HIV acquisition risks remain high for pregnant and breastfeeding populations in South Africa. Oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine (TDF-FTC) can be used daily during periods of sexual activity to prevent HIV infections for cisgender women. In 2021, oral PrEP became the standard of care for HIV prevention during pregnancy and breastfeeding periods. The objective of this dissertation was to evaluate trends in oral PrEP initiation, continuation, and adherence among adolescent girls and young women, women experiencing intimate partner violence, and by sexual behaviors throughout gestational periods and postpartum. We used data from the PrEP in Pregnancy and Postpartum (PrEP-PP) study, a prospective cohort in Cape Town of 1200 participants without HIV. The PrEP-PP study provided HIV prevention counselling and offered PrEP to pregnant and breastfeeding women.The first study evaluated the oral PrEP cascade framework among adolescent girls and young women (AGYW) in the PrEP-PP study. Approximately 83% of AGYW initiated PrEP at their first antenatal care (ANC) visit, 34% continued PrEP at 6 months, and 11% stopped and restarted. AGYW with a higher HIV risk had an increased adjusted likelihood of continuing PrEP through 6 months (adjusted odds ratio[aOR]:1.91 [95% CI, 1.15-3.16]). About 7% of AGYW had high adherence to PrEP at 6 months. The second study examined the relationship between recent and past-year intimate partner violence (IPV) experienced by pregnant and postpartum women and oral PrEP continuation and adherence. Women who experienced past-year IPV were less likely to discontinue PrEP(adjusted hazards ratio: 0.80 (95% CI: 0.61, 1.06) and had higher adherence(quantifiable tenofovir-diphosphate[TFV-DP] in dried blood spots; aOR=1.82 (95% CI: 1.02, 3.25) at 6-month follow-up visits. The third study evaluated prevention-effective adherence by gestational trimesters of pregnancy and postpartum. Prevention-effective adherence(initiation/quantifiable TFV-DP or reported use during follow-up among those engaging in condomless sex) was 65% overall, with the highest adherence in trimester 1(81%) and lowest at early postpartum(49%). There was a positive association between engaging in condomless sex and PrEP use(quantifiable TFV-DP or self-reported use; adjusted risk ratio:1.88; 95% CI: 1.67, 2.12). In conclusion, AGYW during pregnancy and postpartum had high oral uptake, but retention in PrEP by 6 months was low. Those with higher HIV risks are more likely to continue PrEP. Pregnant/postpartum women who experienced past-year IPV were more likely to stay in the study and had greater adherence. The findings suggest that pregnant and postpartum women align their PrEP use with their potential HIV risks. Implementing violence screening and oral PrEP counselling (with conversations about changing HIV risks) at ANC may improve HIV prevention for women during pregnancy and postpartum in South Africa and beyond.

Men who have Sex with Men (MSM) face sociopolitical hardships that can manifest into a Homonegativity, a form of psychological distress. As Homonegativity is associated with poor mental health outcomes, it could also extend into physiological outcomes like obesity where the relationship would hypothetically be positively correlated. Participants of this study come from the mStudy, a Los Angeles based cohort focusing on young MSM of color. Logistic Regression was used to analyze the association between Homonegativity and obesity (defined as having a Body Mass Index ≥ 30), where quasibinomial and generalized additive models (GAMs) were used to assess the robustness of the logistic regression. Increasing Homonegativity was associated with about 3.5% lower odds (OR: 0.965, CI: 0.94-0.99) for both unadjusted and fully adjusted models, a finding contrary to the original hypothesis.

BACKGROUND: Substance use drives worse HIV outcomes among men who have sex with men, while reducing substance use can improve physical and mental health. Despite this, there has been limited research on the outcomes that men who have sex with men experience in the community after they have exited treatment for substance use. This dissertation examines the factors that are associated with community-based men who have sex with men engaging with treatment for substance use, as well as the substance use and mental health outcomes that follow treatment.METHODS: This dissertation uses data from men who have sex with men participating in the mSTUDY cohort based in Los Angeles, CA (2014-2024). Chapter 2 examines the socioeconomic, substance use, and health factors that are associated with engaging with treatment for substance use. Chapter 3 assesses how treatment for substance use impacts reductions in the frequency of methamphetamine, cannabis, binge alcohol, and tobacco use over time. Chapter 4 examines the prevalence of high depression and anxiety symptoms in the time period after treatment for substance use, and analyzes the impact of 12-step group participation on mental health among men in recovery. RESULTS: Factors associated with treatment for substance use included homelessness, incarceration, methamphetamine use, and living with HIV. After adjusting for other factors, Black and Latinx men were less likely than white men to enter treatment for substance use during follow up. Treatment for substance use at different time points was associated with reduced frequency of methamphetamine and cannabis use, as well as increased high frequency binge alcohol use. Twelve-step group participation was associated with reduced frequency of methamphetamine, cannabis, and binge alcohol use. Men in recovery had worse depression and anxiety symptoms than men who had not received treatment, but 12-step participation was also associated with improved depression and anxiety symptoms. CONCLUSION: These analyses found that factors that are known to be syndemic with the HIV epidemic are also associated with engagement in and outcomes following treatment for substance use. Community-based, equity-focused interventions to support men who have sex with men who use substances could improve quality of life in recovery.

