ItemA longitudinal daily diary analysis of condom use during bleeding-associated vaginal sex among adolescent females(BMJ, 2016) Hensel, Devon J.; Tanner, Amanda E.; Sherrow, Ashley; Fortenberry, J. Dennis; Medicine, School of MedicineObjective: Sex during bleeding is a risk factor for sexually transmitted infection (STI) and other bloodborne viruses, including HIV. We examined daily predictors of adolescent women's male condom use during bleeding-associated vaginal sex. Methods: Adolescent females (N=387; 14-17 years) were recruited from primary care clinics for a longitudinal cohort study of STIs and sexual behaviour. Data were daily partner-specific sexual diaries; generalised estimating equation logistic regression assessed the likelihood of condom use during bleeding-associated vaginal sex. Results: Less than 30% of bleeding-associated vaginal sex events were condom protected. Condom use during these events was less likely with younger age, higher partner support, higher partner negativity or past week bleeding-associated sex with a given partner; condom use was more likely with high individual mood and past week condom use during bleeding-associated vaginal sex with a given partner. Conclusions: Low condom rates during bleeding-associated vaginal sex can increase STI and bloodborne virus risk. Providers should consider integrating partner-specific and behavioural factors when they deliver sexual health messages to young women. ItemWhat is sexual wellbeing and why does it matter for public health?(Elsevier, 2021-08) Mitchell, Kirstin R.; Lewis, Ruth; O'Sullivan, Lucia F.; Fortenberry, J. Dennis; Pediatrics, School of MedicineSexual health has provided a guiding framework for addressing sexuality in public health for several decades. Although the WHO definition of sexual health is revolutionary in acknowledging positive sexuality, public health approaches remain focused on risk and adverse outcomes. The long-standing conflation of sexual health and sexual wellbeing has affected our ability to address everyday sexual issues. This Viewpoint provides a way forward to resolve this impasse. We propose sexual wellbeing as a distinct and revolutionary concept that can be operationalised as a seven-domain model. We situate sexual wellbeing alongside sexual health, sexual justice, and sexual pleasure as one of four pillars of public health enquiry. We argue that sexual wellbeing is imperative to public health as a marker of health equity, a meaningful population indicator of wellbeing, a means to capture population trends distinct from sexual health, and an opportunity to refocus the ethics, form, and practices of public health. ItemTransmission Risk among Youth Living with HIV in the United States(Elsevier, 2020-07) van den Berg, Jacob J.; Gamarel, Kristi E.; Westfall, Andrew O.; Fortenberry, J. Dennis; Hosek, Sybil G.; Wilson, Craig M.; Lally, Michelle A.; Medicine, School of MedicinePurpose: HIV treatment as prevention is effective for reducing the risk of HIV transmission and the messaging campaign, undetectable = untransmittable, is gaining recognition. As youth living with HIV (YLWH) who have condomless sex may acquire and potentially transmit other sexually transmitted infections (STIs), the purpose of this study was to assess potential differences in transmission risk of HIV and other STIs among YLWH to inform subsequent HIV and STI prevention efforts. Methods: A cohort of 600 HIV behaviorally infected youth aged 13-24 years who were engaged in medical care completed an audio computer-assisted self-interview including questions about demographics, HIV disclosure, mental health, substance use, and sexual behaviors and beliefs. HIV viral loads and the presence of other STIs were abstracted from medical records. A viral load <200 copies/mL was considered undetectable. Univariate and bivariate analyses were conducted to examine differences by viral load and STIs. Results: Participants were categorized into four groups: (1) undetectable without STIs (55.2%); (2) undetectable with STIs (14.2%); (3) detectable without STIs (22.8%); and (4) detectable with STIs (7.8%). In comparison to the other three groups, youth in the undetectable group with STIs reported more favorable sexual risk reduction attitudes and beliefs, internet use for finding sex partners, anal sex with male partners, and condomless anal sex with male partners. Conclusions: YLWH with undetectable viral loads and other STIs engaged in higher risk behaviors. To realize the promise of the messaging campaign, undetectable = untransmittable, efforts must focus on sustained viral suppression and prevention of STIs among YLWH. ItemAn Intervention for the Transition From