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BackgroundFemale sex workers (FSWs) are an important population for HIV acquisition and transmission. Their risks are shaped by behavioral, sexual network, and structural level factors. Violence is pervasive and associated with HIV risk behavior and infection, yet interventions to address the dual epidemics of violence and HIV among FSWs are limited.MethodsWe used participatory methods to develop a brief, trauma-informed intervention, INSPIRE (Integrating Safety Promotion with HIV Risk Reduction), to improve safety and reduce HIV risk for FSWs. A quasi-experimental, single group pretest-posttest study evaluated intervention feasibility, acceptability and efficacy among FSWs in Baltimore, MD, most of whom were drug-involved (baseline n = 60; follow-up n = 39 [65%]; non-differential by demographics or outcomes). Qualitative data collected at follow-up contextualizes findings.ResultsBased on community partnership and FSW input, emergent goals included violence-related support, connection with services, and buffering against structural forces that blame FSWs for violence. Qualitative and quantitative results demonstrate feasibility and acceptability. At follow-up, improvements were seen in avoidance of client condom negotiation (p = 0.04), and frequency of sex trade under the influence of drugs or alcohol (p = 0.04). Women’s safety behavior increased (p < 0.001). Participants improved knowledge and use of sexual violence support (p < 0.01) and use of intimate partner violence support (p < 0.01). By follow-up, most respondents (68.4%) knew at least one program to obtain assistance reporting violence to police. Over the short follow-up period, client violence increased. In reflecting on intervention acceptability, participants emphasized the value of a safe and supportive space to discuss violence.DiscussionThis brief, trauma-informed intervention was feasible and highly acceptable to FSWs. It prompted safety behavior, mitigated sex trade under the influence, and bolstered confidence in condom negotiation. INSPIRE influenced endpoints deemed valuable by community partners, specifically improving connection to support services and building confidence in the face of myths that falsely blame sex workers for violence. Violence persisted; prevention also requires targeting perpetrators, and longer follow-up durations as women acquire safety skills. This pilot study informs scalable interventions that address trauma and its impact on HIV acquisition and care trajectories for FSWs.ConclusionAddressing violence in the context of HIV prevention is feasible, acceptable to FSWs, and can improve safety and reduce HIV risk, thus supporting FSW health and human rights.

Background Due to the concerns about the overtreatment of low-risk prostate cancer (PCa), active surveillance (AS) is now a recommended alternative to the active treatments (AT) of surgery and radiotherapy. However, AS is not widely utilized, partially due to psychological and decision-making factors associated with treatment preferences. Methods In a longitudinal cohort study, we conducted pretreatment telephone interviews (N=1,140, 69.3% participation) with newly diagnosed, low-risk PCa patients (PSA≤10, Gleason≤6) from Kaiser Permanente Northern California. We assessed psychological and decision-making variables, and treatment preference [AS, AT, No Preference (NP)]. Results Men were 61.5 (SD=7.3) years old, 24 days (median) post-diagnosis, and 81.1% white. Treatment preferences were: 39.3% AS, 30.9% AT, and 29.7% NP. Multinomial logistic regression revealed that men preferring AS (vs. AT) were older (OR=1.64, CI 1.07-2.51), more educated (OR=2.05, CI 1.12-3.74), had greater PCa knowledge (OR=1.77, CI 1.43-2.18) and greater awareness of having low-risk cancer (OR=3.97, CI 1.96-8.06), but also were less certain about their treatment preference (OR=0.57, CI 0.41 - 0.8), had greater PCa anxiety (OR=1.22, CI 1.003-1.48), and preferred a shared treatment decision (OR=2.34, CI 1.37-3.99). Similarly, men preferring NP (vs. AT) were less certain about treatment preference, preferred a shared decision, and had greater knowledge. Conclusions Although a substantial proportion of men preferred AS, this was associated with anxiety and uncertainty, suggesting that this may be a difficult choice. Impact Increasing the appropriate use of AS for low-risk PCa will require additional reassurance and information, and reaching men almost immediately post-diagnosis while the decision-making is ongoing.

Pre-exposure prophylaxis (PrEP) has the potential to be an empowering HIV prevention tool among female sex workers (FSW), yet little is known about PrEP awareness and interest in this population. Sex workers and Police Promoting Health in Risky Environments (SAPPHIRE) is a prospective cohort study of street-based FSW in Baltimore, MD. A cross-sectional analysis explored awareness and interest in PrEP among HIV-negative FSW. Multivariable Poisson regressions modeled associations between individual, interpersonal, and structural variables and PrEP awareness and interest. Of n = 232 FSW, 66% were white, half were less than 35 years old, 59% injected drugs daily, and 66% sold sex daily. Only 21% of FSW were aware of PrEP, though 74% were interested. PrEP awareness was associated with experiencing client condom coercion [adjusted incidence rate ratio (aIRR) = 0.50, 95% CI: 0.28-0.90] and condomless sex with an intimate partner (aIRR = 0.54, 95% CI: 0.30-0.98). PrEP interest was associated with perceiving PrEP as ''very easy'' to take (aIRR = 1.91, 95% CI: 1.49-2.45) and moving to an unfamiliar geographic area to sell sex (aIRR = 1.20, 95% CI: 1.04-1.39). Women who had a current gonorrhea or chlamydia infection were less likely to be interested in PrEP (aIRR = 0.75, 95% CI: 0.59-0.95). Though PrEP awareness among FSW is low, there are FSW who are significantly more likely to express interest in PrEP and outreach efforts should target these women. Results suggest that women-controlled HIV prevention methods may be important for reducing incidence among FSW.