Introduction:Cambodia has set a goal to test at least 95% of all pregnant women for HIV. Thanks to Cambodia’s “Boosted Linked Response” strategy, the HIV testing rate among pregnant women attending antenatal care (ANC) has gradually increased but plateaued out at approximately 90% for the past several years. Moreover, since 2012, the strategy has failed to test more than one-fourth of male partners of ANC-attending pregnant women. Therefore, we examined factors associated with HIV testing during ANC among pregnant women and their male partners. In addition, we also explored men’s barriers to attending ANC with their pregnant partners, and their perspectives on three HIV testing alternative strategies (home-based HIV testing, free-of-charge pregnant woman–delivered HIV self-testing, and out-of-pocket community pharmacy–delivered HIV self-testing.

Methods: In Study 1, we pooled together three Cambodia Demographic Health Surveys (2005, 2010, and 2014) and adopted Anderson’s Behavioral Model of Health Services to guide our data analysis. The study population consisted of all Cambodian women aged 15–49 years with one or more live births in the three years preceding each survey who attended ANC for the most recent birth (weighted N=11,181). In Study 2, we conducted a Case-Control study. The study population consisted of men who attended ANC with their pregnant partners from September 2020 to December 2020. The outcome was defined as declining or accepting an HIV test as part of ANC. 132 cases and 264 controls were recruited from three government-run ANC health facilities in Phnom Penh (the National Maternal and Child Health Center, Chaktomuk Referral Hospital, and Posenchey Health Center). An Extended Theory of Planned Behavior (ETPB) was applied to guide our data analysis. In Study 3, a qualitative study was nested within the Case-Control study. The study population consisted of 30 men (10 HIV testing decliners, 10 acceptors, and 10 ANC non-attendees). All participants were recruited using consecutive sampling from ANC and postpartum departments of the National Maternal and Child Health Center.

Results: In Study 1, HIV testing rates as part of ANC increased significantly by year (15.5% in 2005, 46.2% in 2010, and 77.4% in 2014, p<0.001). Women who received adequate pre-test counseling had consistently greater odds of being tested for HIV than those who did not: aOR=17.3 [95% CI: 12.4–24.0] in 2005, aOR=7.2 [95% CI: 5.9–8.9] in 2010, aOR=8.5 [95% CI: 6.5–11.2] in 2014, and aOR=8.9 [95% CI: 7.7–10.3] in the pooled dataset. In Study 2, male partners with a low intention to test and low perceived behavioral control (PBC) had greater odds of declining an HIV test (low intention with aOR=3.2 [95% CI: 1.8–5.6] and low PBC with aOR=1.8 [95% CI: 1.1–2.8]). A low intention to test was predicted by an absence of perceived risk of HIV infection (aOR=2.0 [95% CI: 1.1–3.6]), unsupportive subjective norms (aOR=2.3 [95% CI: 1.4–3.9]), and an absence of partner communication about HIV testing (aOR=3.0 [95% CI: 1.5–5.7]). In Study 3, barriers to attending ANC visits included individual-level factors (being unable to take time off work, waiting outside the health facility watching over an older child, not wanting to pay for a parking fee, and a negative attitude toward male ANC attendance), relationship-level factors (a negative couple dynamic, meaning men taking healthcare decisions alone as they considered themselves heads of the family), community-level factors (a negative attitude toward male ANC attendance), and health system-level factors (not being invited by providers to come inside the ANC consultation room). Concerns about home-based HIV testing included worries that neighbors would be suspicious, not being home at the time of the home visit, an inability to verify the identity of the testing team, the feeling of being coerced into testing, feeling offended by a home visit, the potential for contamination of testing instruments, the potential for confidentiality breaches by the testing team, and the potential for improper management of biological specimens. For pregnant woman–delivered HIVST, perceived concerns included a lack of pre-and post-test counseling, questionable accuracy of the test kit, instructions of use in foreign languages, not being capable of using the kit correctly, and questions about why the provider or his partner wanted him to be tested. For community pharmacy–delivered HIVST, perceived concerns included low availability, feeling shy or embarrassed when purchasing the kits, cost, and potential lack of technical assistance provided by pharmacy staff.