Pediatric or Adolescent to Adult-Oriented HIV Care: Protocol for the Development and Pilot Implementation of iTransition(JMIR Publications, 2021-04-07) Tanner, Amanda E.; Dowshen, Nadia; Philbin, Morgan M.; Rulison, Kelly L.; Camacho-Gonzalez, Andres; Lee, Susan; Moore, Shamia J.; Fortenberry, J. Dennis; Hussen, Sophia A.; Medicine, School of MedicineBackground: In the United States, adolescents and young adults are disproportionately affected by HIV and have poorer HIV-related health outcomes than adults. Health care transition (HCT) from pediatric or adolescent to adult-oriented HIV care is associated with disruptions to youths' care retention, medication adherence, and viral suppression. However, no evidence-based interventions exist to improve HCT outcomes for youth living with HIV. Objective: There are 2 phases of this project. Phase 1 involves the iterative development and usability testing of a Social Cognitive Theory-based mobile health (mHealth) HIV HCT intervention (iTransition). In phase 2, we will conduct a pilot implementation trial to assess iTransition's feasibility and acceptability and to establish preliminary efficacy among youth and provider participants. Methods: The iterative phase 1 development process will involve in-person and virtual meetings and a design team comprising youth living with HIV and health care providers. The design team will both inform the content and provide feedback on the look, feel, and process of the iTransition intervention. In phase 2, we will recruit 100 transition-eligible youth across two clinical sites in Atlanta, Georgia, and Philadelphia, Pennsylvania, to participate in the historical control group (n=50; data collection only) or the intervention group (n=50) in a pilot implementation trial. We will also recruit 28 provider participants across the pediatric or adolescent and adult clinics at the two sites. Data collection will include electronic medical chart abstraction for clinical outcomes as well as surveys and interviews related to demographic and behavioral characteristics; Social Cognitive Theory constructs; and intervention feasibility, acceptability, and use. Analyses will compare historical control and intervention groups in terms of HCT outcomes, including adult care linkage (primary), care retention, and viral suppression (secondary). Interview data will be analyzed using content analysis to understand the experience with use and acceptability. Results: Phase 1 (development) of iTransition research activities began in November 2019 and is ongoing. The data collection for the phase 2 pilot implementation trial is expected to be completed in January 2023. Final results are anticipated in summer 2023. Conclusions: The development and pilot implementation trial of the iTransition intervention will fill an important gap in understanding the role of mHealth interventions to support HCT outcomes for youth living with HIV. Item“I just keep quiet about it and act as if everything is alright” – The cascade from trauma to disengagement among adolescents living with HIV in western Kenya(Wiley, 2021-04) Enane, Leslie A.; Apondi, Edith; Omollo, Mark; Toromo, Judith J.; Bakari, Salim; Aluoch, Josephine; Morris, Clemette; Kantor, Rami; Braitstein, Paula; Fortenberry, J. Dennis; Nyandiko, Winstone M.; Wools-Kaloustian, Kara; Elul, Batya; Vreeman, Rachel C.; Pediatrics, School of MedicineIntroduction: There are approximately 1.7 million adolescents living with HIV (ALHIV, ages 10 to 19) globally, including 110,000 in Kenya. While ALHIV experience poor retention in care, limited data exist on factors underlying disengagement. We investigated the burden of trauma among disengaged ALHIV in western Kenya, and its potential role in HIV care disengagement. Methods: We performed in-depth qualitative interviews with ALHIV who had disengaged from care at two sites, their caregivers and healthcare workers (HCW) at 10 sites, from 2018 to 2020. Disengagement was defined as not attending clinic ≥60 days past a missed scheduled visit. ALHIV and their caregivers were traced through phone calls and home visits. Interviews ascertained barriers and facilitators to adolescent retention in HIV care. Dedicated questions elicited narratives surrounding traumatic experiences, and the ways in which these did or did not impact retention in care. Through thematic analysis, a conceptual model emerged for a cascade from adolescent experience of trauma to disengagement from HIV care. Results: Interviews were conducted with 42 disengaged ALHIV, 34 caregivers and 28 HCW. ALHIV experienced a high burden of trauma from a range of stressors, including experiences at HIV disclosure or diagnosis, the loss of