Risk behavior, attitudes toward HIV testing and treatment, perception of HIV-related stigma, and medical mistrust were not associated with ordering a self-test kit. Finally, we recorded high prevalence of alcohol and cannabis use among participants. Overall, information search sites performed poorly in recruiting and enrolling individuals. The site advertisement metrics showed a better click-through rate than social media and a similar number of users screened, but ultimately only a small number of individuals enrolled in the study. Search engines have a broad audience as they are available to everyone with access to the internet, and they do not require an account. In comparison, dating apps had the highest click-through rate, screening numbers, and enrollment. Users of dating apps are more likely to be MSM and engage in high-risk behaviors, which could explain the higher engagement with the promoted study advertisements. Consequently, dating apps may be more cost-efficient in enrolling select individuals compared to other platforms. Using search engines for promotion may reach higher numbers of individuals, but dating apps achieved higher interaction with the promotion message in this study. Another important difference between platforms that may have affected individual site performance is the type of advertisement message. Social media and dating apps use blast advertisements with images and text,drying room whereas search engines use text-only promotional content.
Researchers attempting to identify the best type of advertisement to reach MSM through the internet for free at-home HIV testing showed that the click-through rate for a text-only advertisement on Google was 0.38%, whereas that for advertisements with images, such as the ones used in social media and dating apps, was higher, between 0.77% and 2%. There is a lack of published data regarding the performance of promotional campaigns to enroll participants or promote HIV prevention messages. This limits our capacity to make comparisons with similar campaigns. Our data showed that the cost of enrolling individuals from dating apps is lower compared to that for social media and information search sites. This is mainly due to the higher engagement and higher number of participants enrolled through dating apps. Future studies should collect and report advertisement campaign metrics as well as the costs of enrollment per participant screened and enrolled, which can allow for a better evaluation of the cost-effectiveness of different platforms. We enrolled Latino and Black MSM at a high risk for HIV infection in 10 areas with a high incidence of HIV infection. The study population included individuals with inconsistent and infrequent condom use, and nearly 25% of them reported that they had never tested for HIV. We also identified individuals who reported a preliminary positive result, which demonstrates the capacity of HIV home testing to reach hard-to-reach populations, overcome obstacles, and increase testing. Our findings underline the importance of identifying the best possible promotional platform that will allow public health programs to reach an even larger number of individuals at risk.
Our findings did not identify any major differences between participants who ordered a kit compared to those who did not order a test kit. However, our data showed a small statistical difference in terms of the questionnaires on self-perceived stigma, as well as the participant perceptions about the risks of HIV infection. Public health stakeholders should continue their efforts to educate individuals about HIV and support vulnerable individuals against stigma. Substance use was common among study participants, especially alcohol and cannabis use. Similarly, Westmoreland et al also reported a high incidence of cannabis use and alcohol use among a sample of MSM, transgender men,and transgender women. Heavy alcohol use is associated with an increase in sexual behaviors that might put persons at risk for HIV acquisition and transmission. Therefore, HIV prevention programs should include substance use screening and intervention services. Medical mistrust has been associated with low intention of PrEP uptake and poor medication adherence. Medical mistrust is also a barrier to HIV testing and causes disruptions in HIV care. Study participants expressed a high level of mistrust toward medical providers and institutions. However, that did not seem to affect self-test kit ordering in our study. Additional research is needed to evaluate how medical mistrust may impact HIV testing and PrEP uptake. Regarding PrEP, participants reported being informed of its benefits, comfortable taking PrEP, and not embarrassed about taking PrEP; however, they did report concerns about the adverse effects and the cost of PrEP. Similar concerns have been reported by Kota et al in a cohort of MSM. Although PrEP is generally considered safe, public health messages should include more information about its low frequency of adverse effects and overall safety. Further awareness about access to low-cost PrEP might improve uptake and retention.
There are established state-sponsored programs that offer low-cost or free PrEP through in-person or telemedicine visits or with simple delivery via regular mail. Additional efforts to promote those initiatives and programs in high-incidence areas, such as in the areas included in this study, may be necessary.To our knowledge, this is the largest examination of prenatal alcohol exposure and psychological, behavioral, and neurodevelopmental outcomes in preadolescence. The estimated total number of drinks consumed during pregnancy ranged from 0 to 90 following outlier conversion. This alcohol dose is relatively low, and the parent-reported exposure patterns prevalent in the ABCD cohort are more typical and reflective of the general population than those investigated in previous studies of fetal alcohol spectrum disorder . Prenatal alcohol exposure of any severity was associated with greater psychopathology, impulsivity, and likelihood of being diagnosed with separation anxiety and oppositional defiant disorder, with some observed dose-related associations. Heavier exposure was also associated with greater withdrawn or depressed behavior, attention deficits, rule breaking, aggression, and a greater likelihood of being diagnosed with ADHD. Early, light exposure, compared with no exposure, was associated with better attention and inhibitory skills. Exposed youths also exhibited greater cerebral volume, in a dose-dependent manner, and greater volume and surface area, but not cortical thickness, throughout regions of the parietal, temporal, and occipital lobes, after accounting for potentially confounding factors. Resting-state functional connectivity was largely unaltered in these youths. Aberrant brain structure partially mediated associations between prenatal alcohol exposure and psychological, behavioral, and cognitive outcomes at baseline and at the 1-year follow-up. Unmodifiable factors greatly contributed to the large effect sizes in the adjusted models. Of the modifiable factors, prenatal alcohol exposure was a critical determinant of brain structure, and some neurobehavioral outcomes, accounting for >50% of the explained variance by modifiable factors. The findings were in a largely substance-naive cohort of youths , allowing for investigation of the effects of prenatal alcohol exposure on the developing brain and behavior in the absence of youths’ own substance use, which is known to affect neurodevelopment . Our findings replicate previous clinical studies indicating that children exposed to alcohol in utero have higher rates of mental disorders and present with behavioral anomalies,how to trim cannabis including impulsiveness and attention deficits . Results from our dose-dependent and exposure pattern analyses support the notion that the severity of psychopathology and behavioral problems depends on alcohol dose and timing of exposure. The present results are also consistent with previous reports using the ABCD cohort of associations between psychopathology, brain structure, and resting-state functional connectivity . Consistent with previous meta-analyses, a small, beneficial association between prenatal alcohol exposure and cognitive ability was observed . However, when participants were demographically matched, the vast majority of associations were no longer significant. This association may be the result of residual confounding from socioeconomic status and other demographic variables, as previously hypothesized . Other confounding variables not captured in this analysis may be contributing to the positive association between early, light exposure and attention and inhibition. The long-term neurostructural and functional effects of light maternal drinking, where offspring who do not necessarily present with fetal alcohol spectrum disorder, have not been well studied.
