How to improve HIV prevention?:Development, implementation and evaluationof combination prevention interventionsamong key populations

Infections with the human immune deficiency virus (HIV) remain an important health issue. In Europe and Belgium, high numbers of new HIV diagnoses persist. Without the prospect of a cure for HIV within the coming years, prevention, early diagnosis, linkage and access to specialized care and treatment are cornerstones of the management of HIV. Effective HIV prevention has been prioritized since the beginning of the HIV epidemic. An approach with a high and sustainable impact is combination prevention. Combination prevention for HIV covers a set of prevention interventions involving three dimensions: biomedical, behavioral and structural.The general objective of this thesis was to improve HIV prevention across all three dimensions of the HIV combination prevention concept. In the different chapters, we presented projects that aimed to provide evidence on the effectiveness of innovative prevention activities on HIV prevention. On the biomedical dimension, testing has been highlighted as a prevention intervention. After having provided an overview of innovation and evolution of HIV testing activities in Europe in chapter two, we presented results of two consecutive HIV testing projects in Belgium in chapters three and four. Both projects used outreach approaches for sample collection. In the second project, we added a self-sampling approach allowing people to order a sampling kit via a website. We combined collection of blood and oral fluid samples with a test executed in the laboratory and delayed communication of HIV test results using cell phone messages (chapter three) and a secured website (chapter four). Although we aimed for innovation in both projects, safeguarding quality in all aspects of the HIV testing approach was fundamental. Both testing interventions were found to be effective as 2.9% and 2.2% of participants were newly diagnosed with HIV respectively. These proportions are higher than the consensus of 0.1% newly diagnosed participants as cut-off for cost-effectiveness in HIV testing projects.Regarding the behavioral dimension of HIV combination prevention, results from a survey research project were presented in chapter five. We observed a decline in sexual inactivity among a group of European men who have sex with men living with HIV since the introduction of antiretroviral treatment for HIV. This finding suggests a tendency towards normalization of the sex life of people living with HIV. This implies investment to support people living with HIV in their sexual health. In chapter six, we presented results from a project studying the effectiveness of a computer-assisted counselling intervention for safer sex for people living with HIV. This intervention was tested among a group of European men who have sex with men, and consisted of three individual counselling sessions with a trained counsellor using computer-assisted tools (including video clips and interactive slide shows) to increase condom use in sexual encounters. A significant increase in condom use was observed three months after completion of the intervention, providing evidence for short term effectiveness. This effect could not be sustained up to six months after completion. Booster sessions may yield a longer term effect.Structural prevention interventions aim to tackle circumstances that hinder people to practise safer sex, or make them vulnerable for HIV acquisition. In this light, identifying groups at risk for HIV acquisition may be considered as a structural prevention intervention. Using an online survey, we assessed the sexual health of a group of swingers, their risk for acquisition of HIV and sexually transmitted infections (STI), and testing experiences, as presented in chapter seven. Compared to the general population, swingers were sexually very active, and several risk factors for acquisition of HIV and STI were identified. Swingers were more likely to have been diagnosed with an STI. Although swingers found their way to existing structures for testing, strengthening these structures and providing alternative testing options should be considered.The different projects presented in chapters two to seven provided evidence on the effectiveness of a combination approach in HIV prevention. Turning this knowledge into practice is a key element to success of prevention. Therefore, a collaboration between policy makers, program officers, health care providers, researchers and communities is required to ensure access to qualitative support and functioning programs. Improving quality and functionality may also include innovation to find appealing ways of the delivery of services and programs. Computerized technologies may attract new users, and should receive attention in research and practice. Adapting prevention to new trends, their consequences and responses, is important in effective prevention. In chapter eight, effects and responses to pre-exposure prophylaxis, chemsex and couple testing were discussed.Combination prevention for HIV covers a range of interventions on a structural, behavioral and biomedical level. All three levels are necessary to achieve highly effective prevention. Securing rights of key populations to reduce stigma and discrimination, and safeguarding or improving access to services are crucial structural ambitions. Investment in the development and evaluation of effective behavioral interventions using appealing ways of program delivery is a challenge on the behavioral dimension. An important biomedical goal is to diagnose as many people living with HIV unaware of their status as possible by expanding HIV and STI testing approaches. Although testing for HIV is critical, linkage to care, and retention in care should be integrated in the evaluation of each testing approach. Optimizing linkage and retention requires qualitative HIV care. Quality is reflected in accessibility, and a team of professional health care providers with medical and psychological expertise who treat patients with an open and respectful attitude

