Nuria Gallego Marquez

Introduction: People from underserved groups experience disproportionately poor sexual health and challenges accessing care. Asynchronous online consultations (a user completes a health questionnaire online, which is reviewed by a clinician) are being used within sexual healthcare to prescribe chlamydia treatment. Users require sufficient health and digital literacy to access online services and use them safely. Methods: We used the PROGRESS-Plus (PROGRESS: Place of Residence, Race/Ethnicity, Occupation, Gender/Sex, Religion, Education, Socio-economic Status, Social Network; Plus: e.g., Age, Sexual Orientation, Disability) framework to guide purposive recruitment of 35 participants from diverse underserved groups, from community settings and sexual health services in contrasting areas of the UK (15 October 2021–18 March 2022). We conducted qualitative semistructured interviews and thematic analyses to derive key barriers and facilitators to using asynchronous online consultations. We applied the Behaviour Change Wheel to specify recommendations to address them. Results: Over half of participants were from the most deprived areas and 40% were from minoritised ethnic groups. Key barriers included: lack of familiarity with online healthcare; perceived need to see a healthcare professional in person; privacy concerns; concerns about difficulty interpreting the questions; discomfort answering personal questions online. Key facilitators included: familiarity with online consultations; perceived low sexually transmitted infection risk; perceived increase in convenience, control and privacy; simple wording and design; and support while completing them. Recommendations included: increasing awareness and familiarity by promoting them offline and online and providing demonstrations and instructions on how to use them; encouraging people to choose them by highlighting available support, equivalence to in-person consultations and privacy and convenience; and reducing attrition by using simple wording and design, providing additional explanations and offering audio and visual alternatives to text. Conclusions: Incorporating these evidence-based, theoretically informed recommendations could widen access to underserved groups and increase the usability and safety of asynchronous online consultations for chlamydia treatment. Recommendations are likely to benefit all users and could be of use across health more broadly.

Introduction People from underserved groups experience disproportionately poor sexual health and challenges accessing care. Asynchronous online consultations (a user completes a health questionnaire online, which is reviewed by a clinician) are being used within sexual healthcare to prescribe chlamydia treatment. Users require sufficient health and digital literacy to access online services and use them safely. Methods We used the PROGRESS-Plus framework to guide purposive recruitment of 35 participants from diverse underserved groups, from community settings and sexual health services in contrasting areas of the UK (15/10/21-18/03/22). We conducted qualitative semi-structured interviews and thematic analyses to derive key barriers and facilitators to using asynchronous online consultations. We used the Behaviour Change Wheel to specify recommendations to address them. Results Over half of participants were from the most deprived areas and 40% were from minoritised ethnic groups. Key barriers included: lack of familiarity with online healthcare; perceived need to see a healthcare professional in person; privacy concerns; concerns about difficulty interpreting the questions; discomfort answering personal questions online. Key facilitators included: familiarity with online consultations; perceived low sexually transmitted infection (STI) risk; perceived increase in convenience, control, and privacy; simple wording and design; and support whilst completing them. Recommendations included: increasing awareness and familiarity by promoting them offline and online, and providing demonstrations and instructions on how to use them; encouraging people to choose them by highlighting available support, equivalence to in-person consultations, and privacy and convenience; and reducing attrition by using simple wording and design, providing additional explanations, and offering audio and visual alternatives to text. Conclusions Incorporating these evidence-based, theoretically informed recommendations could widen access to underserved groups, and increase the usability and safety of asynchronous online consultations for chlamydia treatment. Recommendations are likely to benefit all users and could be of use across health more broadly. Main Messages Some sexual health services provide chlamydia treatment through asynchronous online consultations, where patients complete an online health questionnaire which is reviewed by a clinician before issuing a prescription, without the need for direct interaction with a healthcare professional. Safe and effective use of asynchronous online consultations requires adequate digital and health literacy but there is limited evidence on how to design these consultations inclusively, posing a risk of excluding underserved groups and exacerbating health inequalities. Among people from underserved groups, we found key barriers to using asynchronous online consultations included: a lack of familiarity with online healthcare; perceived need to see a healthcare professional in person; privacy concerns; concern about difficulty interpreting the questions; discomfort answering personal questions online. Key facilitators included: familiarity with online consultations; perceived low STI risk; perceived increase in convenience, control, and privacy; simplicity in consultation wording and design; and support whilst completing them. Recommendations include: increasing awareness and familiarity by promoting asynchronous online consultations offline (e.g. in GP practices) and online (e.g., social media), and providing demonstrations/instructions on how to use them; encouraging uptake by highlighting options for support, equivalence to in-person consultations, and privacy and convenience; and reducing attrition by using simple wording and design, providing additional explanations, and offering audio/visual alternatives to text.