Conclusion: HIV testing uptake among ANC-attending pregnant women in Cambodia can be increased by delivering high-quality pre-test counseling. Therefore, health system-level interventions should include regular refreshment training to counselors at ANC sites without understaffing issues and lower the ratio of ANC clients to counselors at ANC sites plagued by understaffing issues. Among male partners, trans-theoretical approaches could be adopted to increase their intention to test by altering their risk perception, subjective norms, and partner communication. Potential community-level interventions using mass media, peer educators, and small-group education sessions may be useful in changing men’s behavior. Home-based HIV testing and HIV self-testing have the potential to become complementary services to the current ANC-based HTC.

Objectives: Research from high-income countries (HICs) appeared to suggest that Human Immunodeficiency Virus (HIV) and antiretroviral therapy (ART) contribute to, alongside other well-established traditional risk factors, higher prevalence of non-communicable diseases (NCDs) such as diabetes and hypertension among people living with HIV (PLWH). Many of these chronic metabolic disorders are known to increase cardiovascular disease (CVD) risk, which can be assessed using available risk stratification models. However, in certain low- and middle-income countries (LMICs), such as Cambodia, the relationship between NCDs and CVD risk and HIV is generally under-studied. This is even more so for young people living with HIV (YLWH). Therefore, I examined the relationship between NCDs and HIV among Cambodian general population and PLWH including YLWH.

Design: Cross-sectional studies.

Methods: Chapter 2 and 3 used merged data from two surveys among PLWH (n=510) and the general population (n=2747), aged between 22-65+ years, conducted by KHANA Center for Population Health Research (nongovernmental organization) in 2015 and by the University of Health Sciences in 2016, respectively. Both employed a standardized questionnaire and physical/biochemical measurement protocols developed by the World Health Organization (STEPwise Approach to Surveillance or STEP survey or STEPS). Chapter 4 employed a STEP survey to gather information on 370 YLWH, aged 18-29 years, from three HIV clinics (known as Opportunistic Infections and Antiretroviral therapy or OI/ART clinics) in Phnom Penh. The information on the young general population was then obtained from the 2016 STEP survey. For each study, we computed NCD prevalence, plus CVD risk score based on the Framingham Risk Score (FRS) equations (study 2). We performed logistic regression to examine the relationship between NCDs and CVD risk and HIV while adjusting for age, sex, residence location, behavioral risk factors (such as smoking, heavy alcohol consumption, less than 5 servings of fruits and vegetables and low physical activity) and body mass index (BMI).

Results: Chapter 2 showed that the prevalence of hypertension and high cholesterolemia among adult PLWH were lower than that of the general population. However, the prevalence of diabetes and prediabetes was higher among PLWH; the odds of prediabetes, aOR=7.30 (95% CI: 5.69, 9.36), and of diabetes, aOR=1.46 (95% CI: 0.99, 2.17), were higher among PLWH than the general population. Next, chapter 3 showed that PLWH appeared to be as likely as the general population to have moderate-to-high (estimated) 10-year CVD risk, aOR=0.88 (95% CI: 0.60, 1.29). Finally, among YLWH (chapter 4), the prevalence of diabetes and hypertension is 4% (n=16) and 6% (n=22), respectively, among YLWH, compared to 1% (n=4) and 4% (n=22), among the general population of the same age group. We observed higher odds of diabetes/prediabetes among YLWH compared with the young general population, aOR=6.64 (95% CI: 3.62, 12.19). Additionally, YLWH were at much higher odds of high cholesterolemia, aOR=7.95 (95% CI: 3.98, 15.87), than the young general population.

Conclusion: To combat a future burden of NCDs and potentially their related morbidity and mortality, our studies underlined the need to set up essential intervention strategies, be it behavioral modification or medical intervention, in order to properly address these conditions among population living with HIV including YLWH. In addition to interventions, monitoring and screening efforts should also be put in place among this population given their susceptibility to develop these conditions at a younger age than the general population.

