Pramila Karki

Correlates of willingness to initiate pre-exposure prophylaxis and anticipation of practicing safer drug- and sex-related behaviors among high-risk drug users on methadone treatment

BACKGROUND Although people who use drugs (PWUD) are key populations recommended to receive pre-exposure prophylaxis (PrEP) to prevent HIV, few data are available to guide PrEP delivery in this underserved group. We therefore examined the willingness to initiate PrEP and the anticipation of HIV risk reduction while on PrEP among high-risk PWUD. METHODS In a cross-sectional study of 400 HIV-negative, opioid dependent persons enrolled in a methadone program and reporting recent risk behaviors, we examined independent correlates of being willing to initiate PrEP. RESULTS While only 72 (18%) were aware of PrEP, after being given a description of it, 251 (62.7%) were willing to initiate PrEP. This outcome was associated with having neurocognitive impairment (aOR=3.184, p=0.004) and higher perceived HIV risk (aOR=8.044, p<0.001). Among those willing to initiate PrEP, only 12.5% and 28.2%, respectively, indicated that they would always use condoms and not share injection equipment while on PrEP. Consistent condom use was associated with higher income (aOR=8.315, p=0.016), always using condoms with casual partners (aOR=6.597, p=0.001), and inversely associated with ongoing drug injection (aOR=0.323, p=0.027). Consistent safe injection, however, was inversely associated with age (aOR=0.948, p=0.035), ongoing drug injection (aOR=0.342, p<0.001), and perceived HIV risk (aOR=0.191, p=0.019). CONCLUSIONS While willingness to initiate PrEP was high and correlated with being at elevated risk for HIV, anticipated higher risk behaviors in this group even while on PrEP suggests that the next generation of HIV prevention approaches may need to combine biomedical and behavioral components to sustain HIV risk reduction over time.

Treatment Engagement Moderates the Effect of Neurocognitive Impairment on Antiretroviral Therapy Adherence in HIV-Infected Drug Users in Treatment

&NA; Neurocognitive impairment (NCI) and treatment engagement (TE) have been shown to significantly predict antiretroviral therapy (ART) adherence, but no studies have explored the ways and the extent to which similar outcomes might occur when these factors operate together, particularly for people who use drugs (PWUDs). We sought to discover whether TE moderated the effect of NCI on adherence to ART in HIV‐infected individuals. One hundred sixteen HIV‐infected, methadone‐maintained people who reported HIV risk behaviors were enrolled in the study. Variables of interest (NCI, ART adherence, TE) were assessed using audio computer‐assisted self‐interview. Results revealed a significant interactive effect of NCI and TE on ART adherence, which supported the moderation effect. Findings from post hoc analyses showed that NCI was negatively associated with adherence to ART at low levels of TE. Findings suggest the need to accommodate individual NCI and improve TE as a means to enhance ART adherence in HIV‐infected PWUDs.

Willingness to Use Pre-Exposure Prophylaxis (PrEP): An Empirical Test of the Information-Motivation-Behavioral Skills (IMB) Model among High-Risk Drug Users in Treatment

Evidence from recent pre-exposure prophylaxis (PrEP) trials has demonstrated its safety and efficacy in significantly reducing the risk of HIV acquisition for those who are at considerable risk of acquiring HIV infection. With a rapid increase in the amount of research on the efficacy of PrEP for HIV prevention, complementary research on the willingness to use PrEP has grown, especially among MSM, but limited research has been focused among people who use drugs (PWUD). As part of the formative process, we utilized the information-motivation-behavioral skills (IMB) model of health behavior change to characterize and guide intervention development for promoting willingness to use PrEP among high-risk PWUD. The analysis included 400 HIV-negative high-risk PWUD enrolled in a community-based methadone maintenance treatment who reported drug- and/or sex-related HIV risk behaviors in the past 6-months. Analyses revealed support for the IMB model as PrEP-related behavioral skills were found to mediate the influence of PrEP-related information and motivation on willingness to use PrEP. The results provide evidence as to the utility of the IMB model to increase willingness to use PrEP among high-risk PWUD. It therefore makes an important contribution to our understanding of the applicability of theoretically-grounded models of willingness to use PrEP among high-risk PWUD, who are one of the key risk populations who could benefit from the use of PrEP.