Background: The ability to access and navigate online sexual health information and support is increasingly needed in order to engage with wider sexual healthcare. However, people from underserved populations may struggle to pass though this “digital doorway”. Therefore, using a behavioural science approach, we first aimed to identify barriers and facilitators to i) seeking online sexual health information and ii) seeking online sexual health support. Subsequently, we aimed to generate theory-informed recommendations to improve these access points. Methods: The PROGRESSPlus framework guided purposive recruitment (15.10.21–18.03.22) of 35 UK participants from diverse backgrounds, including 51% from the most deprived areas and 26% from minoritised ethnic groups. Using semi-structured interviews and thematic analysis, we identified barriers and facilitators to seeking online sexual health information and support. A Behaviour Change Wheel (BCW) analysis then identified recommendations to better meet the needs of underserved populations. Results: We found diverse barriers and facilitators. Barriers included low awareness of and familiarity with online information and support; perceptions that online information and support were unlikely to meet the needs of underserved populations; overwhelming volume of information sources; lack of personal relevancy; chatbots/automated responses; and response wait times. Facilitators included clarity about credibility and quality; inclusive content; and in-person assistance. Recommendations included: Education and Persuasion e.g., online and offline promotion and endorsement by healthcare professionals and peers; Training and Modelling e.g., accessible training to enhance searching skills and credibility appraisal; and Environmental Restructuring and Enablement e.g., modifications to ensure online information and support are simple and easy to use, including video/audio options for content. Conclusions: Given that access to many sexual health services is now digital, our analyses produced recommendations pivotal to increasing access to wider sexual healthcare among underserved populations. Implementing these recommendations could reduce inequalities associated with accessing and using online sexual health service.

Female sex workers are disproportionately affected by sexual violence, which is associated with an increased risk of poor mental health outcomes, substance use, and decreased access to health resources. Understanding the pathways through which sexual violence impacts these outcomes can inform strategies that appropriately and effectively meet the health needs of sex workers. This study investigated the prevalence of sexual violence among female sex workers in Côte d’Ivoire, and the relationship between sexual violence and adverse mental health and substance use outcomes. We examined survey data from female sex workers recruited between November 2019 and May 2020 across five regions of Côte d’Ivoire using respondent driven sampling (RDS), as part of an integrated bio-behavioral survey. The primary exposure of interest was self-reported lifetime experience of sexual violence, and the main outcomes of interest included depression, suicidal ideation, counselling seeking, alcohol consumption, and substance use. Multivariable logistic regression models investigated associations between exposure to sexual violence and the key mental health and substance use outcomes of interest. For each outcome, a directed acyclic graph was developed to identify a minimally sufficient set of covariates for adjustment. Additional sociodemographic characteristics, experiences, and sex work-related behaviors were explored in descriptive analyses using crude and RDS adjusted estimates. Out of 1,177 participants, 376 (31.9%; RDS weighted: 30.5%; 95% CI: 24.7, 36.3) reported having experienced sexual violence in their lifetime, and of those 31.9% (RDS weighted: 31.2%; 95% CI: 21.3, 41.1) had experienced sexual violence within the previous 12 months. Experience of sexual violence was associated with an increased odds of suicidal ideation (aOR: 1.95; 95% CI: 1.48, 2.55), illicit drug use in the last 12 months (aOR: 2.40; 95% CI: 1.50, 3.86), daily alcohol use (aOR: 1.63; 95% CI: 0.99, 2.67), and having spoken to a counselor or confidant (aOR: 1.90; 95% CI: 1.34, 2.68). Findings confirm a high burden of sexual violence among female sex workers in Côte d’Ivoire, and a need to implement large structural changes that enable female sex workers to seek protection as well as health resources after experiencing sexual violence. This may include reform in the form of targeted social, clinical and mental health resources, along with community development opportunities.