BACKGROUND: Gay, bisexual and other men who have sex with men (GBMSM) remain most at risk of HIV acquisition in the US. Despite the increasing number of providers reporting PrEP prescribing in recent years, uptake remains sub-optimal. This analysis examines sexual and substance use factors influencing consistent PrEP care engagement and the impact of the COVID-19 pandemic on PrEP services.

METHODS: Chapter 2 uses data from the mSTUDY cohort to describe the association between relationship-level substance use factors and consistent PrEP care engagement. Chapters 3 and 4 use health record data from the Los Angeles LGBT Center. Chapter 3 includes a survival analysis describing the median time to PrEP discontinuation in this population and associations between gender identity and substance use factors on time to PrEP discontinuation. Chapter 4 uses an interrupted time series analysis to review the population-level impact of facility closures related to the COVID-19 pandemic on PrEP follow up care retention.

RESULTS: Patients reporting chemsex at the LA LGBT Center had significantly longer follow up time on PrEP than those who did not. After controlling for chemsex, cisgender men had significantly longer follow up time on PrEP than non-cis PrEP users in this facility. Participants in mSTUDY who reported that either they or their partner used methamphetamine or that both they and their partner used methamphetamine had nearly 2.5 or 3.8 times higher odds, respectively, of inconsistent PrEP care engagement compared to those who reported no methamphetamine use. COVID-19 significantly impacted PrEP follow up at the LA LGBT Center compared to the pre-COVID-19 period, resulting in a nearly 40% decrease in follow up visits. The extent to which PrEP follow up visits decreased varied by important demographic factors including race/ethnicity, experiences of homelessness, sexual identity and chemsex.

CONCLUSION: The reach and impact of HIV prevention tools like PrEP can be maximized through better targeting of services and better integration of psychosocial and substance use treatment services. Further examination of novel PrEP follow up strategies will be essential in the changing PrEP method landscape and in the context of the changing healthcare landscape as a result of COVID-19.

Rates of sexually transmitted infections (STIs) in the U.S. military have historically been higher than those of civilians. One likely contributor to high military STI rates is the high prevalence of behaviors that correspond with transmission of STIs, including binge drinking, lack of condom use, and multiple sexual partnerships. Other potential contributors include the high prevalence of mental health conditions as well as unwanted sexual contact (i.e., sexual assault). In particular, women in the military tend to have higher rates of STIs than both their male colleagues in the military and their female peers in the general population. This dissertation aims to better understand the differences in sexual risk behaviors and risk for STIs between men and women in the military, and between women in the military and women in the general U.S. population. It also aims to describe the factors associated with unwanted sexual contact and mental health among service women in particular.

This dissertation utilizes data from the 2008 Department of Defense Survey of Health Related Behaviors among Active Duty Personnel (HRBS) in order to estimate the prevalence of STIs and sexual risk behaviors among military personnel. Chapter 1 identifies and provides background information on women in the military as well as STI risk factors. Chapter 2 compares STI risk behaviors between men and women in the military and describes the factors that are associated with report of an STI and with report of multiple sexual partners, among both genders. Chapter 3 examines the relationships between unwanted sexual contact, sexual risk behaviors, mental health, and substance use among women in the military. Finally, Chapter 4 utilizes data from the 2007-2010 National Health and Nutrition Examination Survey (NHANES) in order to estimate the prevalence of STIs and sexual risk behaviors among women in the general population. These estimates are then compared to those of service women in the 2008 HRBS. Findings from this dissertation expand the current understanding of sexual risk behaviors among women in the military, and have implications for the development of interventions that promote sexual health among female service members in the United States.

