INTRODUCTION: Human Immunodeficiency Virus (HIV) infection remains prevalent among the minority and drug using population in the United States. Testing for HIV is an important and cost effective way to reduce HIV prevalence. OBJECTIVE: To assess the HIV testing behavior of people who use non-injected drugs (PWND) and compare it to that of people who use injected drugs (PWID), in order to determine which factors, in terms of social context as well as individual risks, predict HIV testing among the PWND. METHOD: A cross-sectional study of HIV testing behavior of PWND compared to PWID was conducted and the data was analyzed by applying negative binomial regression models. Then, a negative binomial regression using generalized estimating equation (GEE) was employed in order to identify the predictive factors for HIV testing among PWND over a 2-year period. RESULTS: Individuals who reported using injected drugs tended to undergo HIV tests more often compared to those who used non-injected drugs, PR (95% CI) = 1.24 (1.02, 1.51), p = 0.03. The interaction term between injection status and emotional support in relation to HIV testing was significant, 0.75 (0.59, 0.97), p = 0.03. PWID that had access to greater emotional support on average tended to test for HIV less frequently than did PWID with less emotional support. In stratified analyses, emotional support was negatively associated with testing among PWID and positively associated among PWND, though both relationships were borderline significant. HIV testing among users of illicit drugs was dependent on emotional support. According to the GEE models examining the factors predicting HIV testing among PWND, sexually transmitted infections, non-injected heroin use, being in drug treatment, engagement in sexual transactions, and instability in drug networks were the main factors contributing to being HIV tested, as well as frequency of testing. The positive influence of emotional support on these variables was borderline significant. CONCLUSION: People who use non-injected drugs are less likely to test for HIV compared to those who use injected drugs, though they may share similar risk factors for HIV transmission and acquisition. To exert a greater impact on the HIV epidemic, interventions and policies encouraging HIV testing in this subpopulation, which remains under-recognized by both researchers and health practitioners in terms of the potential risks for contracting the HIV, are warranted.

Adolescents and young adults represent a growing proportion of people living with HIV around the world and have worse outcomes than all other age groups. Retention along each step of the HIV care cascade is essential for optimal care, but importantly, achieving sustained adherence to antiretroviral therapy (ART) and subsequent viral suppression is necessary for decreasing morbidity and mortality and reducing further transmission. The overarching goal of this dissertation was to assess health-services interventions aimed at improving ART adherence among adolescents and young adults living with HIV, and prospectively evaluate one such intervention – point-of-care viral load testing – in a randomized control trial. First, a systematic review was conducted to assess and synthesize recent research on interventions aimed at improving ART adherence among adolescents and young adults living with HIV in a resource-limited setting. Evidence from the review indicated that comprehensive models of HIV care, re-structuring how HIV services were delivered to patients, which included increased monitoring of adolescents and young adults through home visits or case management in addition to standard clinical care improved ART adherence. Second, a randomized control trial was conducted to evaluate the implementation and effect of point-of-care viral load testing compared to standard laboratory-based testing. The trial had two primary objectives: 1) to assess the efficiency of point-of-care viral load testing, and 2) evaluate the effect of point-of-care viral load testing on health outcomes including ART adherence and viral suppression. The research protocol is described including study design, the point-of-care viral load testing intervention, analysis plan, and outcome definitions. Lastly, the results of this trial are reported which indicate that point-of-care viral load testing can be feasibly integrated into a low-resource, clinical setting. A majority of point-of-care viral load test results (81.8%; 148/181) were processed and returned the same day, with a mean time between blood collection and participant receipt of results of 2.7 hours (IQR: 2.5-3.2; range 1.7-6.0). Point-of-care viral load testing also appeared to improve the accuracy of reported ART adherence, an unanticipated finding. In the point-of-care arm, participants who reported sub-optimal ART adherence on any of 3 adherence questions were more likely to have a VL >1,000 copies/mL (OR: 6.57; 95% CI: 2.12-25.21), compared to participants in the standard arm among whom the association was weaker (OR: 2.62; 95% CI: 0.97-7.44). There was no difference in viral load outcomes between arms. Overall, this dissertation addresses gaps in our knowledge about interventions aimed at improving ART adherence among adolescents and young adults living with HIV. The key finding is that point-of-care viral load testing can simplify the viral load monitoring process and help clinicians accurately identify adolescents and young adults with a high viral load in order to provide enhanced adherence counseling or make clinical decisions regarding appropriate treatment options faster. Point-of-care viral load testing could be used in concert with other interventions which address additional barriers to ART adherence among adolescents and young adults such as forgetfulness, stigma, or lack of social support. As the public health field continues to focus on improving HIV outcomes among this vulnerable age group, these findings can guide the optimization of HIV services and the development of combination interventions which could increase the number of adolescents and young adults who achieve sustained ART adherence and viral suppression.

Renewed efforts are needed to address rapidly rising HIV incidence among sexual and gender diverse (SGD) individuals—particularly cisgender gay, bisexual, and other men (MSM) and transgender and nonbinary individuals (TSM) who have sex with men—in Kazakhstan. Intervention research is uniquely positioned to advance HIV prevention through surveying factors shaping the HIV epidemic among MSM and TSM in Kazakhstan, developing and testing the effects of an HIV prevention intervention, and assessing overall social impacts of conducting research. This research proceeded to describe strategies and lessons learned during implementation of a stepped wedge clinical trial of an intervention designed to increase the number of MSM and TSM in the HIV care continuum in Kazakhstan cities of Almaty, Shymkent, and Nur-Sultan. Thus, this three-paper dissertation aimed to: (1) identify psychosocial factors associated with lifetime, past-12-month, and past-6-month HIV testing among a sample of MSM and TSM enrolled in the clinical trial; (2) describe the process of implementing remote training of facilitators for remotely delivering the HIV preventive intervention; and (3) assess social impacts of participating in the clinical trial. MSM and TSM from the study cities were recruited into the clinical trial and administered a structured behavioral survey at their primary visit and at follow-up visits every six months thereafter. After a period of no intervention implementation (‘pre-implementation period’), the intervention was implemented sequentially every six months in the study cities. Among 304 MSM and TSM enrolled in the clinical trial during the pre-implementation period, lifetime and past-12-month HIV testing were positively associated with polydrug use and negatively with sexual transmission HIV risk, and past-6-month HIV testing was negatively associated with sexual risk. The process of developing and implementing remote training of facilitators was guided by a protocol outlining phases involving formative assessment and planning, fundamentals training, and feedback loop and technical assistance. Out of 627 MSM and TSM who completed their primary assessment during the clinical trial, 579 (92%) returned for at least one follow-up visit; of these individuals, 88% reported at least one positive social impact, while 2% reported at least one negative social impact. Findings underscore the value of expanding access to substance use treatment for HIV prevention among MSM and TSM in Kazakhstan, the viability of remote training of facilitators for remote intervention delivery, and the feasibility of conducting HIV prevention research involving MSM and TSM with many benefits and few risks.