Identifying Opportunities for Collaboration Across the Social Sciences to Reach the 10-10-10: A Multilevel Approach.

BACKGROUND:The national and global strategy to combat HIV, often referred to as the "90-90-90," aims to diagnose 90% of people living with HIV, get 90% of those diagnosed onto antiretroviral treatment (ART), and achieve viral suppression in 90% of those on ART. The remaining 10-10-10 who will be undiagnosed, not on ART, or not virally suppressed, include vulnerable persons and populations most affected by social determinants of health. Given their foci on the social determinants of health at the individual, social, and structural levels, social scientists are in a prime position to help reach the 10-10-10. A potentially effective way for social scientists to achieve this goal is to examine the issues that affect the 10-10-10 using a multilevel framework, to understand at what levels their own approaches fit within such a multilevel framework, and to seek intentional collaborations with other social scientists who may work at different levels but whose approaches may complement their own within multilevel collaborations. APPROACH:The present article describes how a multilevel framework can guide collaboration across disciplines within the social sciences toward the common goal of reaching the 10-10-10. CONCLUSIONS:Within a multilevel framework, social scientists can work collaboratively to address the needs of individuals among the 10-10-10 within the social and structural contexts (eg, social norms, stigma, poverty, and barriers to care) that affect their health. Such an approach draws on the unique strengths and approaches of different social-science disciplines while also building capacity for individuals most affected by social determinants of health

Reaching truckers in Brazil with non-stigmatizing and effective HIV/STI services

Research with mobile populations has demonstrated that men in the mobile workforce tend to be exposed to greater HIV risk, and have higher sexually transmitted infection (STI) and HIV prevalence, than those in less mobile or non-mobile professions. At the request of the Brazilian Ministry of Health and with support from USAID/Brazil, the Population Council conducted an assessment in Brazilian border areas to determine which populations were most in need of HIV prevention activities. The research revealed the presence of an extremely mobile, international truck driver community with little to no access to HIV prevention, testing, and treatment services. The intervention strategy of placing a health unit inside the customs station and offering HIV/STI-related services with other services to meet the general health needs of truckers was successful for reaching truckers, was acceptable and well received, and promoted some important HIV-related behavior change

The role of drug resistance in poor viral suppression in rural South Africa: findings from a population-based study.

BACKGROUND:Understanding factors driving virological failure, including the contribution of HIV drug resistance mutations (DRM), is critical to ensuring HIV treatment remains effective. We examine the contribution of drug resistance mutations for low viral suppression in HIV-positive participants in a population-based sero-prevalence survey in rural South Africa. METHODS:We conducted HIV drug resistance genotyping and ART analyte testing on dried blood spots (DBS) from HIV-positive adults participating in a 2014 survey in North West Province. Among those with virologic failure (> 5000 copies/mL), we describe frequency of DRM to protease inhibitors (PI), nucleoside reverse transcriptase inhibitors (NRTI), and non-nucleoside reverse transcriptase inhibitors (NNRTI), report association of resistance with antiretroviral therapy (ART) status, and assess resistance to first and second line therapy. Analyses are weighted to account for sampling design. RESULTS:Overall 170 DBS samples were assayed for viral load and ART analytes; 78.4% of men and 50.0% of women had evidence of virologic failure and were assessed for drug resistance, with successful sequencing of 76/107 samples. We found ≥1 DRM in 22% of participants; 47% were from samples with detectable analyte (efavirenz, nevirapine or lopinavir). Of those with DRM and detectable analyte, 60% showed high-level resistance and reduced predicted virologic response to ≥1 NRTI/NNRTI typically used in first and second-line regimens. CONCLUSIONS:DRM and predicted reduced susceptibility to first and second-line regimens were common among adults with ART exposure in a rural South African population-based sample. Results underscore the importance of ongoing virologic monitoring, regimen optimization and adherence counseling to optimize durable virologic suppression

Improvements in the South African HIV care cascade: findings on 90-90-90 targets from successive population-representative surveys in North West Province.