BACKGROUND: The COVID-19 pandemic and related state policy has had varying effects on economic, social, and behavioral factors especially among marginalized populations such as sexual minority (SM) groups. Of specific interest is how cannabis use and cannabis behaviors have been influenced during the COVID-19 pandemic. This dissertation examines changes in sharing of prepared cannabis and cannabis-related paraphernalia (a risk factor for COVID-19 infection) due to the COVID-19 pandemic and COVID-19 state policy among a sample of United States adults who report cannabis use. This dissertation also assess cannabis use and sharing of cannabis among sexual minority and non-sexual minority individuals in the United States. We define sharing of cannabis as sharing of prepared cannabis (cigarettes/joints/blunts) and cannabis-related paraphernalia (pipes/water pipes/rigs/vaporizers/ e-cigarettes/vapes).METHODS: Chapters 2, 3, and 4 use data collected as part of the COVID-19 Cannabis Survey, supported by US National Institute on Drug Abuse and Semel Charitable Foundation. This anonymous cross-sectional web-based survey was among US adults (18 years or older), who reported non-medical cannabis, medical cannabis, or cannabidiol (CBD) use in the last 12 months. The survey was sent out in August - September 2020 where 2,000 respondents were recruited and 1,883 remained eligible after exclusion criteria were applied. Recruitment was based on a convenience sample of respondents on internet-based platforms including Reddit, Bluelight (forum for illicit drug use), Craigslist, and Twitter. This survey included cannabis (non-medical/medical) and CBD frequency of use, reasons for changing cannabis use during the COVID-19 pandemic, sharing behaviors of prepared cannabis and cannabis-related paraphernalia, education, sex, age, sexual orientation, and geographical location (ascertained by collected zip code and state residency). Cannabis use behaviors were assessed in this single survey for a three-month timeframe before the COVID-19 pandemic (January-March 2020) and a three-month timeframe during the COVID-19 pandemic (June-August 2020). Chapter 2 descriptively assessed changes in sharing of prepared cannabis and cannabis-related paraphernalia before and during the COVID-19 pandemic and evaluated the association of non-medical cannabis frequency of use during the pandemic on cannabis sharing. Chapter 3 assessed the association of sexual orientation (sexual minority compared to non-sexual minority respondents) on cannabis use and cannabis sharing during the pandemic. Finally, chapter 4 utilized a semi-individual study design to assess the association of state’s COVID-19 policy on sharing of prepared cannabis and cannabis-related paraphernalia. COVID-19 state policy was drawn from the Kaiser Family Foundation’s (KFF) State COVID-19 Data and Policy Actions for June, July, and August 2020. We scored policies by strength using a standardized coding method ranging from 0 (no policy action) to 5 (very high/all actions prohibited). RESULTS: Overall, there was an absolute change of 12.7% for no sharing, 4.2% change for sometimes sharing, 2.3% change in sharing about half the time, 8.1% change in sharing most of the time, and 2.6% change in always sharing of prepared cannabis and cannabis-related paraphernalia between the two time periods (before and during the COVID-19 pandemic). Moreover, after adjusting for age, education, tobacco use, and alcohol use, the odds of daily/weekly cannabis use among SM respondents was 0.55 (95% CI 0.41, 0.72) times that of non-SM respondents. After adjusting for age, education, and tobacco use, the odds of any sharing during the pandemic among SM respondents was 1.60 (95% CI 1.13, 2.26) compared to non-SM respondents. Finally, state’s COVID-19 policy was associated with sharing of prepared cannabis and cannabis-related paraphernalia. After adjusting for state’s cannabis regulation, COVID-19 infection prevalence, state’s percent urbanicity, age, sex, and education, the odds of any sharing given COVID-19 state policy in June, July, and August were 0.77 (95% CI 0.60, 0.97), 0.80 (95% CI 0.66, 0.96) and 0.82 (95% CI 0.67, 0.98) respectively per every 5-unit increase in score. CONCLUSION: There was a decrease in sharing of prepared cannabis and cannabis related-paraphernalia during the COVID-19 pandemic compared to before the pandemic which varied across levels of cannabis frequency of use before the pandemic and sex. SM individuals were less likely to use cannabis daily/weekly but more likely to share prepared cannabis and cannabis-related paraphernalia compared to non-SM respondents during the pandemic. Furthermore, those in states with more stringent COVID-19 policies were less likely to share prepared cannabis and cannabis-related paraphernalia compared to those in states with less stringent policies. Public health messaging and education toward sharing practices of prepared cannabis and cannabis-related paraphernalia may be useful for future COVID-19 resurgence and with other respiratory infections such as during the cold and influenza season for individuals who use cannabis in the United States.