OBJECTIVE To examine the association between treatment-related side effects and cancer-specific and general quality of life (QOL) among long-term prostate cancer survivors. MATERIALS AND METHODS Within the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, we conducted telephone interviews with prostate cancer survivors (N = 518) who were 5-10 years after diagnosis. We assessed demographic and clinical information, sexual, urinary, and bowel treatment-related side effects (Expanded Prostate Cancer Index Composite), cancer-specific QOL (Functional Assessment of Cancer Therapy—total score), and general QOL (the Medical Outcomes Study Short Form 12’s physical and mental subscales). RESULTS Participants were aged 74.6 years on average, primarily White (88.4%), and married (81.7%). Pearson correlation coefficients between the 3 treatment-related side effect domains (urinary, sexual, and bowel) and QOL ranged between 0.14 and 0.42 (P <.0001). Multivariable linear regression analyses revealed that poorer urinary and sexual functioning and greater bowel side effects were independently associated with poorer cancer-specific QOL (P <.0001). Bowel and urinary functions were also associated with poorer general QOL on the Medical Outcomes Study Short Form 12’s physical component summary and mental component summary (P <.05). Bowel side effects demonstrated the strongest association with all QOL outcomes. CONCLUSION Treatment-related side effects persisted for up to 10 years after diagnosis and continued to be associated with men’s QOL. These results suggest that each of the treatment-related side effects was independently associated with cancer-specific QOL. Compared with the other Expanded Prostate Cancer Index Composite domains, bowel side effects had the strongest association with cancer-specific and general QOL. These associations emphasize the tremendous impact that bowel side effects continue to have for men many years after their initial diagnosis.

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Biomedical HIV prevention tools including oral pre-exposure prophylaxis (PrEP) and vaginal microbicidal rings hold unique value for high-risk women who may have limited capacity for condom negotiation, including the key populations of sex workers and drug users. Commercial sex is a PrEP indicator in CDC guidelines, yet little is known about female sex workers’ (FSWs) knowledge of and attitudes toward PrEP or the newly developed monthly vaginal microbicide rings. We describe knowledge and attitudes toward PrEP and microbicide rings in a sample of 60 mostly drug-using FSWs in Baltimore, Maryland, a high HIV-prevalence US city. Just 33% had heard of PrEP, but 65% were interested in taking daily oral PrEP and 76% were interested in a microbicide vaginal ring. Self-efficacy for daily oral adherence was high (79%) and 78% were still interested in using PrEP even if condoms were still necessary. Women who had experienced recent client-perpetrated violence were significantly more interested in PrEP (86% vs 53%, p=0.009) and microbicidal rings (91% vs 65%, p=0.028) than women who had not recently experienced violence. No differences were observed by demographics nor HIV risk behaviors, suggesting broad potential interest in daily PrEP and monthly-use vaginal microbicides in this high-risk population.

BACKGROUND: Patient decision aids facilitate informed decision making for medical tests and procedures that have uncertain benefits. OBJECTIVE: To describe participants' evaluation and utilization of print-based and web-based prostate cancer screening decision aids that were found to improve decisional outcomes in a prior randomized controlled trial. DESIGN: Men completed brief telephone interviews at baseline, one month, and 13 months post-randomization. PARTICIPANTS: Participants were primary care patients, 45-70 years old, who received the print-based (N=628) or web-based decision aid (N = 625) and completed the follow-up assessments. MAIN MEASURES:We assessed men's baseline preference for web-based or print-based materials, time spent using the decision aids, comprehension of the overall message, and ratings of the content. KEY RESULTS: Decision aid use was self-reported by 64.3 % (web) and 81.8 % (print) of participants. Significant predictors of decision aid use were race (white vs. non-white, OR=2.43, 95 % CI: 1.77, 3.35), higher education (OR=1.68, 95 % CI: 1.06, 2.70) and trial arm (print vs. web, OR=2.78, 95 % CI: 2.03, 3.83). Multivariable analyses indicated that web-arm participants were more likely to use the website when they preferred web-based materials (OR: 1.91, CI: 1.17, 3.12), whereas use of the print materials was not significantly impacted by a preference for print-based materials (OR: 0.69, CI: 0.38, 1.25). Comprehension of the decision aid message (i.e., screening is an individual decision) did not significantly differ between arms in adjusted analyses (print: 61.9 % and web: 68.2 %, p=0.42). CONCLUSIONS: Decision aid use was independently influenced by race, education, and the decision aid medium, findings consistent with the 'digital divide.' These results suggest that when it is not possible to provide this age cohort with their preferred decision aid medium, print materials will be more highly used than web-based materials. Although there are many advantages to web-based decision aids, providing an option for print-based decision aids should be considered.KEY WORDS: prostate cancer screening; decision aid; informed decision making; shared decision making.