Self-Control as Conceptual Framework to Understand and Support People Who Use Drugs During Sex

Few theory-informed interventions to support people who use drugs during sex have been conceptualized and developed. We conceptualize sexualized drug use, also referred to as chemsex or pharmacosex, as a self-control challenge, and draw on extant theory and research to propose intervention approaches that can be tailored to meet the differing needs of people who engage in sexualized drug use. We draw on a continuum perspective of sexualized drug use, in particular chemsex, and discuss the role of reasoned and automatic processes in behavioral decisions, as well as critical components of effective self-control of behavior. A self-control approach can empower people to tackle their sexualized drug use, and classify their experienced sex-related drug use as problematic. Self-control encompasses clarifying one's goals and identifying strategies to mitigate behaviors to achieve these goals, despite competing pharmacosex desires. Our approach to self-control sexualized drug use contains three critical components: goal setting, goal enactment, and goal progress appraisal and goal adjustment. Goals should be formulated specific, ambitious yet realistic, and tailored to the individual's needs and wishes. Goals may target aspects of drug use, protecting sexual health and mitigating negative impacts. Implementing goal enactment implies translating goals into concrete (short-term) actions to move toward the higher-order goal via goal intentions and action/coping plans. During the goal progress appraisal and adjustment stage, people compare their actual with their planned behavior. This reflection may result in goal adjustment through feedback loops to adjust their goals and action/coping plans. We propose that our self-control approach can guide the development of interventions to effectively support people to prevent or limit pharmacosex, and helps to effectively mitigate or reduce negative impacts via self-help, peer support or professional support, offered via personal counseling or digital tools

The HepHIV 2023 Madrid conference: A call to action for political leadership in reaching the sustainable development goals on earlier testing and linkage to care for HIV, viral hepatitis, and sexually transmitted infections

info:eu-repo/semantics/publishedVersio

COBA-Cohort : a prospective cohort of HIV-negative men who have sex with men, attending community-based HIV testing services in five European countries (a study protocol)

Altres ajuts: This work was supported by the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA, European Commission); grant number 2013-11-01-613233.Community-based voluntary counselling and testing (CBVCT) services for men who have sex with men (MSM) can reach those most-at-risk and provide an environment for gay men that is likely to be non-stigmatising. Longitudinal data on the behaviour of HIV-negative MSM are scarce in Europe. The aim of this protocol, developed during the Euro HIV Early Diagnosis And Treatment (EDAT) project, is to implement a multicentre community-based cohort of HIV-negative MSM attending 15 CBVCT services in 5 European countries. (1) To describe the patterns of CBVCT use, (2) to estimate HIV incidence, and to identify determinants of (3) HIV seroconversion and (4) HIV and/or sexually transmitted infection (STI) test-seeking behaviour. All MSM aged 18 years or over and who had a negative HIV test result are invited to participate in the COmmunity-BAsed Cohort (COBA-Cohort). Study enrolment started in February 2015, and is due to continue for at least 12 months at each study site. Follow-up frequency depends on the testing recommendations in each country (at least 1 test per year). Sociodemographic data are collected at baseline; baseline and follow-up questionnaires both gather data on attitudes and perceptions, discrimination, HIV/STI testing history, sexual behaviour, condom use, and pre- and post-exposure prophylaxis. Descriptive, exploratory and multivariate analyses will be performed to address the main research objectives of this study, using appropriate statistical tests and models. These analyses will be performed on the whole cohort data and stratified by study site or country. The study was approved by the Public Health authorities of each country where the study is being implemented. Findings from the COBA-Cohort study will be summarised in a report to the European Commission, and in leaflets to be distributed to study participants. Articles and conference abstracts will be submitted to peer-reviewed journals and conferences

HIV-related stigma within communities of gay men: A literature review

While stigma associated with HIV infection is well recognised, there is limited information on the impact of HIV-related stigma between men who have sex with men and within communities of gay men. The consequences of HIV-related stigma can be personal and community-wide, including impacts on mood and emotional well-being, prevention, testing behaviour, and mental and general health. This review of the literature reports a growing division between HIV-positive and HIV-negative gay men, and a fragmentation of gay communities based along lines of perceived or actual HIV status. The literature includes multiple references to HIV stigma and discrimination between gay men, men who have sex with men, and among and between many gay communities. This HIV stigma takes diverse forms and can incorporate aspects of social exclusion, ageism, discrimination based on physical appearance and health status, rejection and violence. By compiling the available information on this understudied form of HIV-related discrimination, we hope to better understand and target research and countermeasures aimed at reducing its impact at multiple levels

