COVID-19, Telemedicine, and Patient Empowerment in HIV Care and Research

Perceptions of Nurses and Counselors Regarding the Use of Telehealth in HIV Care

BACKGROUND

The human immunodeficiency virus continues to pose a significant global health challenge. The coronavirus (COVID-19) pandemic disrupted efforts to end HIV/AIDS as a public health threat by 2030 but also accelerated the adoption of telehealth services to support care for people living with HIV (PLWH). However, in some settings, the effective deployment of telehealth was limited by insufficient evidence on how to engage diverse patient populations.

OBJECTIVE

The objective of this study was to explore the perspectives of Ugandan nurses and counselors on the use of telehealth for follow-up care and treatment of PLWH.

METHODS

This descriptive qualitative study was conducted in 2022 among nurses and counselors in Kampala, Uganda. Data were collected through face-to-face focus group discussions and analyzed using a conventional qualitative approach. Participants' perspectives are organized into four levels: individual, interpersonal, health facility, and public policy.

RESULTS

The study included 36 participants, of whom 80.6% were female and 52.8% were nurses, with ages ranging from 29 to 57 years and a mean age of 37.6 years (SD = 7.8). Participants perceived telehealth as beneficial in several areas, including reducing healthcare costs, improving the quality of care, strengthening patient-provider relationships, minimizing loss to follow-up, and supporting medication adherence. In addition, telehealth was considered suitable for various services, such as counseling, monitoring medication adherence, providing health education, and facilitating patient triage.

CONCLUSIONS

Telehealth holds significant potential to enhance HIV healthcare delivery and should be considered by all health systems providing HIV care.

Implementation and early outcomes of a telehealth visit model to deliver tecovirimat for mpox infection in New York City

The 2022 mpox outbreak in New York City posed challenges to rapidly scaling up treatment capacity. We describe a telehealth treatment model launched during this outbreak that facilitated healthcare provider treatment capacity, and was able to adhere to a Centers for Disease Control and Prevention (CDC)-sponsored expanded access investigational new drug (EA-IND) protocol for tecovirimat. Sixty-nine patients were evaluated and prescribed tecovirimat for mpox through telehealth visits at NYC Health + Hospitals/Bellevue and NYU Langone Health from June to August 2022. Thirty-two (46.4%) were previously diagnosed with HIV. Forty-four (63.8%) reported full recovery, with the remainder lost to follow-up. Most patients (n = 60, 87.0%) attended at least one follow-up visit (either in person or through telehealth) after starting treatment. We observed favorable treatment outcomes, with no serious adverse events, hospitalizations, or deaths related to mpox. While equitable access to telehealth remains a limitation that needs to be addressed, this telehealth model enabled a rapid scale-up of tecovirimat prescription during the mpox outbreak, and should be considered as an important tool used to respond to future infectious disease outbreaks.

Patient perceptions and predictors of intention to use telehealth for follow-up care: a mixed methods study among adults living with HIV in Kampala, Uganda

BACKGROUND

The human immunodeficiency virus (HIV) remains a significant global public health challenge. Despite progress in addressing the pandemic, people living with HIV continue to report challenges in accessing HIV testing, care, and treatment services. Telehealth presents a promising solution to some of these barriers. However, its potential remains unrealized, particularly in low- and middle-income settings, partly due to insufficient supporting evidence.

METHODS

Our mixed methods study investigated patient perceptions and predictors of intention to use telehealth for follow-up HIV care in Uganda. Quantitative data were collected from 266 participants using a questionnaire, followed by one-on-one interviews with 12 people living with HIV. Quantitative analysis involved Chi-square tests, t-tests, and binary logistic regression, while qualitative data were analyzed using conventional content analysis.

RESULTS

Our findings show that the intention to use telehealth was significantly associated with effort expectancy (aOR 1.26, CI 1.13-1.41), facilitating conditions (aOR 1.44, CI 1.19-1.73), estimated monthly income (aOR 2.94, CI 1.05-8.23; aOR 7.29, CI 1.12-47.49), and antiretroviral medication adherence (aOR 1.93, CI 1.12-3.33). Qualitative insights underscore the importance of digital literacy and availability of support services to enhance the utilization of telehealth. While performance expectation and stigma score did not significantly predict intention to use telehealth, participants perceived telehealth to be beneficial in combating stigma and improving access to HIV care services.

CONCLUSIONS

To optimize the utilization of telehealth, we recommend measures aimed at addressing economic disparities and enhancing digital literacy among people living with HIV. Future research should explore the effectiveness of economic empowerment programs in promoting telehealth use and investigate the impact of telehealth on HIV care models, stigma reduction, and linkage and retention in HIV care.

Insights on HIV Care Engagement Strategies from Seven Interventions Serving Key Populations in the United States: A Qualitative Study

As HIV diagnoses continue to decrease and rates of viral suppression increase in the United States, key populations of underserved individuals represent a disproportionate share of those left undiagnosed, unengaged in care, and not virally suppressed. In 2021, the Health Resources and Services Administration's HIV/AIDS Bureau funded 20 HIV care organizations across the United States to implement seven innovative evidence-based interventions to engage individuals in the following four focus areas: LGBTQ+ youth, people with substance-use disorder, individuals with incarceration experience, and those for whom telehealth may reduce barriers to care. This article explores themes of implementer experiences common across interventions serving the four focus areas. Data sources include key informant interviews (n = 94) with members of the implementation teams, observation, and document review. Thematic analytic methods were first inductive, identifying semantic themes from observation and document review, then deductive, selecting coded interview data for analysis of latent themes present and salient across focus areas. We identified three main themes as follows: (1) challenging by design, (2) enhanced client-centered care, and (3) leveraging relationships. We present these themes as distinct concepts and discuss how they operate in relation to one another using the Exploration, Preparation, Implementation, Sustainment framework. Teams implementing interventions to engage people with HIV who remain out of care may benefit from adopting the following: an enhanced client-centered orientation with a focus on understanding the context of clients' lives; a high level of organizational and programmatic flexibility; an individualized, trauma-informed approach to enrollment and intervention delivery; and thoughtfully cultivated relationships among implementers, clients, and organizational partners.

Acceptance and adoption determinants of telemedicine in public healthcare institutions

BACKGROUND

 One of the challenges facing the usage of telemedicine technology in South Africa, particularly in the North West province (NWP), is lack of user acceptance by health care professionals which prevents piloted project to produce the desired outcomes.

OBJECTIVES

 The purpose of this study was to investigate the influential factors for the adoption of telemedicine by health care professionals from three selected hospitals (Bophelong, Taung and Klerksdorp) in the NWP.

METHOD

 The study adopted a case study approach and gathered data through questionnaires, which were distributed to the health care professionals of the three selected hospitals. In order to ensure that the instrument was accurate, a pilot study was carried out prior to the main investigation. Both the alpha and power values were set at 0.05 for the statistical analysis. The statistical tool used for the data analysis was SPSS v. 23.0.

RESULTS

 Attitude towards the use of telemedicine technology (ATUTT), perceived usefulness (PU) and acceptance of telemedicine technology (ATT) were considered to be the influential factors in the adoption of telemedicine technology. The association between perceived ease of use (PEOU) and perceived usefulness (PU) (0.150, p = 0.034), PEOU and Attitude towards the use of telemedicine technology (ATUTT) (0.211, p = 0.002), PEOU and Acceptance of telemedicine technology (ATT) (0.245, p = 0.000), PU and (ATT) (0.212, p = 0.002), ATUTT and (ATT) (0.189, p = 0.005). However, PEOU was found to have an insignificant relationship with (0.048, p = 0.093). Hypotheses 1, 3, 4, 5, and 6 are supported while H2 was not supported.

CONCLUSION

 The study aims to fill the knowledge vacuum identified, helping poor countries effectively implement telemedicine technology to modernise the health care sector. In addition, results from this study shed insight on the varied impacts of individual, technical, clinical and multidimensional social influence variables on health care providers' decisions to use telemedicine.Contribution: This study contributes to the body of knowledge by investigating the success factors for telemedicine technology adoption in South African public hospitals. These results have important implications for the public health care system in South Africa, both for the direction of future research and for the methods used to promote the use of telemedicine.