Developing an Integrated, Brief Biobehavioral HIV Prevention Intervention for High-Risk Drug Users in Treatment: The Process and Outcome of Formative Research

To date, HIV prevention efforts have largely relied on singular strategies (e.g., behavioral or biomedical approaches alone) with modest HIV risk-reduction outcomes for people who use drugs (PWUD), many of whom experience a wide range of neurocognitive impairments (NCI). We report on the process and outcome of our formative research aimed at developing an integrated biobehavioral approach that incorporates innovative strategies to address the HIV prevention and cognitive needs of high-risk PWUD in drug treatment. Our formative work involved first adapting an evidence-based behavioral intervention—guided by the Assessment–Decision–Administration–Production–Topical experts–Integration–Training–Testing model—and then combining the behavioral intervention with an evidence-based biomedical intervention for implementation among the target population. This process involved eliciting data through structured focus groups (FGs) with key stakeholders—members of the target population (n = 20) and treatment providers (n = 10). Analysis of FG data followed a thematic analysis approach utilizing several qualitative data analysis techniques, including inductive analysis and cross-case analysis. Based on all information, we integrated the adapted community-friendly health recovery program—a brief evidence-based HIV prevention behavioral intervention—with the evidence-based biomedical component [i.e., preexposure prophylaxis (PrEP)], an approach that incorporates innovative strategies to accommodate individuals with NCI. This combination approach—now called the biobehavioral community-friendly health recovery program—is designed to address HIV-related risk behaviors and PrEP uptake and adherence as experienced by many PWUD in treatment. This study provides a complete example of the process of selecting, adapting, and integrating the evidence-based interventions—taking into account both empirical evidence and input from target population members and target organization stakeholders. The resultant brief evidence-based biobehavioral approach could significantly advance primary prevention science by cost-effectively optimizing PrEP adherence and HIV risk reduction within common drug treatment settings.

Adapting an Evidence-Based HIV Prevention Intervention Targeting High-Risk Migrant Workers: The Process and Outcome of Formative Research

Background Historically, HIV prevention efforts in Nepal have primarily focused on heterosexual transmission, particularly, among female sex workers and their male clients, with little acknowledgment of the contribution of migrant workers to the epidemic. The very few HIV prevention efforts that have been attempted with migrants have been unsuccessful primarily due to stigma, discrimination, and insufficient availability of culturally relevant evidence-based interventions (EBIs). As an initial step toward addressing this unmet need, we conducted formative research aimed at adapting an evidence-based HIV risk-reduction intervention for implementation among migrants in Nepal. Methods Our formative work involved a critical examination of established EBIs and associated published reports complemented by data elicited through structured interviews with members of the target population and key stakeholders. Between July and August, 2014, we conducted structured one-on-one interview with migrants (n = 5) and key stakeholder (e.g., counselors, field workers, and project coordinator; n = 5), which focused on the HIV risk profiles of the migrants and on ways to optimize intervention content, delivery, and placement within the community-based settings. Data analysis followed a thematic analysis approach utilizing several qualitative data analysis techniques, including inductive analysis, cross-case analysis, and analytical coding of textual data. Results Based on formative research, we adapted the Holistic Health Recovery Program, an EBI, to consist of four 30-min sessions that cover a range of topics relevant to migrants in Nepal. The intervention was adapted with flexibility, so that it could be provided in an individual format, implemented within or outside the community-based organization, and it can be delivered in either consecutive or weekly sessions based on time constraints. Conclusion This paper provides a detailed description of the formative research process in preparation for the adaptation of an EBI – taking into account both empirical evidence and input from target population and key stakeholders – for use with migrants in Nepal. We hope that this study will help to inform similar work in the future as a growing number of EBIs have become widely available, but may not yet be in optimal form for implementation in real-world community-based settings.

Intent to Use Preexposure Prophylaxis (PrEP), HIV Risk Behaviors, and Self-Report Neurocognitive Symptoms by High-Risk Drug Users: A Mediation Analysis

&NA; Neurocognitive impairment (NCI) and HIV risk are significant correlates of intent to use preexposure prophylaxis (PrEP). The extent to which similar outcomes could occur when these factors operate together, particularly for people who use drugs (PWUD), remains an important unanswered question. We therefore sought evidence that HIV risk behavior mediated the relationship between NCI and intent to use PrEP in high‐risk PWUD in treatment. HIV‐uninfected, methadone‐maintained people who reported HIV‐risk behaviors were enrolled (n = 400). Variables of interest (NCI, HIV risk behaviors, intent to use PrEP) were assessed using audio computer‐assisted self‐interview. We found preliminary evidence of indirect effect of HIV risk behaviors, such that NCI had an increased impact on intent to use PrEP via HIV risk behaviors. As a result of having this information, clinicians and researchers will be better equipped for evidence‐informed targeting and dissemination efforts to optimize PrEP uptake by this underserved population.

Interest in use of mHealth technology in HIV prevention and associated factors among high-risk drug users enrolled in methadone maintenance program

ABSTRACT The adoption of mobile technologies for health (mHealth) in healthcare has grown considerably in recent years, but systematic assessment of interest in the use of mHealth in HIV prevention efforts among people who use drugs (PWUD) is lacking. We therefore examined interest in use of mHealth technology in HIV prevention and associated individual-level factors among high-risk PWUD enrolled in methadone maintenance program. A total of 400 HIV-negative PWUD, who reported drug- and/or sex-related risk behaviors completed a standardized assessment using audio computer assisted self-interview (ACASI). Results revealed significant interest in using mHealth-based approaches for specific purposes, including: to receive medication reminders (72.3%), to receive information about HIV risk reduction (65.8%), and to assess HIV risk behaviors (76.5%). Multivariate analysis showed that interest in receiving medication reminders was associated with currently taking medication and being neurocognitively impaired, whereas interest in receiving HIV-risk reduction information was associated with being non-white, married, and perceiving the person was at high-risk for contracting HIV. Similarly, participants’ interested in using mHealth for HIV risk behavior assessment was associated with having recently visited a healthcare provider and exhibiting depressive symptoms. Overall, this study demonstrated that high-risk PWUD are interested in using mHealth-based tools as a key part of an HIV prevention approach within a common type of drug treatment settings. Thus, formative research on preferences for design and functionality of mHealth-based HIV prevention tools are now needed, followed by practical development, implementation, and evaluation of these new intervention strategies.

