independent correlates of smartphone use to seek online sexual health information included older age (aOR 0.943, p = 0.005), higher education (aOR 2.14, p = 027), recent (past year) HIV testing (aOR 3.91, p = 0.026), and seeking sexual partners using geosocial networking apps (aOR 5.58, p = 0.006). These findings suggest high smartphone use by high-risk MSM to seek sexual health information and suggests that mHealth strategies may be an effective strategy to engage MSM in HIV prevention activities.

Background: Few primary HIV prevention strategies have successfully integrated both behavioral and biomedical components, with modest HIV risk reduction outcomes among opioid-dependent people who use drugs (PWUD). In response to this unmet need, we developed a brief, bio-behavioral intervention to simultaneously promote PrEP adherence and reduce HIV risk among opioid-dependent PWUD.

Methods: Using a Hybrid Type I implementation science design, we will examine the efficacy of the integrated bio-behavioral, Community-friendly Health Recovery Program (CHRP-BB) compared to a time-and-attention matched control condition among HIV-negative, opioid-dependent PWUD who are prescribed PrEP and enrolled in a methadone maintenance program (MMP) using a randomized controlled trial (RCT). Participants are assessed at baseline, immediately post-intervention (8 weeks) and follow-ups at weeks 20, 32, and 44 post-intervention. The primary outcome is biomedical (PrEP adherence), with secondary outcomes including behavioral (self-reported drug- and sex-related HIV risk behaviors), ongoing drug use (confirmed with urine drug testing), and related domains of the theoretical information-motivation-behavioral skills (IMB) model of behavior change related to PrEP adherence and HIV-transmission-risk reduction. Additionally, we will conduct a process evaluation of delivery/implementation of the intervention to collect valuable information to be used in future implementation.

Conclusions: This study will be among the first prospective trial to test an integrated bio-behavioral intervention to improve adherence to PrEP and HIV risk reduction among opioid-dependent PWUD.