Telehealth for HIV care and management among people living with HIV in Australia: results from an online survey

Background The aims of this study were to evaluate the experiences of telehealth for routine HIV care and identify preferred models of HIV routine care for the future. Methods Anonymous, online questionnaire among people living with HIV aged 18years or older. This survey was advertised via posters with a QR code in six sexual health clinics and one community organisation as well as on social media from November 2021 to December 2022. Results Of 89 participants, the majority were males (80/89, 89.9%), between 36 and 55years old (49/89, 55.1%), spoke English at home (74/89, 84.1%), had been living with HIV for >5years (68/89, 76.4%) and reported having a telehealth consultation since the COVID-19 pandemic began (69/89, 77.5%). The top three liked aspects of telehealth were: the convenience of not leaving home or work (50/69, 72.5%); less travel time (48/69, 69.6%); and avoiding contact with other people (30/69, 43.5%). The top three dislikes of telehealth were: they could not be screened for sexually transmitted infections (STIs) or have a physical examination at the same time (29/69, 42.0%); it was an impersonal experience (20/69, 29.0%); and it was more difficult to discuss health concerns (18/69, 26.1%). Among all participants, the preference for future consultations was to have a mix between in-person and telehealth (40/89, 44.9%); however, nearly one-quarter prefer in-person consultations only (20/89, 22.5%). Conclusions Use of telehealth during COVID-19 has been evaluated positively among people living with HIV that participated in this survey. Participants support the use of telehealth for routine care in conjunction with in-person consultations.

The Role of the Multidisciplinary HIV Care Center in Mitigating Social Isolation Among Patients with HIV During the Early COVID-19 Pandemic

As the COVID-19 pandemic began in 2020, significant public health mitigation efforts were vital to combat an unprecedented health crisis. These efforts, which involved social distancing and self-quarantine, likely worsened a public health crisis of social isolation and loneliness in the U.S., particularly among people with HIV (PWH). Multidisciplinary HIV care centers, which served as the main source of clinical care for PWH and in some cases the only point of social contact, faced evolving dynamics of in-person visits during the COVID-19 pandemic, as well as a shift to telehealth services. Using in-depth interviews, we explored the role that multidisciplinary HIV care centers and providers played in the experience of social isolation among PWH in New York City. We recruited participants (n = 30) from a multidisciplinary HIV care center in NYC between October 2020 and June 2021. We conducted semi-structured interviews to understand the specific domains of social isolation that were mitigated. In this cohort, the major theme that drove both in-person and telehealth care continuity was the strength of the patient-provider relationship. We found that participants saw members of the HIV care center as part of their social network, and providers served both as a source of emotional support and provided important social resources and benefits. Thus, in times of heightened social isolation, HIV care centers can play a critical role in providing social support in addition to clinical care.

HealthCall: Smartphone Enhancement of Brief Interventions to Improve HIV Medication Adherence Among Patients in HIV Care

Heavy drinking among people living with HIV (PLWH) reduces ART adherence and worsens health outcomes. Lengthy interventions are not feasible in most HIV care settings, and patients infrequently follow referrals to outside treatment. Utilizing visual and video features of smartphone technology, we developed HealthCall as an electronic means of increasing patient involvement in a brief intervention to reduce drinking and improve ART adherence. The objective of the current study is to evaluate the efficacy of HealthCall to improve ART adherence among PLWH who drink heavily when paired with two brief interventions: the National Institute on Alcoholism and Alcohol Abuse (NIAAA) Clinician's Guide (CG) or Motivational Interviewing (MI). Therefore, we conducted a 1:1:1 randomized trial among 114 participants with alcohol dependence at a large urban HIV clinic. Participants were randomized to one of three groups: (1) CG only (n = 37), (2) CG and HealthCall (n = 38), or (3) MI and HealthCall (n = 39). Baseline interventions targeting drinking reduction and ART adherence were ~ 25 min, with brief (10-15 min) booster sessions at 30 and 60 days. The outcome was ART adherence assessed using unannounced phone pill-count method (possible adherence scores: 0-100%) at 30-day, 60-day, 3, 6, and 12 months. Analyses were conducted using generalized linear mixed models with pre-planned contrasts. Of the 114 enrolled patients, 58% were male, 75% identified as Black/African American, 28% were Hispanic, and 62% had less than a high school education. The mean age was 47.5 years (standard deviation [SD]  10 years) and the mean number of years since they were diagnosed with HIV was 18.6 (SD 7.6). Participants assigned to HealthCall to extend the CG had increased levels of ART adherence at 60-day and 6-month follow-up (compared to CG only), although there was no statistically significant difference by 12-month follow-up. Participants who were assigned to HealthCall to extend the MI never had statistically significant higher levels of ART adherence. These results suggest that the use of a smartphone app can be used to initially extend the reach of a brief drinking intervention to improve ART adherence over a short period of time; however, sustained long-term improvements in ART adherence after intervention activity ends remains a challenge.

Impact of COVID-19 on People Living With HIV: Data From Five Medical Monitoring Project Sites, 2020-2022

BACKGROUND

The COVID-19 pandemic disrupted global economic and healthcare systems. People living with HIV (PLWH) represent a marginalized and stigmatized population who may have been particularly impacted. The purpose of this analysis was to describe the impact of the COVID-19 pandemic on PLWH in the United States.

SETTING

United States.

METHODS

We analyzed surveys of behavioral and clinical characteristics of PLWH residing in 5 states that participated in the Medical Monitoring Project between 2020 and 2022. We described the impact of COVID-19 illness, testing, and diagnoses; receipt of medical care; social service access; employment; and preventive measures by project site and demographic characteristics.

RESULTS

Unweighted data from 1715 PLWH were analyzed. A high proportion of PLWH had medical care disrupted by the pandemic; 31% of PLWH missed medical appointments, 26% missed routine laboratory test results, and 7% missed antiretroviral therapy doses. In total, 30% of PLWH reported losing wages and 19% reported difficulty in accessing social services. Overall, 88% reported receiving at least 1 dose of COVID-19 vaccine, but vaccine uptake was low among younger, Black, and Hispanic or Latina/o/x PLWH.

CONCLUSIONS

This descriptive analysis reinforces previous findings that show that COVID-19 negatively impacted PLWH and their ability to obtain medical care. Additional efforts will be critical to ameliorating the longer-term impacts of COVID-19 on the health of PLWH and supporting PLWH through future pandemics and healthcare system disruptions.

Patients' perceptions of use, needs, and preferences related to a telemedicine solution for HIV care in a Norwegian outpatient clinic: a qualitative study

BACKGROUND

Telemedicine in outpatient services for people living with human immunodeficiency virus (PLHIV) was scaled up during the COVID-19 pandemic as services transitioned to remote care. Many studies have reported on the challenges and advantages of telemedicine care during the pandemic. However, there is limited research on the provision of telemedicine human immunodeficiency virus (HIV) care beyond the COVID-19 pandemic, which entails different telemedicine components and focuses on ways to improve the telemedicine experience for patients. This study aimed to explore PLHIV's perceptions of use, needs, and preferences related to a telemedicine solution for HIV care in an outpatient clinic in Norway. The telemedicine solution included a pre-consultation questionnaire, asynchronous digital messages, and video consultation.

METHODS

Qualitative interviews were conducted with 12 PLHIV. The interviews were analysed using thematic analysis.

RESULTS

We identified four main themes that covered the participants' perceptions, needs, and preferences: (1) perceived usability, (2) maintaining confidentiality, (3) accommodating personal preferences, and (4) perceived usefulness. Some participants had difficulty logging into the telemedicine solution. Other participants suggested additional functionalities, such as picture sharing and access to test result. Telemedicine care enabled the avoidance of stigmatising clinic experiences, although a few participants reported concerns about confidentiality and data security. Accommodating personal preferences and needs in terms of the type of consultations (in-person or video) and frequency of visits was essential to the participants. With telemedicine care, participants felt more in control of their own lives, perceiving that it increased their perceived quality of life and saved them both time and money for travelling to the clinic.

CONCLUSIONS

Our study identified several specific needs and preferences related to the assessed technical solution and the provision of current and future telemedicine care services. Nevertheless, the telemedicine solution was perceived as a usable, flexible, and person-centred approach to HIV care, contributing to accommodating the participants' personal preferences. However, healthcare professionals need to ensure that individual requirements and preferences are consistent with evidence-based follow-up and supported by person-centred care. Thus, the practice of shared decision making is important in telemedicine care.

Virtual counselling of tobacco cessation during the COVID-19 pandemic: A qualitative study on the experiences and perceptions of Malaysian dental undergraduates and their patients

INTRODUCTION

When dental institutions had to close down during the Movement Control Order (MCO) implementation due to the COVID-19 pandemic, dental students were faced with delays in completing their tobacco cessation schedule. An alternative was to allow students to conduct virtual counselling (VC) for smoking cessation for their patients to address their clinical requirements. This study aimed to explore Malaysian dental undergraduates' and patients' experiences undergoing smoking cessation counselling through virtual platforms.