Background: During the COVID-19 pandemic, online sexual health service delivery increased across Britain. We investigated inequalities in STI testing access and methods of access during the first year of the pandemic. Methods: Natsal-COVID, an online-survey of people 18–59 years in Britain, explored sexual health experiences in the first year of the pandemic. We describe the socio-demographics of participants who used STI testing services and compare those who reported being “online service users”, defined as using services with no direct clinician interactions (regardless of whether they also used other methods), with those who were exclusively “other service users”, defined as face-to-face, telephone, or video calls. Results: 246/6,064 participants (4.2%) reported STI testing between 03/2020–03/2021. Of those, 35.8% (95%CI 29.2–42.8) used online services. Online service users (compared to other service users) were more often white (74.9% (62.2–84.4) versus 68.5% (59.4–76.3)), less often had anxiety (39.0% (28.4–50.9) versus 57.2% (48.4–65.6)) and less often had disabilities (25.8% (16.8–37.4) versus 48.1% (39.4–56.9)). Among women (only), online users were more often in good health (91.4% (81.3–96.2) versus 69.3% (57.4–79.2)). Conclusions: More than one third of STI testers used online services during this period. Differences exist in the characteristics of people accessing online versus other testing services. These data suggest that online services were more likely to be accessed by groups with typically lower risk of poor sexual health (white and in good health). Further investigation is needed, especially if online services are the only option offered, as differences in ability to access services could widen inequalities.

Background The ability to access and navigate online sexual health information and support is increasingly needed in order to engage with wider sexual healthcare. However, people from underserved populations may struggle to pass though this “digital doorway”. Therefore, using a behavioural science approach, we first aimed to identify barriers and facilitators to: i) seeking online sexual health information and ii) seeking online sexual health support. Subsequently, we aimed to generate theory-informed recommendations to improve these access points. Methods The PROGRESS framework guided purposive recruitment (October 2021–April 2022) of 35 UK participants from diverse backgrounds, including 51% from the most deprived areas and 26% from minoritised ethnic groups. Semi-structured interviews and thematic analysis identified barriers and facilitators to seeking online sexual health information and support. A Behaviour Change Wheel (BCW) analysis then identified recommendations to better meet the needs of underserved populations. Results We found diverse barriers and facilitators. Barriers included low awareness of and familiarity with online information and support; perceptions that online information and support were unlikely to meet the needs of underserved populations; overwhelming volume of information sources; lack of personal relevancy; chatbots/automated responses; and response wait times. Facilitators included clarity about credibility and quality; inclusive content; and in-person assistance. Recommendations included: Education and Persuasion e.g., online and offline promotion and endorsement by healthcare professionals and peers; Training and Modelling e.g., accessible training to enhance searching skills and credibility appraisal; and Environmental Restructuring and Enablement e.g., modifications to ensure online information and support are simple and easy to use, including video/audio options for content. Conclusions Given that access to many sexual health services is now digital, our analyses produced recommendations pivotal to increasing access to wider sexual healthcare among underserved populations. Implementing these recommendations could reduce inequalities associated with accessing and using online sexual health service.

Background: Living with HIV is a risk factor for severe acute COVID-19, but it is unknown whether it is a risk factor for long COVID. Objective: This study aims to characterize symptoms, sequelae, and cognition formally and prospectively 12 months following SARS-CoV-2 infection in people living with HIV compared with people without HIV. People with no history of SARS-CoV-2 infection, both with and without HIV, are enrolled as controls. The study also aims to identify blood-based biomarkers or patterns of immune dysregulation associated with long COVID. Methods: This prospective observational cohort study enrolled participants into 1 of the following 4 study arms: people living with HIV who had SARS-CoV-2 infection for the first time <4 weeks before enrollment (HIV+COVID+ arm), people without HIV who had SARS-CoV-2 infection for the first time within 4 weeks of enrollment (HIV−COVID+ arm), people living with HIV who believed they never had SARS-CoV-2 infection (HIV+COVID− arm), and people without HIV who believed they never had SARS-CoV-2 infection (HIV−COVID− arm). At enrollment, participants in the COVID+ arms recalled their symptoms, mental health status, and quality of life in the month before having SARS-CoV-2 infection via a comprehensive survey administered by telephone or on the web. All participants completed the same comprehensive survey 1, 2, 4, 6, and 12 months after post–acute COVID-19 symptom onset or diagnosis, if asymptomatic, (COVID+ arms) or after enrollment (COVID− arms) on the web or by telephone. In total, 11 cognitive assessments were administered by telephone at 1 and 4 months after symptom onset (COVID+ arms) or after enrollment (COVID− arms). A mobile phlebotomist met the participants at a location of their choice for height and weight measurements, orthostatic vital signs, and a blood draw. Participants in the COVID+ arms donated blood 1 and 4 months after COVID-19, and participants in the COVID− arms donated blood once or none. Blood was then shipped overnight to the receiving study laboratory, processed, and stored. Results: This project was funded in early 2021, and recruitment began in June 2021. Data analyses will be completed by summer 2023. As of February 2023, a total of 387 participants were enrolled in this study, with 345 participants having completed enrollment or baseline surveys together with at least one other completed study event. The 345 participants includes 76 (22%) HIV+COVID+, 121 (35.1%) HIV−COVID+, 78 (22.6%) HIV+COVID−, and 70 (20.3%) HIV−COVID− participants. Conclusions: This study will provide longitudinal data to characterize COVID-19 recovery over 12 months in people living with and without HIV. Additionally, this study will determine whether biomarkers or patterns of immune dsyregulation associate with decreased cognitive function or symptoms of long COVID.