IntroductionTo achieve epidemic control of HIV by 2030, countries aim to meet 90-90-90 targets to increase knowledge of HIV-positive status, initiation of antiretroviral therapy (ART) and viral suppression by 2020. We assessed the progress towards these targets from 2014 to 2016 in South Africa as expanded treatment policies were introduced using population-representative surveys.MethodsData were collected in January to March 2014 and August to November 2016 in Dr. Ruth Segomotsi Mompati District, North West Province. Each multi-stage cluster sample included 46 enumeration areas (EA), a target of 36 dwelling units (DU) per EA, and a single resident aged 18 to 49 per DU. Data collection included behavioural surveys, rapid HIV antibody testing and dried blood spot collection. We used weighted general linear regression to evaluate differences in the HIV care continuum over time.ResultsOverall, 1044 and 971 participants enrolled in 2014 and 2016 respectively with approximately 77% undergoing HIV testing. Despite increases in reported testing, known status among people living with HIV (PLHIV) remained similar at 68.7% (95% Confidence Interval (CI) = 60.9-75.6) in 2014 and 72.8% (95% CI = 63.6-80.4) in 2016. Men were consistently less likely than women to know their status. Among those with known status, PLHIV on ART increased significantly from 80.9% (95% CI = 71.9-87.4) to 91.5% (95% CI = 84.4-95.5). Viral suppression (<5000 copies/mL using DBS) among those on ART increased significantly from 55.0% (95% CI = 39.6-70.4) in 2014 to 81.4% (95% CI = 72.0-90.8) in 2016. Among all PLHIV an estimated 72.0% (95% CI = 63.8-80.1) of women and 45.8% (95% CI = 27.0-64.7) of men achieved viral suppression by 2016.ConclusionsOver a period during which fixed-dose combination was introduced, ART eligibility expanded, and efforts to streamline treatment were implemented, major improvements in the second and third 90-90-90 targets were achieved. Achieving the first 90 target will require targeted and improved testing models for men

Reaching truckers in Brazil with non-stigmatizing and effective HIV/STI services

A study conducted by the Population Council in 2001 found that truckers crossing Brazil’s southern border had easy access to commercial sex and extremely limited access to health services, condoms, HIV testing and counseling, and HIV/STI prevention messages. In response, the Population Council’s Horizons Program conducted an intervention study from 2002 to 2005. The study examined the feasibility, acceptability, and impact of providing a range of health services to truckers at a health post inside a customs station, where truckers wait anywhere from one day to a week for documents and cargo to clear customs. As noted in this brief, truckers responded positively to HIV-related services offered together with other health services, such as blood pressure and glucose screening. Truckers passing through the intervention site reported greater uptake of HIV counseling and testing, as well as increased condom use and partner communication compared to truckers surveyed at the comparison site. These data suggest that the strategy was successful in reducing HIV risk among truckers

A Guaranteed Income Intervention to Improve the Health and Financial well-being of low-income black emerging adults: study protocol for the Black Economic Equity Movement randomized controlled crossover trial

Background Economic inequity systematically affects Black emerging adults (BEA), aged 18–24, and their healthy trajectory into adulthood. Guaranteed income (GI)–temporary, unconditional cash payments–is gaining traction as a policy solution to address the inequitable distribution of resources sewn by decades of structural racism and disinvestment. GI provides recipients with security, time, and support to enable their transition into adulthood and shows promise for improving mental and physical health outcomes. To date, few GI pilots have targeted emerging adults. The BEEM trial seeks to determine whether providing GI to BEA improves financial wellbeing, mental and physical health as a means to address health disparities. Methods/design Using a randomized controlled crossover trial design, 300 low-income BEA from San Francisco and Oakland, California, are randomized to receive a $500/month GI either during the first 12-months of follow-up (Phase I) or during the second 12-months of a total of 24-months follow-up (Phase II). All participants are offered enrollment in optional peer discussion groups and financial mentoring to bolster financial capability. Primary intention-to-treat analyzes will evaluate the impact of GI at 12 months among Phase I GI recipients compared to waitlist arm participants using Generalized Estimating Equations (GEE). Primary outcomes include: (a) financial well-being (investing in education/training); (b) mental health status (depressive symptoms); and (c) unmet need for mental health and sexual and reproductive health services. Secondary analyzes will examine effects of optional financial capability components using GEE with causal inference methods to adjust for differences across sub-strata. We will also explore the degree to which GI impacts dissipate after payments end. Study outcomes will be collected via surveys every 3 months throughout the study. A nested longitudinal qualitative cohort of 36 participants will further clarify how GI impacts these outcomes. We also discuss how anti-racism praxis guided the intervention design, evaluation design, and implementation. Discussion Findings will provide the first experimental evidence of whether targeted GI paired with complementary financial programming improves the financial well-being, mental health, and unmet health service needs of urban BEA. Results will contribute timely evidence for utilizing GI as a policy tool to reduce health disparities

Reducing intersectional stigma among transgender women in Brazil to promote uptake of HIV testing and PrEP: study protocol for a randomised controlled trial of Manas por Manas