MATERIALS AND METHODS

The study consisted of qualitative, semi-structured Focus Group Discussions (for students, n = 23) and in-depth interviews (for patients, n = 9); to phenomenologically describe the perceptions of participants involved in the VC. Each session was recorded with the participants' permission. The recorded session was transcribed verbatim and thematically analysed using the qualitative data analysis software, NVivo™.

RESULTS

The major themes that emerged were: (1) General opinions and experiences, (2) Content of VCs, (3) Remote access to counselling, (4) Patient-clinician relationships, (5) Technical issues, (6) Changes after VCs, and (7) Future application. Most students and patients were quite comfortable with VC as it is convenient, allowing students to be creative and avoid the hassle of transport and traffic. However, some of the students felt that it lacked the personal touch and guidance from lecturers who would normally be present during physical class.

CONCLUSION

Virtual counselling enables remote access to counselling, but it is also subjected to some limitations, especially regarding lack of clinical assessments, human touch and internet issues. Though participants were optimistic about adapting it in the future, multiple factors must be considered. Ultimately, the behavioural change will depend on the patient's motivation in making a difference.

ChatGPT: promise and challenges for deployment in low- and middle-income countries

In low- and middle-income countries (LMICs), the fields of medicine and public health grapple with numerous challenges that continue to hinder patients' access to healthcare services. ChatGPT, a publicly accessible chatbot, has emerged as a potential tool in aiding public health efforts in LMICs. This viewpoint details the potential benefits of employing ChatGPT in LMICs to improve medicine and public health encompassing a broad spectrum of domains ranging from health literacy, screening, triaging, remote healthcare support, mental health support, multilingual capabilities, healthcare communication and documentation, medical training and education, and support for healthcare professionals. Additionally, we also share potential concerns and limitations associated with the use of ChatGPT and provide a balanced discussion on the opportunities and challenges of using ChatGPT in LMICs.

The Future of Telehealth in Human Immunodeficiency Virus Care: A Qualitative Study of Patient and Provider Perspectives in South Carolina

To ensure care continuity during the COVID-19 pandemic, telehealth has been widely implemented in human immunodeficiency virus (HIV) care. However, participation in and benefits from telehealth were unequal. This study aims to assess the willingness of people living with HIV (PWH) and HIV care providers to use telehealth and perceptions of the future role of telehealth. In-depth interviews with 18 PWH and 10 HIV care providers from South Carolina assessed their willingness to use telehealth, their perspectives on the future of telehealth in HIV care, and recommendations to improve telehealth. Interviews were analyzed using thematic analysis. Most PWH were female (61%), Black/African American (67%), and non-Hispanic (78%). Most PWH (61%) and all providers had used telehealth for HIV care. Most PWH and all providers reported being willing to use or (re-)consider telehealth HIV care services in the future. Providers suggested that telehealth is most suitable for routine HIV care encounters and for established, clinically stable, generally healthy PWH. Attitudes toward telehealth were heterogeneous, with most interviewees valuing telehealth similarly or superior to in-person care, yet >20% perceiving it less valuable. Recommendations to improve telehealth included multilevel strategies to address challenges across four domains: technology, the virtual nature of telehealth, administrative processes, and the sociodemographic profile of PWH. Telehealth in HIV care is here to stay; however, it may not yet be suitable for all PWH and all care encounters. Decision processes related to telehealth versus in-person care need to involve providers and PWH. Existing telehealth options require multilevel adjustments addressing persistent challenges.

The impact of COVID-19 on the HIV continuum of care: challenges, innovations, and opportunities

INTRODUCTION

In February 2019, the United States (US) launched the Ending the HIV Epidemic (EHE) initiative with emphasis on improving the various steps of the Human Immunodeficiency Virus (HIV) prevention and care continuum. However, in March 2020, the Coronavirus Disease 2019 (COVID-19) pandemic was declared, curtailing efforts to end the epidemic in the US.

AREAS COVERED

To describe the impact of the pandemic on EHE in the US, the authors performed a comprehensive literature review focusing on outcomes at each step of the HIV care continuum. Simultaneously, they identified examples of pandemic-era innovations that may help EHE.

EXPERT OPINION

Numerous studies demonstrated pandemic-related disruptions across the care continuum as well as the impact on preexisting barriers to care among People with HIV (PWH) at higher risk for poor outcomes. As the pandemic progressed, innovative approaches to delivering healthcare and providing essential services emerged, including widespread use of telemedicine, expansion of home-based care, self-collected sexually transmitted infection (STI) and HIV testing, and co-located testing for COVID-19 and HIV/STIs. While the COVID-19 pandemic initially hindered achieving EHE in the US, the ability to be agile, flexible, and creative led to innovation in HIV care delivery that may ultimately assist in meeting EHE goals as we transition into the post-pandemic era.

How the COVID-19 Pandemic Influenced HIV Care: Are We Prepared Enough for Future Pandemics? An Assessment of Factors Influencing Access, Utilization, Affordability, and Motivation to Engage with HIV Services amongst African, Caribbean, and Black Women

The COVID-19 pandemic resulted in disruption in healthcare delivery for people living with human immunodeficiency virus (HIV). African, Caribbean, and Black women living with HIV (ACB WLWH) in British Columbia (BC) faced barriers to engage with HIV care services prior to the COVID-19 pandemic that were intensified by the transition to virtual care during the pandemic. This paper aims to assess which factors influenced ACB WLWH's access to, utilization and affordability of, and motivation to engage with HIV care services. This study utilized a qualitative descriptive approach using in-depth interviews. Eighteen participants were recruited from relevant women's health, HIV, and ACB organizations in BC. Participants felt dismissed by healthcare providers delivering services only in virtual formats and suggested that services be performed in a hybrid model to increase access and utilization. Mental health supports, such as support groups, dissolved during the pandemic and overall utilization decreased for many participants. The affordability of services pertained primarily to expenses not covered by the provincial healthcare plan. Resources should be directed to covering supplements, healthy food, and extended health services. The primary factor decreasing motivation to engage with HIV services was fear, which emerged due to the unknown impact of the COVID-19 virus on immunocompromised participants.

Pandemic upon Pandemic: Middle-Aged and Older Men Who Have Sex with Men Living with HIV Coping and Thriving during the Peak of COVID-19

When the COVID-19 pandemic emerged in early 2020, not only did it abruptly impede the progress that was being made toward achieving global targets to end the HIV pandemic, but it also created significant impacts on the physical and mental health of middle-aged and older men who have sex with men living with HIV. Utilizing a qualitative, community-based participatory research approach, we conducted semi-structured, one-on-one interviews with 16 ethnoracially diverse, middle-aged and older men who have sex with men living with HIV residing in Southern Nevada, to examine the different ways the COVID-19 pandemic directly impacted their physical and mental health, and explore how they eventually coped and thrived during the peak of the crisis. Using thematic analysis to analyze our interview data, we identified three prominent themes: (1) challenges to obtaining credible health information, (2) the physical and mental health impacts of the COVID-19-pandemic-imposed social isolation, and (3) digital technologies and online connections for medical and social purposes. In this article, we extensively discuss these themes, the current discourse on these themes in academic literature, and how the perspectives, input, and lived experiences of our participants during the peak of the COVID-19 pandemic could be critical to addressing issues they had already been experiencing prior to the emergence of the pandemic in 2020, and just as importantly, helping us best prepare in stark anticipation of the next potentially devastating pandemic.

Measuring Retention in HIV Care in the First Year of the COVID-19 Pandemic: The Impact of Telehealth

It is unknown how the COVID-19 pandemic impacted traditional measures of retention in HIV care. We calculated six different retention measures at an urban HIV care clinic for two time periods: pre-pandemic, and during the first year of the COVID-19 pandemic, with and without inclusion of telehealth appointments. Spearman rank correlation was used to assess correlation between different measures of retention. For both the pre-pandemic and pandemic time periods, there was strong correlation among measures of missed visits (range 0.857-0.957). More patients were considered retained in care during the pandemic when telehealth appointments were included in the analysis.

Pragmatic randomized trial of a pre-visit intervention to improve the quality of telemedicine visits for vulnerable patients living with HIV

INTRODUCTION

The COVID-19 pandemic has required a shift of many routine primary care visits to telemedicine, potentially widening disparities in care access among vulnerable populations. In a publicly-funded HIV clinic, we aimed to evaluate a pre-visit phone-based planning intervention to address anticipated barriers to telemedicine.