BACKGROUND Living with HIV is a risk factor for severe acute COVID-19, but it is unknown whether it is a risk factor for long COVID. OBJECTIVE This study aims to characterize symptoms, sequelae, and cognition formally and prospectively 12 months following SARS-CoV-2 infection in people living with HIV compared with people without HIV. People with no history of SARS-CoV-2 infection, both with and without HIV, are enrolled as controls. The study also aims to identify blood-based biomarkers or patterns of immune dysregulation associated with long COVID. METHODS This prospective observational cohort study enrolled participants into 1 of the following 4 study arms: people living with HIV who had SARS-CoV-2 infection for the first time <4 weeks before enrollment (HIV+COVID+ arm), people without HIV who had SARS-CoV-2 infection for the first time within 4 weeks of enrollment (HIV−COVID+ arm), people living with HIV who believed they never had SARS-CoV-2 infection (HIV+COVID− arm), and people without HIV who believed they never had SARS-CoV-2 infection (HIV−COVID− arm). At enrollment, participants in the COVID+ arms recalled their symptoms, mental health status, and quality of life in the month before having SARS-CoV-2 infection via a comprehensive survey administered by telephone or on the web. All participants completed the same comprehensive survey 1, 2, 4, 6, and 12 months after post–acute COVID-19 symptom onset or diagnosis, if asymptomatic, (COVID+ arms) or after enrollment (COVID− arms) on the web or by telephone. In total, 11 cognitive assessments were administered by telephone at 1 and 4 months after symptom onset (COVID+ arms) or after enrollment (COVID− arms). A mobile phlebotomist met the participants at a location of their choice for height and weight measurements, orthostatic vital signs, and a blood draw. Participants in the COVID+ arms donated blood 1 and 4 months after COVID-19, and participants in the COVID− arms donated blood once or none. Blood was then shipped overnight to the receiving study laboratory, processed, and stored. RESULTS This project was funded in early 2021, and recruitment began in June 2021. Data analyses will be completed by summer 2023. As of February 2023, a total of 387 participants were enrolled in this study, with 345 participants having completed enrollment or baseline surveys together with at least one other completed study event. The 345 participants includes 76 (22%) HIV+COVID+, 121 (35.1%) HIV−COVID+, 78 (22.6%) HIV+COVID−, and 70 (20.3%) HIV−COVID− participants. CONCLUSIONS This study will provide longitudinal data to characterize COVID-19 recovery over 12 months in people living with and without HIV. Additionally, this study will determine whether biomarkers or patterns of immune dsyregulation associate with decreased cognitive function or symptoms of long COVID. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/47079

Purpose The European Men who have sex with men Internet Survey looked over the characteristics and needs of men who have sex with men (MSM) across Europe. Our objective was to estimate the prevalence of HIV testing and its associated factors among MSM younger than 25 years old participating in the EMIS-2017 in Spain. Methods Multivariable regression model was used to compare those who had been tested for HIV within the last 12 months and those that had not. Results Of 2313 participants, 1070 (46.3%) had been tested for HIV in the past 12 months. Increased age (age 19–21 years, aOR=3.38 (95% CI 2.57 to 4.44); age 22–24 years, aOR=5.26 (4.06 to 6.92) compared with age 16–18 years); being migrant (Latin America: aOR=1.34 (0.98 to 1.84); Europe, North America and Mediterranean countries (aOR=1.56 (0.98 to 2.51) compared with those from Spain); living more openly with one’s sexuality (out to some people (aOR=1.53 (1.19 to 1.96)); out to all or almost all people (aOR=2.24 (1.75 to 2.87) compared with those out to none or a few people); having had one condomless steady partners in the las year ((aOR=1.59 (1.26 to 2.02)); having had condomless non-steady partners in the last year (one: aOR=1.76 (1.35 to 2.29)); two or more partners: aOR=2.37 (1.84 to 3.04)); and having practised sex work in the past year (aOR=1.52 (1.07 to 2.13)) were associated with increased odds of HIV testing. Living in a smaller city was associated with less likelihood of HIV testing (Conclusion Young MSM showed low HIV testing rate. Future programming specifically targeting this population, especially those middle adolescents, living in a medium-small city and having less ‘outness’, can help increase HIV testing and prevent access barriers.