IntroductionGlobally, transgender ('trans') women experience extreme social and economic marginalisation due to intersectional stigma, defined as the confluence of stigma that results from the intersection of social identities and positions among those who are oppressed multiple times. Among trans women, gender-based stigma intersects with social positions such as engagement in sex work and substance use, as well as race-based stigma to generate a social context of vulnerability and increased risk of HIV acquisition. In Brazil, trans women are the 'most at-risk' group for HIV, with 55 times higher estimated odds of HIV infection than the general population; further, uptake of HIV testing and pre-exposure prophylaxis (PrEP) among trans women is significantly lower than other at-risk groups. Through extensive formative work, we developed Manas por Manas, a multilevel intervention using HIV prevention strategies with demonstrated feasibility and acceptability by trans women in Brazil, to address intersectional stigma and increase engagement in the HIV prevention continuum.Methods and analysisWe are conducting a two-arm randomised wait-list controlled trial of the intervention's efficacy in São Paulo, Brazil, to improve uptake of HIV testing and PrEP among transgender women (N=400). The primary outcomes are changes in HIV testing (self-testing and clinic based), changes in PrEP uptake and changes in PrEP persistence at baseline and follow-up assessment for 12 months at 3-month intervals.Ethics and disseminationThis study was approved by University of California, San Francisco Institutional Review Board (15-17910) and Comissão Nacional de Ética em Pesquisa (Research Ethics National Commission, CAAE: 25215219.8.0000.5479) in Brazil. Participants provided informed consent before enrolment. We are committed to collaboration with National Institutes of Health officials, other researchers, and health and social services communities for rapid dissemination of data and sharing of materials. The results will be published in peer-reviewed academic journals and scientific presentations.Trial registration numberNCT03081559

Housing Instability Patterns Among Low-Income, Urban Black Young Adults in California and Associations with Mental Health Outcomes: Baseline Data from a Randomized Waitlist-Controlled Trial

Background: Deep-rooted racial residential segregation and housing discrimination have given rise to housing disparities among low-income Black young adults in the US. Most studies have focused on single dimensions of housing instability, and thus provide a partial view of how Black young adults experience multiple, and perhaps overlapping, experiences of housing instability including homelessness, frequent moves, unaffordability, or evictions. We aimed to illuminate the multiple forms of housing instability that Black young adults contend with and examine relationships between housing instability and mental health outcomes. Methods: Using baseline data from the Black Economic Equity Movement (BEEM) guaranteed income trial with 300 urban low-income Black young adults (aged 18–24), we conducted a three-stage latent class analysis using nine housing instability indicators. We identified distinct patterns by using fit indices and theory to determine the optimal number of latent classes. We then used multinomial logistic regression to identify subpopulations disproportionately represented within unstable housing patterns. Finally, we estimated associations between housing experience patterns and mental health outcomes: depression, anxiety, and hope. Results We found high prevalence of housing instability with 27.3% of participants reporting experiences of homelessness in the prior year and 39.0% of participants reporting multiple measures of housing instability. We found the 4-class solution to be the best fitting model for the data based on fit indices and theory. Latent classes were characterized as four housing experience patterns: 1) more stably housed, 2) unaffordable and overcrowded housing, 3) mainly unhoused, and 4) multiple dimensions of housing instability. Those experiencing unaffordable and overcrowded housing and being mainly unhoused were more than four times as likely to have symptoms of depression (Unaffordable: aOR = 4.57, 95% CI: 1.64, 12.72; Unhoused: aOR = 4.67, 95% CI:1.18, 18.48) and more than twice as likely to report anxiety (Unaffordable: aOR = 2.28, 95% CI: 1.03, 5.04; Unhoused: aOR = 3.36, 95% CI: 1.12, 10.05) compared to the more stably housed pattern. We found that hope scores were similarly high across patterns. Conclusions: High prevalence of housing instability and mental health challenges among low-income Black young adults demands tailored interventions to reduce instability, given widening racial disparities and implications for future well-being into adulthood

Correlates of viral suppression among sexual minority men and transgender women living with HIV in Mpumalanga, South Africa

Sexual minority men (SMM) and transgender women in South Africa engage in HIV care at lower rates than other persons living with HIV and may experience population-specific barriers to HIV treatment and viral suppression (VS). As part of a pilot trial of an SMM-tailored peer navigation (PN) intervention in Ehlanzeni district, South Africa, we assessed factors associated with ART use and VS among SMM at trial enrolment. A total of 103 HIV-positive SMM and transgender women enrolled in the pilot trial. Data on clinical visits and ART adherence were self-reported. VS status was verified through laboratory analysis (<1000 copies/ml). We assessed correlates of VS at baseline using Poisson generalized linear model (GLM) with a log link function, including demographic, psychosocial, clinical, and behavioral indicators. Among participants, 52.4% reported ART use and only 42.2% of all participants had evidence of VS. Of the 49.5% who reported optimal engagement in HIV care (consistent clinic visits with pills never missed for ≥ 4 consecutive days) in the past 3-months, 56.0% were virally suppressed. In multivariable analysis, SMM were significantly more likely to be virally suppressed when they were ≥ 25 years of age (Adjusted prevalence ratio [APR] = 2.0, CI 95%:1.0-3.8); in a relationship but not living with partner, as compared to married, living together, or single (APR = 1.7, CI 95%:1.0-2.7), and optimally engaged in care (APR = 2.1, 95% CI:1.3-3.3). Findings indicate a need for targeted treatment and care support programming, especially for SMM and transgender women who are young and married/living with their partners to improve treatment outcomes among this population