METHODS

We conducted a pragmatic randomized controlled trial of patients scheduled for a phone-based HIV primary care visit at the Ward 86 HIV clinic in San Francisco from 15 April to 15 May 2020. Once reached by phone, patients were randomized to either have a structured pre-visit planning intervention to address barriers to an upcoming telemedicine visit versus a standard reminder call. The primary outcome was telemedicine visit attendance.

RESULTS

Of 476 scheduled telemedicine visits, 280 patients were reached by a pre-visit call to offer enrollment. Patients were less likely to be reached if virally unsuppressed (odds ratio (OR) 0.11, 95% confidence intervals (CI) 0.03-0.48), CD4 < 200 (OR 0.24, 95% CI 0.07-0.85), or were homeless (OR 0.24, 95% CI 0.07-0.87). There was no difference between intervention and control in scheduled visit attendance (83% v. 78%, OR 1.38, 95% CI 0.67-2.81).

CONCLUSIONS

A structured phone-based planning call to address barriers to telemedicine in a public HIV clinic was less likely to reach patients with poorly-controlled HIV and patients experiencing homelessness, suggesting additional interventions may be needed in this population to ensure access to telemedicine-based care. Among patients reachable by phone, telemedicine visit attendance was high and not improved with a structured pre-visit intervention, suggesting that standard reminders may be adequate in this population.

Does telehealth affect the adherence to ART among patients with HIV? A systematic review and meta-analysis

BACKGROUND

Several studies have shown different effects of telehealth interventions on adherence to Antiretroviral therapy (ART) among people living with HIV. This study conducted a meta-analysis of Randomized Controlled Trials (RCTs) to estimate the pooled effect of telehealth interventions on the treatment adherence of HIV patients.

METHODS

The researchers conducted literature searches in Scopus, PubMed, Web of Science, Google Scholar, and Cochrane Central Register of Controlled Trials databases. In addition, open grey was systematically searched until January 2022 for RCTs around the effects of telehealth on adherence to treatment ART among patients with HIV. Each study's methodological quality was assessed using the Cochrane Collaboration tool. Pooled Standard Mean Differences (SMD) and Risk Ratio (RR) with 95% CI were calculated using the random effects model.

RESULTS

In total, 12 eligible articles were considered in the present systematic review. A random-effects meta-analysis using 5 RCTs yielded the pooled RR estimate of 1.18 (95% CI: 1.03 to 1.35, p < 0.05); I2 = 0, suggesting the adherence to treatment among patients with HIV who received telehealth intervention was significantly 18% upper than control groups. Moreover, the random effects analysis of SMD showed a positive effect for telehealth with SMR = 0.36 (95% CI: 0.22 to 0.49, p < 0.05); I2 = 91.9%, indicating that telehealth intervention increased ART adherence to the treatment group compared to the control group.

CONCLUSION

Telehealth intervention as a new modality of health care service delivery could be a valuable strategy to improve ART adherence among patients with HIV. It can strengthen the capacity of HIV care services. On a large scale, telehealth can be utilized as a supplementary component for ART delivery and retention toward successful adherence to the therapy.

Health literacy mediates the effects of educational attainment on online pharmacy navigation skills in older adults with HIV disease

ObjectiveThe Internet serves an increasingly critical role in health behaviors for older adults with chronic medical conditions. Guided by theories of health behaviors and literacy, this study examined whether the relationship between educational attainment and online pharmacy skills in older persons with HIV disease (PWH) is mediated by health literacy. Design: Participants included 98 PWH age 50 and older who completed the Test of Online Pharmacy Skills (TOPS), which required them to navigate an experimenter-controlled online pharmacy to perform several naturalistic tasks (e.g., refill an existing prescription). Participants also completed the Medication-Management Test-Revised (MMT-R). Results: Mediation analyses revealed a significant indirect effect of education on both online pharmacy accuracy and MMT-R, which was fully mediated by health literacy. In contrast, there was no direct or indirect effect of education on online pharmacy speed when health literacy was included as a mediator. Conclusion: Health literacy plays an important role in the relationship between years of education attained and the ability of older PWH to successfully navigate online pharmacy tasks and manage their medications. Future studies might examine whether interventions to improve electronic health literacy among older PWH who have lower educational attainment have beneficial effects on online health behaviors.

Telemedicine Use Among People With HIV in 2021: The Hybrid-Care Environment

BACKGROUND

Telemedicine use for the care of people with HIV (PWH) significantly expanded during the COVID-19 pandemic. During 2021, vaccine uptake increased and patients were encouraged to resume in-person care, resulting in a mixture of in-person and telemedicine visits. We studied how different patient populations used telemedicine in this hybrid-care environment.

METHODS

Using observational data from patients enrolled in the Johns Hopkins HIV Clinical Cohort, we analyzed all in-person and telemedicine HIV primary care visits completed in an HIV clinic from January 1st, 2021, to December 31st, 2021. We used log-binomial regression to investigate the association between patient characteristics and the probability of completing a telemedicine versus in-person visit and the probability of completing a video versus telephone visit.

RESULTS

A total of 5518 visits were completed by 1884 patients; 4282 (77.6%) visits were in-person, 800 (14.5%) by phone, and 436 (7.9%) by video. The relative risk (RR) of completing telemedicine vs. in-person visits was 0.65 (95% Confidence Interval (CI): 0.47, 0.91) for patients age 65 years or older vs. age 20-39 years; 0.84 (95% CI: 0.72, 0.98) for male patients vs. female patients; 0.81 (95% CI: 0.66, 0.99) for Black vs. White patients; 0.62 (95% CI: 0.49, 0.79) for patients in the highest vs. lowest quartile of Area Deprivation Index; and 1.52 (95% CI: 1.26, 1.84) for patients >15 miles vs. <5 miles from clinic.

CONCLUSIONS

In the second year of the pandemic, overall in-person care was used more than telemedicine and significant differences persist across subgroups in telemedicine uptake.

Project T-SHARP: study protocol for a multi-site randomized controlled trial of tele-harm reduction for people with HIV who inject drugs

BACKGROUND

The resurgence of HIV outbreaks and rising prevalence among people who inject drugs (PWID) remain exigent obstacles to Ending the HIV Epidemic in the USA. Adapting a low threshold, comprehensive treatment model for PWID with HIV can leverage syringe services programs (SSPs) to increase availability and accessibility of antiretrovirals (ART), medications for opioid use disorder (MOUD), and hepatitis C cure. We developed Tele-Harm Reduction, a telehealth-enhanced, harm reduction intervention delivered within an SSP venue.

METHODS

The T-SHARP trial is an open-label, multi-site, randomized controlled superiority trial with two parallel treatment arms. Participants (n=240) recruited from SSPs in Miami, Ft. Lauderdale, and Tampa, Florida, who are PWID with uncontrolled HIV (i.e., HIV RNA>200) will be randomized to Tele-Harm Reduction or off-site linkage to HIV care. The primary objective is to compare the efficacy of Tele-Harm Reduction for initiation of ART at SSPs vs. off-site linkage to an HIV clinic with respect to viral suppression across follow-up (suppression at 3, 6, and 12 months post randomization). Participants with HIV RNA<200 copies/ml will be considered virally suppressed. The primary trial outcome is time-averaged HIV viral suppression (HIV RNA <200 copies/ml) over 3-, 6-, and 12-month follow-up. Secondary outcomes include initiation of MOUD measured by urine drug screen and HCV cure, defined as achieving 12-week sustained virologic response (negative HCV RNA at 12 weeks post treatment completion). A cost-effectiveness analysis will be performed.

DISCUSSION

The T-SHARP Trial will be the first to our knowledge to test the efficacy of an innovative telehealth intervention with PWID with uncontrolled HIV delivered via an SSP to support HIV viral suppression. Tele-Harm Reduction is further facilitated by a peer to support adherence and bridge the digital divide. This innovative, flipped healthcare model sets aside the traditional healthcare system, reduces multi-level barriers to care, and meets PWID where they are. The T-SHARP trial is a pragmatic clinical trial that seeks to transform the way that PWID access HIV care and improve HIV clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05208697. Trial registry name: Tele-Harm Reduction. Registration date: January 26, 2022.