How to improve HIV prevention?: Development, implementation and evaluationof combination prevention interventionsamong key populations

Infections with the human immune deficiency virus (HIV) remain an important health issue. In Europe and Belgium, high numbers of new HIV diagnoses persist. Without the prospect of a cure for HIV within the coming years, prevention, early diagnosis, linkage and access to specialized care and treatment are cornerstones of the management of HIV. Effective HIV prevention has been prioritized since the beginning of the HIV epidemic. An approach with a high and sustainable impact is combination prevention. Combination prevention for HIV covers a set of prevention interventions involving three dimensions: biomedical, behavioral and structural.The general objective of this thesis was to improve HIV prevention across all three dimensions of the HIV combination prevention concept. In the different chapters, we presented projects that aimed to provide evidence on the effectiveness of innovative prevention activities on HIV prevention. On the biomedical dimension, testing has been highlighted as a prevention intervention. After having provided an overview of innovation and evolution of HIV testing activities in Europe in chapter two, we presented results of two consecutive HIV testing projects in Belgium in chapters three and four. Both projects used outreach approaches for sample collection. In the second project, we added a self-sampling approach allowing people to order a sampling kit via a website. We combined collection of blood and oral fluid samples with a test executed in the laboratory and delayed communication of HIV test results using cell phone messages (chapter three) and a secured website (chapter four). Although we aimed for innovation in both projects, safeguarding quality in all aspects of the HIV testing approach was fundamental. Both testing interventions were found to be effective as 2.9% and 2.2% of participants were newly diagnosed with HIV respectively. These proportions are higher than the consensus of 0.1% newly diagnosed participants as cut-off for cost-effectiveness in HIV testing projects.Regarding the behavioral dimension of HIV combination prevention, results from a survey research project were presented in chapter five. We observed a decline in sexual inactivity among a group of European men who have sex with men living with HIV since the introduction of antiretroviral treatment for HIV. This finding suggests a tendency towards normalization of the sex life of people living with HIV. This implies investment to support people living with HIV in their sexual health. In chapter six, we presented results from a project studying the effectiveness of a computer-assisted counselling intervention for safer sex for people living with HIV. This intervention was tested among a group of European men who have sex with men, and consisted of three individual counselling sessions with a trained counsellor using computer-assisted tools (including video clips and interactive slide shows) to increase condom use in sexual encounters. A significant increase in condom use was observed three months after completion of the intervention, providing evidence for short term effectiveness. This effect could not be sustained up to six months after completion. Booster sessions may yield a longer term effect.Structural prevention interventions aim to tackle circumstances that hinder people to practise safer sex, or make them vulnerable for HIV acquisition. In this light, identifying groups at risk for HIV acquisition may be considered as a structural prevention intervention. Using an online survey, we assessed the sexual health of a group of swingers, their risk for acquisition of HIV and sexually transmitted infections (STI), and testing experiences, as presented in chapter seven. Compared to the general population, swingers were sexually very active, and several risk factors for acquisition of HIV and STI were identified. Swingers were more likely to have been diagnosed with an STI. Although swingers found their way to existing structures for testing, strengthening these structures and providing alternative testing options should be considered.The different projects presented in chapters two to seven provided evidence on the effectiveness of a combination approach in HIV prevention. Turning this knowledge into practice is a key element to success of prevention. Therefore, a collaboration between policy makers, program officers, health care providers, researchers and communities is required to ensure access to qualitative support and functioning programs. Improving quality and functionality may also include innovation to find appealing ways of the delivery of services and programs. Computerized technologies may attract new users, and should receive attention in research and practice. Adapting prevention to new trends, their consequences and responses, is important in effective prevention. In chapter eight, effects and responses to pre-exposure prophylaxis, chemsex and couple testing were discussed.Combination prevention for HIV covers a range of interventions on a structural, behavioral and biomedical level. All three levels are necessary to achieve highly effective prevention. Securing rights of key populations to reduce stigma and discrimination, and safeguarding or improving access to services are crucial structural ambitions. Investment in the development and evaluation of effective behavioral interventions using appealing ways of program delivery is a challenge on the behavioral dimension. An important biomedical goal is to diagnose as many people living with HIV unaware of their status as possible by expanding HIV and STI testing approaches. Although testing for HIV is critical, linkage to care, and retention in care should be integrated in the evaluation of each testing approach. Optimizing linkage and retention requires qualitative HIV care. Quality is reflected in accessibility, and a team of professional health care providers with medical and psychological expertise who treat patients with an open and respectful attitude