parents, enacted stigma and physical or sexual violence. A confluence of factors - trauma, stigma and isolation, and lack of social support - led to hopelessness and depression. These factors compounded each other, and resulted in complex mental health burdens, poor antiretroviral adherence and care disengagement. HCW approaches aligned with the factors in this model, suggesting that these areas represent targets for intervention and provision of trauma-informed care. Conclusions: Trauma is a major factor underlying disengagement from HIV care among Kenyan adolescents. We describe a cascade of factors representing areas for intervention to support mental health and retention in HIV care. These include not only the provision of mental healthcare, but also preventing or addressing violence, trauma and stigma, and reinforcing social and familial support surrounding vulnerable adolescents. In this conceptualization, supporting retention in HIV care requires a trauma-informed approach, both in the individualized care of ALHIV and in the development of strategies and policies to support adolescent health outcomes. ItemMental health outcomes from direct and indirect exposure to firearm violence: A cohort study of nonfatal shooting survivors and family members(Elsevier, 2022-06-30) Magee, Lauren A.; Aalsma, Matthew; Fortenberry, J. Dennis; Gharbi, Sami; Wiehe, SarahBackground: Firearm violence is a public health crisis in the US. Beyond the survivor, firearm violence also impacts family members and communities of firearm violence survivors. Despite the known health inequities that exist among nonfatal shooting survivors, little research has focused on the mental health needs of family members of nonfatal shootings survivors. Methods: Police and Medicaid claims data linked at the individual level between January 1, 2007 – December 31, 2016 in Indianapolis, Indiana. The Medicaid case number was used to identify nonfatal shooting survivors and family members. Differences in mental health prevalence and clinical care utilization were examined in the 12-months preceding and following an index nonfatal shooting for both survivors and family members. Results were stratified by age. Results: Mental health prevalence rates increased by nearly three percent for family members of nonfatal shooting survivors in the 12-months following a nonfatal shooting, compared to the preinjury period. Among youth with a new mental health diagnosis over half were family members and no differences were observed in mental health conditions between survivors and family members. Conclusions: Findings indicate a need for improved trauma informed services and connection to mental health care for both youth survivors and family members of nonfatal shootings. ItemChanging epidemiology of firearm injury: a cohort study of non-fatal firearm victimisation before and during the COVID-19 pandemic, Indianapolis, Indiana(British Medical Journal, 2022-03-01) Magee, Lauren A.; Lucas, Bailee; Fortenberry, J. Dennis; Medicine, School of MedicineObjective To examine victimisation rates, geographic patterns and neighbourhood characteristics associated with non-fatal firearm injury rates before and during the COVID-19 pandemic. Design A retrospective cohort study. Setting City of Indianapolis, Indiana, USA, 1 January 2017–30 June 2021. Participants Intentional non-fatal firearm injury victims from Indianapolis Metropolitan Police Department records. The study included information on 2578 non-fatal firearm injury victims between ages 0 and 77 years. Of these victims, 82.5% were male and 77.4% were black. Primary and secondary outcome measures Rates of non-fatal firearm injuries per 100 000 population by victim age, race, sex and incident motive. Prepandemic and peripandemic non-fatal firearm injury rates. Results Non-fatal shooting rates increased 8.60%, from 57.0 per 100 000 person-years in prepandemic years to 65.6 per 100 000 person-years during the pandemic (p<0.001). Rates of female victims (15.2 vs 23.8 per 100,000; p<0.001) and older victims (91.3 vs 120.4 per 100,000; p<0.001) increased significantly during the pandemic compared with the prepandemic period. Neighbourhoods with higher levels of structural disadvantage (IRR: 1.157, 95% CI 1.012 to 1.324) and prepandemic firearm injury rates (IRR: 1.001, 95% CI 1.001 to 1.002) was positively associated with higher rates of non-fatal firearm injuries during the pandemic, adjusting for neighbourhood characteristics. Conclusions Non-fatal firearm injuries increased significantly during the COVID-19 pandemic, particularly among female and older victims. Efforts are needed to expand and rethink current firearm prevention efforts that