COVID-19, Retention in HIV Care, and Access to Ancillary Services for Young Black Men Living with HIV in Chicago

This study conducted 28 semi-structured, in-depth interviews with Young Black Men who have Sex with Men in Chicago to investigate the impact of COVID-19 on their HIV care and ancillary service access. The qualitative analysis identified both negative and positive effects. The negative effects included: (l) mixed disruptions in linkage to and receipt of HIV care and ancillary services, and (2) heightened concerns about police and racial tensions in Chicago following the murder of George Floyd, contributing to possible disruption of retention in care. The positive effects included: (1) the ability to reflect and socially connect, contributing to heightened self-care and retention in care, and (2) some improvements in receipt of medical care. These findings suggest that while COVID-19 disruptions in care reduced in-person use of HIV care, the expansion of telemedicine allowed more administrative tasks to be handled online and focused in-person interactions on more substantive interactions.

Concurrent validity and reliability of at-home teleneuropsychological evaluations among people with and without HIV

OBJECTIVE

To determine the reliability of teleneuropsychological (TNP) compared to in-person assessments (IPA) in people with HIV (PWH) and without HIV (HIV-).

METHODS

Participants included 80 PWH (Mage = 58.7, SDage = 11.0) and 23 HIV- (Mage = 61.9, SDage = 16.7). Participants completed two comprehensive neuropsychological IPA before one TNP during the COVID-19 pandemic (March-December 2020). The neuropsychological tests included: Hopkins Verbal Learning Test-Revised (HVLT-R Total and Delayed Recall), Controlled Oral Word Association Test (COWAT; FAS-English or PMR-Spanish), Animal Fluency, Action (Verb) Fluency, Wechsler Adult Intelligence Scale 3rd Edition (WAIS-III) Symbol Search and Letter Number Sequencing, Stroop Color and Word Test, Paced Auditory Serial Addition Test (Channel 1), and Boston Naming Test. Total raw scores and sub-scores were used in analyses. In the total sample and by HIV status, test-retest reliability and performance-level differences were evaluated between the two consecutive IPA (i.e., IPA1 and IPA2), and mean in-person scores (IPA-M), and TNP.

RESULTS

There were statistically significant test-retest correlations between IPA1 and IPA2 (r or ρ = .603-.883, ps < .001), and between IPA-M and TNP (r or ρ = .622-.958, ps < .001). In the total sample, significantly lower test-retest scores were found between IPA-M and TNP on the COWAT (PMR), Stroop Color and Word Test, WAIS-III Letter Number Sequencing, and HVLT-R Total Recall (ps < .05). Results were similar in PWH only.

CONCLUSIONS

This study demonstrates reliability of TNP in PWH and HIV-. TNP assessments are a promising way to improve access to traditional neuropsychological services and maintain ongoing clinical research studies during the COVID-19 pandemic.

Telehealth Interventions for HIV in Low- and Middle-Income Countries

PURPOSE OF REVIEW

This review summarizes technology-based interventions for HIV in low- and middle-income countries (LMICs). We highlight potential benefits and challenges to using telehealth in LMICs and propose areas for future study.

RECENT FINDINGS

We identified several models for using telehealth to expand HIV health care access in LMICs, including telemedicine visits for pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) services, telementoring programs for providers, and virtual peer-support groups. Emerging data support the acceptability and feasibility of these strategies. However, further investigations are needed to determine whether these models are scalable and sustainable in the face of barriers related to cost, infrastructure, and regulatory approval. HIV telehealth interventions may be a valuable approach to addressing gaps along the HIV care cascade in LMICs. Future studies should focus on strategies for expanding existing programs to scale and for assessing long-term clinical outcomes.

Impact of COVID-19 on HIV services and anticipated benefits of vaccination in restoring HIV services in Ethiopia: A qualitative assessment

Background

HIV services were inevitably disrupted and affected due to COVID-19. There are many challenges in implementing appropriate HIV services, particularly in the provision of health care and the link between people living with HIV/AIDS and retention in care. The study investigated the impact of COVID-19 on HIV services and the anticipated benefit of the COVID-19 vaccination on HIV service restoration in North Shewa, Oromia, Ethiopia.

Methods

A qualitative descriptive study approach was used to explore how healthcare delivery evolved during the outbreak of COVID-19 in Ethiopia. Sixteen antiretroviral therapy (ART) clinics were selected from 13 districts and one administrative town in Ethiopia. From them, 32 ART providers were purposively selected based on their experience in ART provision. Data were collected from June to July 2021 using in-depth interviews. A thematic analysis approach was used to analyze the data, based on themes and subthemes emerging from the data. ATLAS.ti software was used for coding.

Results

Healthcare for people living with HIV was interrupted due to the COVID-19 pandemic. Medical appointments, HIV testing and counseling services, opportunistic infection treatment, medicine supply, and routine viral load and CD₄ T-cell count tests were interrupted. Due to a shortage of healthcare staff, outreach testing services and home index testing were discontinued and HIV testing was limited only to hospitals and health centers. This has substantially affected accessibility to HIV testing and reduced the quality of HIV service delivery. Telehealth and less frequent visits to health facilities were used as alternative ways of delivering HIV services. The COVID-19 vaccination campaign is expected to restore healthcare services. Vaccination may also increase the confidence of healthcare providers by changing their attitudes toward COVID-19.

Conclusions

The COVID-19 pandemic has substantially impacted HIV services and reduced the quality of HIV care in Ethiopia. Health facilities could not provide routine HIV services as they prioritize the fight against COVID-19, leading to an increase in service discontinuation and poor adherence.

"When you have an immune disease like HIV and there is a pandemic, you still have to pay your bills": COVID-19-related challenges among people living with HIV and lessons for care delivery

COVID-19 has disrupted routine medical care and increased psychosocial and economic stressors on a global scale, yet the full impact on people living with HIV (PLWH) and the HIV continuum of care remains unknown. As the pandemic continues to pose a significant threat to PLWH and their care, this research qualitatively aimed to elicit COVID-19-related challenges and perspectives of PLWH during the early phase of the pandemic and to identify lessons learned and impactful strategies for facilitating HIV care. We recruited 32 PLWH who receive care at a large academic medical center for semi-structured remote interviews to assess psychological/structural stressors experienced during the pandemic and to discern strategies for improving care. Most participants identified as Black (91%) and heterosexual (56%). Overall, PLWH reported exacerbated mental health stressors (e.g., anxiety, depression, substance use). Most participants cited no issues with antiretroviral therapy (ART) adherence or retention in care, yet five participants reported appointment cancellations or physician inaccessibility. Participants provided specific feedback for facilitating continued engagement in care during the pandemic, including telemedicine and education/patient empowerment. By seeking participant-provided solutions, this study centered on PLWH's experiences and emphasized proactive HIV care strategies for prioritizing patient empowerment and healthcare adaptability during a rapidly evolving pandemic.

Response of Care Services for Patients with HIV/AIDS during a Pandemic: Perspectives of Health Staff in Bolivia

The COVID-19 pandemic has caused an unprecedented crisis striking health services, generating risks of setbacks in health care and affecting the most vulnerable populations such as HIV patients. This study aims to explore the impact of the COVID-19 pandemic on the operational management of health services for people living with HIV/AIDS in Cochabamba, Bolivia. We applied a qualitative approach using semi-structured in-depth interviews with ten key health professionals who care for patients with HIV/AIDS in Cochabamba, Bolivia. Interviews were transcribed verbatim and uploaded to Atlas.ti software for analysis. We used an ethnographic approach within the interpretive paradigm to carry out the thematic analysis, considering the "Determinants of health systems resilience framework" of five dimensions developed by the World Health Organization. Even though the provision of services in public care services was not interrupted during the COVID-19 pandemic, health service delivery was severely affected. Digital technology could be used to compensate in urban areas. Regarding the distribution of medications, adaptative strategies to reduce patient complications were implemented. Unfortunately, the complementary tests availability was limited. The COVID-19 pandemic had a significant impact on HIV/AIDS patient care services in Cochabamba, with repercussions for HIV treatment access and virologic suppression.

Experiences of Migrant People Living with HIV in a Multidisciplinary HIV Care Setting with Rapid B/F/TAF Initiation and Cost-Covered Treatment: The 'ASAP' Study

This study aimed to explore the experiences of migrant people living with HIV (MLWH) enrolled in a Montreal-based multidisciplinary HIV care clinic with rapid antiretroviral treatment (ART) initiation and cost-covered ART. Between February 2020 and March 2022, 32 interviews were conducted with 16 MLWH at three time-points (16 after 1 week of ART initiation, 8 after 24 weeks, 8 after 48 weeks). Interviews were analyzed via the Framework Method. Thirty categories were identified, capturing experiences across the HIV care cascade. At diagnosis, most MLWH described "initially experiencing distress". At linkage, almost all MLWH discussed "navigating the health system with difficulty". At treatment initiation, almost all MLWH expressed "being satisfied with treatment", particularly due to a lack of side effects. Regarding care retention, all MLWH noted "facing psychosocial or health-related challenges beyond HIV". Regarding ART adherence, most MLWH expressed "being satisfied with treatment" with emphasis on their taking control of HIV. At viral suppression, MLWH mentioned "finding more peace of mind since becoming undetectable". Regarding their perceived health-related quality of life, most MLWH indicated "being helped by a supportive social network". Efficient, humanizing, and holistic approaches to care in a multidisciplinary setting, coupled with rapid and free ART initiation, seemed to help alleviate patients' concerns, address their bio-psycho-social challenges, encourage their initial and sustained engagement with HIV care and treatment, and ultimately contribute to positive experiences.