Consistent with our findings, one study has reported larger regional volume among youths prenatally exposed to alcohol relative to unexposed youths . However, in contrast to our results, a common finding, when investigated both categorically and continuously, has been less volume and surface area among youths with fetal alcohol spectrum disorder and those with heavier prenatal alcohol exposure compared with unexposed youths . Furthermore, a previous study of youths with fetal alcohol spectrum disorder reported hypoconnectivity between numerous large-scale neurocognitive networks , yet in the present study, no significant alterations in resting-state functional connectivity were observed within or between these networks . The disparate findings may be explained by the large discrepancies in clinical severity of prenatal alcohol exposure between the ABCD sample and previous cohorts. The impact of heavier prenatal alcohol exposure may have a differential effect on preadolescent brain structure and function. Interestingly, some regions of the occipital, temporal, and parietal lobes exhibited an inverted-U association between alcohol dose and volume or surface area . It is possible, therefore, that we would have observed reduced volume and surface area among youths exposed to heavier doses . Furthermore, potentially confounding factors in previous studies of children with heavier prenatal alcohol exposure or fetal alcohol spectrum disorder may contribute to the discrepant findings, such as greater co-occurring substance exposure, early-life stress, and quality of parental care. Importantly, our findings suggest that youths exposed to even light alcohol doses in utero exhibit widespread differences in brain structure, when compared with unexposed youths. Finally, our results are consistent with previous studies of children with fetal alcohol spectrum disorder that have linked behavioral, psychological, and cognitive outcomes to changes in brain structure . However, our study is the first to test and identify inconsistent mediation between these variables . Similar to previous conclusions drawn on the effects of prenatal alcohol exposure , our results suggest that there is no safe threshold for alcohol consumption during pregnancy.Alcohol is a known teratogen in utero, and it is thought to affect regions of the developing fetal brain via neural proliferation and migration errors, hypoxia, and cell death . The teratogenic effects likely differ as a result of dose, frequency, and timing of exposure and may vary across brain regions. Our findings demonstrate that there are complex effects of prenatal alcohol exposure on offspring development. Here, we provide four potential interpretations of mechanisms underlying associations between prenatal alcohol exposure, differences in brain structure, and neurobehavioral consequences. First, our results may reflect a compensatory response of some brain regions attempting to counter the effects of other, poorer functioning regions affected by low alcohol doses . Our inconsistent mediation findings provide some support for this interpretation, where greater brain volume and surface area were associated with better neurobehavioral outcomes, yet youths who were exposed to alcohol in utero exhibited greater volume and surface area but more neurobehavioral problems at baseline and follow-up. Despite a potential compensatory response of the brain to counter the effects of relatively low doses of alcohol, these youths continue to show subtle, yet poorer, psychological and behavioral outcomes through early life. Second, our findings may also suggest that relatively light prenatal alcohol exposure may result in slightly atypical neurodevelopment. Such exposure may slow or alter the overall process of gray matter maturation, where greater absolute volume and surface area in exposed youths represent delayed or incomplete cortical pruning compared with this process in unexposed, prepubertal youths . Consistent with this hypothesis, we observed this trend largely in regions where gray matter loss in unexposed children progresses linearly from childhood through adolescence . Typically among this age group, the left hemisphere matures earlier than the right . Greater volume and surface area among exposed youths in left posterior cortices known to develop most rapidly between childhood and adolescence provide further support of delayed development. Examining the developmental trajectories of this cohort when multiple waves of imaging data are available will provide further insight into whether atypical development is occurring among exposed youths. Third, the inconsistent mediation findings may also be partly capturing the effects of the inverted-U associations between total alcohol dose and regional brain volume and surface area. Youths exposed to greater alcohol doses exhibited greater psychopathology and behavioral problems between ages 9 and 10 than youths exposed to lighter doses , and these more heavily exposed youths exhibited lower volume and surface area in regions of the parietal and temporal lobes than youths exposed to lighter doses. Lastly, there may be other critical changes resulting from prenatal alcohol exposure that mediate associations with brain structure differences and psychological and behavioral outcomes. For example, ethanol provokes a wide range of epigenetic modifications, including altered DNA and histone methylation, which persist from birth through childhood .