Using Intervention Mapping to Develop an mHealth Intervention to Support Men Who Have Sex With Men Engaging in Chemsex (Budd): Development and Usability Study

BackgroundChemsex refers to the intentional use of drugs before or during sex among men who have sex with men (MSM). Engaging in chemsex has been linked to significant negative impacts on physical, psychological, and social well-being. However, no evidence-based support tools have addressed either these harms or the care needs of MSM who engage in chemsex. ObjectiveThe purpose of this paper was to describe the development of a mobile health intervention (named Budd) using the intervention mapping protocol (IMP). Budd aims to support and inform MSM who participate in chemsex, reduce the negative impacts associated with chemsex, and encourage more reasoned participation. MethodsThe IMP consists of 6 steps to develop, implement, and evaluate evidence-based health interventions. A needs assessment was carried out between September 2, 2019, and March 31, 2020, by conducting a literature study and in-depth interviews. Change objectives were selected based on these findings, after which theory-based intervention methods were selected. The first version of the intervention was developed in December 2020 and pilot-tested between February 1, 2021, and April 30, 2021. Adjustments were made based on the findings from this study. A separate article will be dedicated to the effectiveness study, conducted between October 15, 2021, and February 24, 2022, and implementation of the intervention. The Budd app went live in April 2022. ResultsBudd aims to address individual factors and support chemsex participants in applying harm reduction measures when taking drugs (drug information, drug combination tool, and notebook), preparing for participation in a chemsex session (articles on chemsex, preparation tool, and event-specific checklist), planning sufficient time after a chemsex session to recover (planning tool), seeking support for their chemsex participation (overview of existing local health care and peer support services, reflection, personal statistics, and user testimonials), taking HIV medication or pre-exposure prophylaxis in a timely manner during a chemsex session (preparation tool), and contacting emergency services in case of an emergency and giving first aid to others (emergency information and personal buddy). ConclusionsThe IMP proved to be a valuable tool in the planning and development of the Budd app. This study provides researchers and practitioners with valuable information that may help them to set up their own health interventions. International Registered Report Identifier (IRRID)RR1-10.2196/3967

Increases in condomless chemsex associated with HIV acquisition in MSM but not heterosexuals attending a HIV testing center in Antwerp, Belgium

Background It has been speculated that the prevalence of chemsex is increasing in men who have sex with men and that this may be playing a role in the spread of HIV. Methods We assessed if the prevalence of reported chemsex was increasing and if chemsex was associated with HIV infection in clients attending the ‘Helpcenter’, Antwerp, between 2011 and 2017. This is a HIV/STI testing center that offers HIV/STI testing to HIV-uninfected individuals from key populations including MSM. Results We found an increase in the reporting of condomless sex associated with the use of a number of drugs, including ecstasy, amphetamines, GHB and cocaine in MSM (from 8 to 17%) but not in heterosexuals. Reporting condomless chemsex was associated with HIV infection (adjusted odds ratio 5.7 [95% confidence interval 3.2–10.4]). Conclusions Our findings provide further evidence of the importance of asking MSM clients about the use of psychoactive substances during consultations and tailoring interventions such as pre exposure prophylaxis, more frequent STI screening and substance abuse counseling accordingly

The problematic chemsex journey:a resource for prevention and harm reduction

Purpose Chemsex is a phenomenon that has gained increasing attention in recent years. The purpose of this paper is to differentiate chemsex from other sexualized substance use, and clarify differences between recreational and problematic chemsex use. Despite plentiful publications, little has been published on underlying determinants that predispose individuals to chemsex, and their process toward problematic chemsex use. Design/methodology/approach During the second European Chemsex Forum, people who engage in chemsex, community organizers, researchers, clinicians, therapists, social workers and (peer) counselors discussed potential pathways to problematic chemsex. In this manuscript, we translate findings from these discussions into a framework to understand the initiation and process toward problematic chemsex. Findings Six stages (loneliness and emptiness, search for connection, sexual connection, chemsex connection, problematic chemsex and severe health impact) and a set of factors facilitating the transition from one stage to the next have been identified. Originality/value It is hoped that this “Journey towards problematic chemsex use” will stimulate reflection and debate, with the ultimate goal of improving prevention and care for people engaging in chemsex