HIV Care Meets Telehealth: a Review of Successes, Disparities, and Unresolved Challenges

Purpose of Review

This review summarizes the current state of telehealth utilization in HIV care delivery by highlighting successes, gaps, and unresolved challenges related to access, disparities, care providers in and standardization of policies and protocol.

Recent Findings

Telehealth adoption in HIV care delivery in the USA has been successful. Despite this success, racial minority groups, older adults, and individuals with low telehealth literacy report low preference, dissatisfaction, and experience poorer health outcomes than other groups. Lack of broadband access, compatible devices, standardization, and government regulations of telehealth in HIV care contribute to poor patient-provider experience and utilization.

Summary

Telehealth remains a valuable tool in HIV care. However, disparities exist in access and health outcomes. Telehealth literacy, broadband access, protecting patients’ data, policies, and standardized protocols are critical in sustaining telehealth for HIV care. Further research is needed on preferences and how specific telehealth platforms influence HIV treatment outcomes.

COVID-19 Telemedicine and Vaccination at an Urban Safety Net HIV Medicine Clinic

In response to the emerging coronavirus disease 2019 (COVID-19) pandemic in March 2020, the Owen Clinic at UC San Diego Health scaled up telemedicine to ensure the continuity of human immunodeficiency virus primary care. A group of nurse practitioners, physicians, and a physician assistant developed a dedicated COVID-19 telemedicine clinic to provide virtual health care services to patients with or at risk for severe acute respiratory syndrome coronavirus 2 infection. This effort contributed to successful health outcomes for the clinic's 476 patients diagnosed with COVID-19. The Owen Clinic was also the first ambulatory clinic within UC San Diego Health to implement on-site COVID-19 vaccines. Nurse practitioners and a physician assistant spearheaded these 2 clinical initiatives.

Competing health risks associated with the COVID-19 pandemic and early response: A scoping review

BACKGROUND

COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats.

OBJECTIVES

We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

METHODS

A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from November 1st, 2019 to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

RESULTS

A total of 1604 published papers and 205 preprints were retrieved in the search. Overall, 8.0% (129/1604) of published studies and 10.2% (21/205) of preprints met the inclusion criteria and were included in this review: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (19/183) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

DISCUSSION

COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

Adaption of an ongoing clinical trial to quickly respond to gaps in changing international recommendations: the experience of D2EFT

A rapidly changing landscape of antiretrovirals and their procurement at scale has permitted the evaluation of new optimised second-line antiretroviral therapy (ART) in low- and middle-income countries. D²EFT is an open-label randomised controlled non-inferiority phase IIIB/IV trial in people living with HIV-1 (PWH) whose first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART is failing. At inception, it compared a standard of care of boosted darunavir with two nucleos(t)ide reverse transcriptase inhibitors (NRTIs) to the novel NRTI-sparing regimen of boosted darunavir with dolutegravir. Implemented in 2017, participating sites were across Africa, Asia and Latin America. Around the time of implementation, the World Health Organization updated its treatment guidelines and recommended scaling up tenofovir disoproxil fumarate-lamivudine-dolutegravir (TLD). This situation pushed D²EFT investigators to consider the impact of the roll-out of TLD on the D²EFT research question. The protocol team agreed it was important to study TLD in second-line when an NNRTI regimen was failing, and focused on options to expedite the work by studying the question within the existing trial and network. All key issues (statistical, programmatic and financial) were reviewed to assess the benefits and risks of adding a third arm to the ongoing study, as opposed to developing a new randomised clinical trial with the same control arm and within the same network. The development of a new trial was deemed to be longer than adding a third arm, and to create a challenging situation with two competing clinical trials at the same sites which would slow down recruitment and impair both trials. On the other hand, adding a third arm would be demanding in terms of operationalisation, increased sample size and statistical biases to control. The optimal strategy was deemed to be the addition of a third arm, arriving retrospectively at a simplified multi-arm multi-stage clinical trial design to achieve statistical validity. The D²EFT study maintains additional value in a quickly evolving second-line ART strategy allowed by the progress in global access to ART.

Utility and Impact of the Implementation of Same-Day, Self-administered Electronic Patient-Reported Outcomes Assessments in Routine HIV Care in two North American Clinics

The PROgress study assessed the value and feasibility of implementing web-based patient-reported outcomes assessments (PROs) within routine HIV care at two North American outpatient clinics. People with HIV (PWH) completed PROs on a tablet computer in clinic before their routine care visit. Data collection included PROs from 1632 unique PWH, 596 chart reviews, 200 patient questionnaires, and 16 provider/staff questionnaires. During an initial setup phase involving 200 patients, PRO results were not delivered to providers; for all subsequent patients, providers received PRO results before the consultation. Chart review demonstrated that delivery of PRO results to providers improved patient-provider communication and increased the number of complex health and behavioral issues identified, recorded, and acted on, including suicidal ideation (88% with vs 38% without PRO feedback) and anxiety (54% with vs 24% without PRO feedback). In post-visit questionnaires, PWH (82%) and providers (82%) indicated that the PRO added value to the visit.

HealthCall: A randomized trial assessing a smartphone enhancement of brief interventions to reduce heavy drinking in HIV care

INTRODUCTION

Heavy drinking among people living with HIV (PLWH) worsens their health outcomes and disrupts their HIV care. Although brief interventions to reduce heavy drinking in primary care are effective, more extensive intervention may be needed in PLWH with moderate-to-severe alcohol use disorder. Lengthy interventions are not feasible in most HIV primary care settings, and patients seldom follow referrals to outside treatment. Utilizing visual and video features of smartphone technology, we developed the "HealthCall" app to provide continued engagement after brief intervention, reduce drinking, and improve other aspects of HIV care with minimal demands on providers. We conducted a randomized trial of its efficacy.

METHODS

The study recruited alcohol-dependent PLWH (n = 114) from a large urban HIV clinic. Using a 1:1:1 randomized design, the study assigned patients to: Motivational Interviewing (MI) plus HealthCall (n = 39); NIAAA Clinician's Guide (CG) plus HealthCall (n = 38); or CG-only (n = 37). Baseline MI and CG interventions took ~25 min, with brief (10-15 min) 30- and 60-day booster sessions. HealthCall involved daily use of the smartphone app (3-5 min/day) to report drinking and health in the prior 24 h. Outcomes assessed at 30 and 60 days and at 3, 6 and 12 months included drinks per drinking day (DpDD; primary outcome) and number of drinking days, analyzed with generalized linear mixed models and pre-planned contrasts.

RESULTS

Study retention was excellent (85%-94% across timepoints). At 30 days, DpDD among patients in MI + HealthCall, CG + HealthCall, and CG-only was 3.80, 5.28, and 5.67, respectively; patients in MI + HealthCall drank less than CG-only and CG + HealthCall (IRRs = 0.62, 95% CI = 0.46, 0.84, and 0.64, 95% CI = 0.48, 0.87, respectively). At 6 months (end-of-treatment), DpDD was lower in CG + HealthCall (DpDD = 4.88) than MI + HealthCall (DpDD = 5.88) or CG-only (DpDD = 6.91), although these differences were not significant. At 12 months, DpDD was 5.73, 5.31, and 6.79 in MI + HealthCall, CG + HealthCall, and CG-only, respectively; DpDD was significantly lower in CG + HealthCall than CG-only (IRR = 0.71, 95% CI = 0.51, 0.98).

CONCLUSIONS

During treatment, patients in MI + HealthCall had lower DpDD than patients in other conditions; however, at 12 months, drinking was lowest among patients in CG + HealthCall. Given the importance of drinking reduction and the low costs/time required for HealthCall, pairing HealthCall with brief interventions merits widespread consideration.