Sex Trafficking Related Knowledge, Awareness, and Attitudes among Adolescent Female Students in Nepal: A Cross-Sectional Study

Background Sex trafficking has been a long-standing concern in Nepal. Very little has been achieved, however, in terms of actual reduction in the number of victims despite numerous anti-sex trafficking programs. This situation may be attributable to a lack of empirical evidence upon which to formulate anti-sexual trafficking interventions. This study aimed to assess sex trafficking-related knowledge, awareness and attitudes, and factors associated with sex trafficking awareness and attitudes towards the victims of sex trafficking and/or anti-sex trafficking campaigns among adolescent female students in Nepal. Methods A cross-sectional study was conducted between August–September 2013 among 292 adolescent female students (>10 years old) using systematic random sampling from three high schools in Sindhupalchowk district, Nepal. As an initial step, descriptive analyses were employed to characterize the data and multivariate logistic regression analyses were used to explore factors associated with sex trafficking awareness and related attitudes. Results Seventy-six percent of sampled students reported that they were aware of sex trafficking and 94.6% indicated media (i.e., radio or television) as the primary sources of their knowledge. Fifty-one percent mentioned relatives/friends as mediators of sex trafficking, 60.4% reported promise for better jobs as the primary attraction behind sex trafficking, and 48.6% mentioned adolescent females as the most vulnerable group for sex trafficking. Over half (56.8%) of the respondents had positive attitudes towards the victims of sex trafficking and/or anti-sex trafficking campaigns. Age (OR = 3.38, 95% CI:2.51–4.55), parents’ occupation (OR = 3.89, 95% CI:1.58–9.58), and having a radio/TV at home (OR = 6.67, 95% CI:3.99–9.54) were significantly associated with awareness, whereas being younger (OR = 0.67, 95% CI:0.55–0.79) and having joint-family (OR = 2.67, 95% CI:1.49–4.80) were significantly associated with having a positive attitudes towards the victims of sex trafficking and/or anti-sex trafficking campaigns. Conclusion Findings presented have important implications for anti-trafficking programs, in particular those designed to educate the adolescent females who are at most-risk of sex trafficking. Educational programs need to include specific interventions to improve knowledge and attitudes towards sex trafficking among adolescent females in Nepal.

The Use of Female Sex Workers Among Men in Nepal: Prevalence, STIs/HIV-Related Risk Behaviors, and Gender Ideology.

Heterosexual sex involving female sex workers (FSWs) is widely documented for its role in facilitating the spread of sexually transmitted infections (STIs)/HIV. Critical to such studies, and increasingly considered essential to HIV prevention efforts, is the gender constructs and power dynamics within relationships. However, little efforts have been made, which focus on male clients of FSWs, particularly on the relationship between gender ideologies and men’s sexual contact with FSWs, within the Nepali context. The present study aims to fill this critical gap by assessing the prevalence of use of FSWs and its association with STIs/HIV-related risk behaviors and gender ideologies among Nepali men. We used data from the nationally representative Nepal Demographic Health Survey (NDHS) 2011. For the purpose of analyses, we included a sample of 4,121 men, aged 15–49 years. During data analyses, we used multivariate logistic regression models, adjusted for the following variables: age, region, residence, religion, educational level, wealth index, employment status, and cigarette smoking status. Of the total sample, approximately 5% reported the use of FSWs in their lifetime. In regression models, men who had sex with FSWs were more likely to report a history of STIs [adjusted odds ratio (aOR): 3.03; 95% confidence interval (CI): 1.69–5.43; P < 0.001], not using condom all the time (aOR: 1.31; 95% CI: 1.05–2.12; P = 0.010), more than one sexual partner (aOR: 3.75; 95% CI: 2.18–5.23; P < 0.001), and have had early sexual debut (aOR: 2.60; 95% CI: 1.85–3.67; P < 0.001). Respondents reporting the endorsement of violence against wives (aOR: 1.65; 95% CI: 1.01–2.84; P = 0.04) and male sexual entitlement (aOR: 1.63; 95% CI: 1.21–2.32; P = 0.001) were significantly more likely to report sexual contact with FSWs. Our findings highlight the need to develop and implement specifically tailored interventions toward male clients of FSWs, with a particular emphasis on promoting equitable gender roles and beliefs.