both address the diversification of victimisation and the larger societal trauma of firearm violence. ItemThe role of sexually transmitted infections (STI) prevention and control programs in reducing gender, sexual and STI-related stigma(Elsevier, 2021-02-24) Garcia, Patricia J.; Miranda, Angelica Espinosa; Gupta, Somesh; Garland, Suzanne M.; Escobar, María Eugenia; Fortenberry, J. Dennis; Pediatrics, School of Medicine ItemChild Sexual Abuse and Negative Affect as Shared Risk Factors for Sexual Aggression and Sexual HIV Risk Behavior in Heterosexual Men(Archives of Sexual Behavior, 2018-02-01) Peterson, Zoё D.; Janssen, Erick; Goodrich, David; Fortenberry, J. Dennis; Hensel, Devon J.; Heiman, Julia R.Previous research has suggested that sexually aggressive behavior and sexual HIV risk behavior are associated. Childhood sexual abuse (CSA) is a well-established risk factor for both types of problematic sexual behavior. Negative affect (i.e., anxiety, depression, and anger) is a less well-studied risk factor, but it has been theorized to relate to both sexual aggression and HIV risk behavior. Thus, this study sought to (1) confirm the relationship between sexual aggression and HIV risk behavior, (2) establish CSA and negative affect as shared risk factors for sexual aggression and HIV risk behavior, and (3) evaluate whether negative affect mediates the relationship between CSA and sexual aggression and between CSA and HIV sexual risk in a sample of heterosexual men. We recruited 18- to 30-year-old heterosexual men (N = 377) from urban sexually transmitted infection clinics. Men completed measures of sexual HIV risk history (number of partners and condom use), sexual aggression history, CSA history, and trait negative affect (anger, anxiety, and depression). Structural equation modeling was used to examine hypothesized direct and indirect relationships. In the final SEM model, sexual aggression history and sexual HIV risk behavior were correlated. CSA was associated with both types of problematic sexual behavior. Anxiety significantly mediated the relationship between CSA and sexual aggression and between CSA and sexual HIV risk behavior (χ2 = 2121.79, p < .001; CFI = 0.905; RMSEA [90% CI] = .044 [.041–.047]). Sexual aggression appears to be part of a constellation of sexual risk behaviors; thus, it may be possible to develop prevention programs that target both sexual HIV risk and sexual aggression. CSA is a shared risk factor for sexual aggression and HIV risk behavior through the pathway of anxiety. Thus, anxiety might be one promising target for intervention. ItemLeveraging a relationship-based sexual health framework for sexual risk prevention in adolescent men in the United States(CSIRO, 2017) Hensel, Devon J.; Bales, Casey L.; Taylor, Julia F.; Fortenberry, J. Dennis; Medicine, School of MedicineBackground: Studies link sexual health to lower sexual risk in adolescent women, yet no empirical literature evaluates these associations in adolescent men. Methods: Data were drawn from a longitudinal cohort study of sexual relationships and sexual behaviour among adolescent men (n = 72; 14–16 years) in the US. Participants contributed quarterly partner-specific interviews, from which sexual health information and partnered sexual behaviours were drawn. A multidimensional measure of sexual health was constructed and linked to partnered outcomes, including oral–genital, vaginal and anal sex, condom use, partner concurrency and intimate partner violence. Random intercept, mixed-effects linear, ordinal logistic or binary logistic regression were for analyses. Models controlled for participant age, race/ethnicity and relationship length. Results: Adolescent men contributed 651 unique partner-specific interviews. A higher sexual health score with partners was significantly associated with more frequent oral–genital and vaginal sex, as well as higher condom use, lower partner concurrency and lower received and perpetuated intimate partner violence. Conclusion: Positive sexually related experiences in adolescent men contribute to a core of sexual wellbeing, which in turn is linked to lower levels of sexual risk with partners. The present study data support both developmental and public health applications of sexual health, with attention on promoting healthy sexuality as well as risk reduction. Higher sexual health among adolescent men from the US is associated with more frequent condom use, lower partner concurrency and less frequent intimate partner violence. Young men’s exercising the skills associated with healthy sexuality may also reinforce the skills needed to both enjoy sexuality with partners and to avoid adverse sexual outcomes.