Challenges and opportunities of telehealth digital equity to manage HIV and comorbidities for older persons living with HIV in New York State

BACKGROUND

Older persons living with HIV (PLWH) need routine healthcare to manage HIV and other comorbidities. This mixed methods study investigated digital equity, constituted as access, use and quality, of HIV and specialty telehealth services for PLWH > 50 years during the initial wave of the COVID-19 pandemic when services transitioned to remote care.

METHODS

A survey of closed and open-ended questions was administered to 80 English (N = 63) and Spanish (N = 17) speaking PLWH receiving HIV care at an Academic Medical Center (N = 50) or a Federally Qualified Health Center (N = 30) in New York State. Quantitative analyses examined characteristics predicting telehealth use and visit quality. Qualitative analyses utilized thematic coding to reveal common experiences. Results were integrated to deepen the interpretation.

RESULTS

Telehealth access and use were shaped by multiple related and unstable factors including devices and connectivity, technology literacy, and comfort including privacy concerns. Participants demonstrated their substantial effort to achieve the visit. The majority of patients with a telehealth visit perceived it as worse than an in-person visit by describing it as less interpersonal, and resulting in poorer outcomes, particularly participants with less formal education. Technology was not only a barrier to access, but also influenced perceptions of quality.

CONCLUSIONS

In the COVID-19 pandemic initial wave, barriers to using telehealth were unequally distributed to those with more significant access and use challenges. Beyond these barriers, examining the components of equity indicate further challenges replicating in-person care using telehealth formats for older PLWH. Work remains to establish telehealth as both equitable and desirable for this population.

Patient Experiences with Telemedicine for HIV Care During the First COVID-19 Wave in Atlanta, Georgia

We explored experiences with telemedicine among persons with HIV (PWH) during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. A convenience sample of adults (>18 years) receiving care in an urban clinic in Atlanta were invited to participate. Patients completed a structured survey that assessed the usefulness, quality, satisfaction, and concerns with telemedicine services (telephone calls) received during the first wave of the COVID-19 pandemic (March-May 2020). Demographic, plasma HIV-1 RNA, and CD4⁺ T cell count data were obtained through medical chart abstraction. Bootstrapped t-tests and chi-square tests were used to examine differences in patient experiences by age, sex, and race. Of 406 PWH contacted, 101 completed the survey (median age 55 years, 84% men, 77% Black, 98% virally suppressed, median CD4 count 572 cells/μL). The main HIV care disruptions experienced were delays in follow-up visits (40%), difficulty getting viral load measured (35%), and difficulty accessing antiretroviral therapy (21%). Participant ratings for quality (median score 6.5/7), usefulness (median score 6.0/7), and satisfaction (median score 6.3/7) with telemedicine were high. However, 28% of patients expressed concerns about providers' ability to examine them and about the lack of laboratory tests. More women had concerns about providers' ability to examine them (92% vs. 50%, p = .005) and about the safety of their personal information (69% vs. 23%, p = .002) compared with men. No age or race differences were observed. Although PWH are generally satisfied with telephone-based telemedicine, concerns with its use were notable, particularly among women. Future HIV telemedicine models should address these.

Rapid, application-based survey to characterise the impacts of COVID-19 on LGBTQ+ communities around the world: an observational study

INTRODUCTION

Emerging evidence indicates that the COVID-19 pandemic, and the responses it has generated, have had disproportionate impacts on lesbian, gay, bisexual, transgender and queer (LGBTQ+) communities. This study seeks to build on existing information and provide regional insight.

METHODS

In response, a cross-sectional survey was administered to a global sample of LGBTQ+ individuals (n=13 358) between 16 April and 20 May 2020 via the social networking application Hornet. The survey contained questions that characterise the impact of COVID-19 and associated mitigation strategies on economics, employment, mental health and access to healthcare.

RESULTS

5191 (43.9%) individuals indicated they were somewhat, slightly or unable to meet basic needs with their current income, while 2827 (24.1%) and 4710 (40.1%) felt physically or emotionally unsafe in their living environment, respectively. 2202 individuals (24.7%) stated they are at risk for losing health insurance coverage. 2685 (22.7%) persons reported having skipped or cut meals as there was not enough money.

CONCLUSION

Many LGBTQ+persons who responded reported adverse consequences to mental health, economics, interruptions to care and lack of support from their government. This data is part of ongoing analyses but accentuates the unique needs of LGBTQ+ communities that will require targeted, ameliorative approaches.

eHealth supported multi-months dispensing of antiretroviral therapy: a mixed-methods preference assessment in rural Lesotho

BACKGROUND

Multi-month dispensing (MMD) of antiretroviral therapy (ART) represents one approach of differentiated service delivery (DSD) aiming to improve quality and cost-effectiveness for HIV services in resource-limited settings. However, reduction in clinic visits for people living with HIV (PLWH) should go along with out-of-clinic care tailored to PLWH`s preferences and comorbidities to maintain quality of care. eHealth supported MMD offers a potential solution.

METHODS

Between October 2019 and January 2020 we assessed preferences on an eHealth supported MMD package among adult PLWH attending routine ART care at a rural clinic in Lesotho using a mixed-methods approach. Participants reported their preferences among different refill and eHealth options. They were invited to test automated text messages (SMS) informing about their viral load results, an automated tuberculosis symptoms screening call and telemedical support by an expert nurse. Telemedical service comprised a call-back option if participants required any additional support and adherence counselling for closer follow-up of participants with unsuppressed viral loads. After 6 weeks, participants were followed-up to assess perception of the chosen eHealth support using a qualitative approach.

RESULTS

Among 112 participants (median age = 43 years; 74% female), 83/112 (75%) preferred MMD for 6-12 months (median = 9 months, IQR = [5, 12]). Neither sex, age, employment, costs and time for travel to clinic, nor the duration of taking ART correlated with the MMD preference. All 17 participants attending routine viral load measurement wished to receive the result via SMS. Fifteen (19.2%) participants requested a telemedical nurse call-back during the study period. All participants with recent unsuppressed viral load (N = 13) requested telemedical adherence counselling for closer follow-up. Among 78 participants followed-up, 76 (97%) would appreciate having the call-back option in future. Seventy-five participants (67%) received and evaluated the automated symptomatic tuberculosis screening call, overall 71 (95%) appreciated it.

CONCLUSIONS

The great majority of PLWH in this study preferred 6-12 months MMD and appreciated the additional eHealth support, including viral load results via SMS, telemedical nurse consultations and automated tuberculosis symptom screening calls. eHealth supported MMD packages appear to be a promising approach for DSD models and should be assessed for clinical endpoints and cost-effectiveness in larger studies.

Examining the Utility of the HIV Disability Questionnaire (HDQ) in Clinical Practice: Perspectives of People Living with HIV and Healthcare Providers

Our aim was to examine the utility of the HIV Disability Questionnaire (HDQ), a patient-reported outcome measure for use in clinical practice from the perspectives of people living with HIV (PLWH) and healthcare providers. We conducted a qualitative descriptive study. Fifteen PLWH and five healthcare providers participated in an interview, of which ten PLWH participated in a follow-up focus group discussion. The HDQ has value in clinical practice, including its role in assessing disability, facilitating communication, tailoring treatments, and guiding referrals. Strengths of the HDQ included its comprehensiveness, relevance of domains, and importance of specific items. Concerns related to length of the HDQ, the potential for some items to trigger emotional response, and negative connotations with the term ‘disability.’ Recommendations for HDQ implementation included the importance of score interpretability, shortening the questionnaire, and tailoring administration to the individual. Results suggest the HDQ possesses clinical utility with PLWH and healthcare providers.

HIV Patients’ Tracer for Clinical Assistance and Research during the COVID-19 Epidemic (INTERFACE): A Paradigm for Chronic Conditions

The health emergency linked to the SARS-CoV-2 pandemic has highlighted problems in the health management of chronic patients due to their risk of infection, suggesting the need of new methods to monitor patients. People living with HIV/AIDS (PLWHA) represent a paradigm of chronic patients where an e-health-based remote monitoring could have a significant impact in maintaining an adequate standard of care. The key objective of the study is to provide both an efficient operating model to “follow” the patient, capture the evolution of their disease, and establish proximity and relief through a remote collaborative model. These dimensions are collected through a dedicated mobile application that triggers questionnaires on the basis of decision-making algorithms, tagging patients and sending alerts to staff in order to tailor interventions. All outcomes and alerts are monitored and processed through an innovative e-Clinical platform. The processing of the collected data aims into learning and evaluating predictive models for the possible upcoming alerts on the basis of past data, using machine learning algorithms. The models will be clinically validated as the study collects more data, and, if successful, the resulting multidimensional vector of past attributes will act as a digital composite biomarker capable of predicting HIV-related alerts. Design: All PLWH > 18 sears old and stable disease followed at the outpatient services of a university hospital (n = 1500) will be enrolled in the interventional study. The study is ongoing, and patients are currently being recruited. Preliminary results are yielding monthly data to facilitate learning of predictive models for the alerts of interest. Such models are learnt for one or two months of history of the questionnaire data. In this manuscript, the protocol—including the rationale, detailed technical aspects underlying the study, and some preliminary results—are described. Conclusions: The management of HIV-infected patients in the pandemic era represents a challenge for future patient management beyond the pandemic period. The application of artificial intelligence and machine learning systems as described in this study could enable remote patient management that takes into account the real needs of the patient and the monitoring of the most relevant aspects of PLWH management today.