HIV/AIDS continues to be a major public health problem throughout the world. In 2011, 23.5 million people were living with HIV/AIDS worldwide, with the greatest burden of disease in Africa, representing 2/3 of the total HIV/AIDS population. Specifically, sub-Saharan Africa bears the highest burden of the disease, with 22.9 million people living with HIV/AIDS (PLWHA), 60% of the total infections worldwide. Furthermore, within this region, women are disproportionately affected, accounting for 58% of people living with HIV/AIDS.1 With the continued high prevalence and incidence of HIV among women, despite an increase in prevention interventions, including pre-exposure prophylaxis (PrEP), suggests behavior change still plays a key role in transmission. This dissertation aims to seek to understand high-risk sexual behaviors and other factors associated with an increased risk of secondary transmission among women in order to inform the implementation of new HIV prevention strategies and reduce the burden of HV. Chapter 1 is a brief introduction into HIV and the high-risk sexual behaviors that affect its transmission. Chapter 2 is based on data from a cohort study of recently sero-converted women from the Microbicide Trials Network (MTN) and demonstrated that depression plays a significant role in the acquisition of STIs. Chapter 3 is based on data from a cohort study of recently sero-converted women from the MTN and demonstrated that there are several factors that influence disclosure and timing of disclosure of HIV status. Chapter 4 is based on data from a cohort study of recently sero-converted women from the MTN and demonstrated that high-risk sexual behaviors are still frequent among HIV-infected women, and that ART may modify the risk of high-risk sexual behaviors. Finally, Chapter 5 is a brief discussion of results as well as their implications for future research.

Adherence to medications for HIV prevention and treatment is essential to reducing HIV transmission risk and improving health outcomes. Adherence to these medications remain insufficient in several key populations, however. Understanding how partnership types and dynamics may encourage or hinder HIV medication adherence is necessary to improving adherence rates among important sub-groups, including young men who have sex with men (YMSM), serodiscordant couples, and adolescent girls.

My first paper identified the partnership and housing factors associated with adherence to oral PrEP among YMSM. PrEP adherence was relatively low in the study, declining from 46% at baseline to 39% at study conclusion. PrEP adherence was significantly associated with increasing age (OR=1.35; 95% CI: 1.14, 1.60), and race (African-Americans vs. other OR=0.37, 95% CI: 0.21, 0.66). Relationship type, length, and depth, number of partners, and partner’s HIV status were not significantly associated with adherence. PrEP adherence was associated with housing insecurity, including ever being kicked out of the home (AOR=0.43; 95% CI: 0.18, 1.04), and the Housing Insecurity Index (AOR=0.64; 95% CI: 0.44, 0.93). PrEP adherence was also associated with privacy, including number of people living in the residence (AOR=0.82; 95% CI: 0.71, 0.95), sleeping in a private bedroom (AOR=2.10, 95% CI: 1.01, 4.40), and the Lack of Privacy Index (AOR=0.82; 95% CI: 0.71, 0.95). YMSM did not modify their PrEP-taking depending on relationship risk. Housing insecurity and lack of privacy may hinder PrEP adherence among YMSM.

My second paper determined whether HIV viral suppression was associated with partnership status and partnership support among HIV-positive individuals and serodiscordant couples in Brazil. Viral suppression did not significantly differ between HIV-positive partnered (79% virally suppressed) and unpartnered (76% virally suppressed) individuals. Among individuals in partnerships, viral load suppression was significantly associated with having partners who attended monthly visits (AOR=2.99; 95% CI: 1.00, 8.93); among women in partnerships, viral load suppression was significantly associated with having a partner who actively reminded them to take ART (AOR=2.67; 95% CI: 1.04, 6.88). Practical measures of social support, including attending monthly visits and reminding a partner to take ART, may improve viral suppression among HIV-positive individuals in serodiscordant partnerships.

My third paper assessed the product, relationship, and sex factors that affect acceptability of a vaginal ring (VR) for HIV prevention among adolescent girls aged 15 to 17 years. Product factors were most frequently mentioned as barriers to VR acceptability. Many participants reported concerns about the large size of the VR upon first impression, and some reported pain with VR insertion. Several participants reported concerns regarding cleanliness of the VR, particularly during menstruation. Relationship factors rarely appeared to act as barriers to VR acceptability; the majority of participants disclosed VR use to their sexual partners, and positive reactions from sexual partners regarding the VR were common. Emotional and/or physical discomfort surrounding VR use during sex was mentioned occasionally as a potentially barrier to VR acceptability.

Relationship factors appear to be important in several populations for adherence to HIV-related medications. YMSM in high-risk sexual relationships may not modify PrEP-taking, leaving them at risk for HIV acquisition. Among serodiscordant couples, practical measures of partnership support may improve ART adherence and promote viral suppression. While adolescent girls most often reported that product-related factors inhibited VR acceptability, lack of partnership disclosure, negative partner reactions, and discomfort during sex may hinder VR acceptability among some girls.