The impact of coronavirus disease 2019 on people with HIV

PURPOSE OF REVIEW

The COVID-19 pandemic materialized in 2020, the year the international community had expected to meet the interim targets to end AIDS by 2030. Forty years into the HIV pandemic, the COVID-19 pandemic challenges the achievements made in HIV and may even reverse some of them.

RECENT FINDINGS

This article provides an overview of the impact of COVID-19 on people with, and at risk of, HIV infection. It addresses where the global response to HIV was expected to be by 2020, analyzes the impact of COVID-19 on HIV-related outcomes and reviews the impact of HIV on COVID-19 related outcomes.

SUMMARY

The COVID-19 pandemic has had a profound impact on the response to HIV infection through disruption of prevention, testing, and access to antiretroviral treatment, as well as on the management of long-term HIV and mental health. This negative impact has been unequal throughout the world and across populations and deepens inequities in health. HIV does not increase Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) susceptibility once confounders are taken into account and inconsistencies are reported regarding its direct role on clinical severity. In post-COVID-19 scenarios, new models for HIV testing and care are likely to be consolidated. Monitoring responses needs high-quality epidemiological data and collaborative research.

The short-term effects of COVID-19 on HIV and AIDS control efforts among female sex workers in Indonesia

Background

The COVID-19 pandemic has raised concerns as to its impact on other health programs. One program that appears particularly vulnerable is HIV and AIDS. We undertook an assessment of COVID-19 impact on HIV control efforts in Indonesia for a sub-population that has received little attention in the global literature—female sex workers (FSW).

Methods

The study was undertaken in 23 National AIDS program priority districts. Four sources of monthly data during January–July 2020 were considered. COVID-19 infection data were extracted from national and district surveillance systems. Combination prevention program outputs were reported by civil society organizations (CSOs) providing community support services to FSW. These organizations also undertook monthly scans of levels of commercial sex activity and HIV testing availability. We also considered data from an ongoing HIV community screening trial. The primary mode of analysis entailed comparisons of levels and trends of indicators from the four data series.

Results

Commercial sex activity was severely curtailed in April–May in many districts. While recovering to pre-COVID-19 levels in “Localization” areas, the number of active FSW in July was one-third below that in February. HIV testing service availability declined by 50% at health facilities before recovering slowly, while mobile clinic services largely ceased during April–June. Numbers of FSW reached, condoms distributed, FSW tested for HIV, HIV cases detected, and FSW starting treatment all declined precipitously in April/May but had largely recovered to pre-COVID-19 levels by July. We found only a temporary dip in treatment initiation rates among HIV positive FSW and no discernible impact on treatment retention. The HIV community screening trial data revealed significant demand for HIV testing among FSW that was not being met even before the onset of COVID-19.

Conclusions

COVID-19 has had at least short-run economic effects on FSW and the national response to HIV and AIDS targeting FSW. However, the effects appear to have been cushioned by community-based services and support in study districts. The findings make a compelling case for the expansion of community-based services irrespective of the future trajectory of COVID-19. As COVID-19 has not yet been contained, the trajectory of economic activity and service delivery is uncertain.

HIV Care Access During the COVID-19 Pandemic as Perceived by Racial/Ethnic Minority Groups Served by the Ryan White Program, Miami-Dade County, Florida

The Ryan White Program (RWP) in Miami-Dade County, Florida made several modifications to keep HIV care accessible during the COVID-19 Pandemic, including expanding telehealth services, increasing access to HIV medications, and waiving required lab tests for service recertification. We assessed ease of access to medical providers, medical case managers, and antiretroviral medications during the COVID-19 Pandemic among 298 Non-Hispanic Black, Hispanic, and Haitian people with HIV (PWH) served by the RWP Part A, Miami-Dade County, Florida using a telephone-administered survey between October 2020 and January 2021. Overall, most clients reported similar or better access compared to before the Pandemic. Use of videocalls to communicate with HIV medical providers varied by race/ethnicity: Hispanics (49.6%), Non-Hispanic Blacks (37.7%), and Haitian clients (16.0%). Results suggest the modifications helped maintain access to care during an unprecedented health crisis. Permanently adopting many of these modifications should be considered to continue to facilitate access to care.

Competing Health Risks Associated with the COVID-19 Pandemic and Early Response: A Scoping Review

BACKGROUND

COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats.

OBJECTIVES

We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

METHODS

A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from January 1st to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

RESULTS

A total of 1604 published papers and 205 preprints met inclusion criteria, including 8.2% (132/1604) of published studies and 10.2% (21/205) of preprints: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (13/166) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

DISCUSSION

COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

Exploring the Social Impacts of the COVID-19 Pandemic on People Living with HIV (PLHIV): A Scoping Review

Understanding the clinical impact of COVID-19 has been central to emerging research in the HIV field, but in focusing on the biomedical, researchers must not overlook the socially embedded nature of HIV and the potential social impacts of this new pandemic on PLHIV. We conducted a scoping review to explore emerging research examining the social impacts of COVID-19 on PLHIV in OECD countries over the first 12 months of the pandemic. Twenty articles were identified and included for review. Key themes included: impacts on HIV care access/telehealth; stress and mental health; social isolation and loneliness; food insecurity; changes to sexual behaviour; changes to substance use; impacts on income, education and employment; and racial and social inequality. Results from this review can help guide research into areas where it is needed to help minimise the negative social impacts of the COVID-19 pandemic.

Telehealth for HIV Care Services in South Carolina: Utilization, Barriers, and Promotion Strategies During the COVID-19 Pandemic

To ensure continuing HIV care services during the COVID-19 pandemic, telehealth has been recommended and implemented in numerous HIV-related facilities. This study aims to understand telehealth utilization for HIV care services in South Carolina (SC), identify barriers to telehealth during COVID-19, and investigate strategies to facilitate remote HIV care delivery. In-depth interviews with 11 management personnel from 8 HIV-related facilities in SC were analyzed using thematic analysis. Utilizations of telehealth were diverse in delivering medical and non-medical HIV care services. Barriers included technological challenges, digital literacy, client/provider experiences, low socio-economic status of client population, and reimbursement issues. Various strategies were mentioned for promoting telehealth utilization, from client empowerment, provider training to improved organizational readiness. For successful telehealth use during and after COVID-19, it is necessary to continue efforts to promote telehealth and remove barriers to telehealth by implementing inclusive multi-level strategies for non-technologically savvy or disadvantaged populations living with HIV.

The HIV Treat Pillar: An Update and Summary of Promising Approaches

The Treat pillar of the Ending the HIV Epidemic in the U.S. plan calls for comprehensive strategies to enhance linkage to, and engagement in, HIV medical care to improve viral suppression among people with HIV and achieve the goal of 95% viral suppression by 2025. The U.S. has seen large increases in the proportion of people with HIV who have a suppressed viral load. Viral suppression has increased 41%, from 46% in 2010 to 65% in 2018. An additional increase of 46% is needed to meet the Ending the HIV Epidemic in the U.S. goal. The rate of viral suppression among those in care increased to 85% in 2018, highlighting the need to ensure sustained care for people with HIV. Greater increases in all steps along the HIV care continuum are needed for those disproportionately impacted by HIV, especially the young, sexual and racial/ethnic minorities, people experiencing homelessness, and people who inject drugs. Informed by systematic reviews and current research findings, this paper describes more recent promising practices that suggest an impact on HIV care outcomes. It highlights rapid linkage and treatment interventions; interventions that identify and re-engage people in HIV care through new collaborations among health departments, providers, and hospital systems; coordinated care and low-barrier clinic models; and telemedicine-delivered HIV care approaches. The interventions presented in this paper provide additional approaches that state and local jurisdictions can use to reach their local HIV elimination plans' goals and the ambitious Ending the HIV Epidemic in the U.S. Treat pillar targets by 2030.