Application of the Consolidated Framework for Implementation Research to Facilitate Violence Screening in HIV Care Settings: a Review of the Literature

Violence experience among cis-gender women living with HIV in Atlanta, Georgia: impact on HIV-related health and their preferences for violence screening and support

Introduction

People living with HIV (PLWH) experience multiple forms of violence at higher rates than the general population; however, research on experiences of violence among cis-gender women living with HIV (CWLH) mainly focuses on intimate partner violence (IPV), with inconsistent documentation across the literature. To begin improving trauma-informed practices in HIV care, we examined experiences of IPV, non-partner violence (NPV), hate crimes, and adverse childhood experiences (ACEs) among CWLH. We then explored experiences and preferences regarding violence screening and support services among CWLH.

Methods

As part of a larger study on violence experiences and screening among PLWH, 88 CWLH in Atlanta, Georgia, completed a cross-sectional survey on violence and mental health from February 2021 to December 2022 and provided consent for medical chart abstraction. A subgroup of 24 participants completed in-depth interviews on experiences and preferences related to violence screening. Univariate and bivariate analyses were used to assess violence prevalence and associations with mental health and chart-abstracted HIV outcomes. Thematic qualitative methods were employed for interview analysis.

Results

Every participant (100%) experienced at least one form of violence in their lifetime, which included IPV among partnered CWLH (83.33%), NPV (96.51%), hate crimes (85.23%), and ACEs (80.68%). More than half of the participants (61.36%) met diagnostic criteria for at least one mental health condition. Multiple forms of violence had high co-occurrence with post-traumatic stress disorder, depression, viral suppression, and retainment in HIV care. Qualitative analysis revealed that most interview participants had discussed violence or trauma with a healthcare professional before, reporting a mix of positive and uncomfortable experiences. Participants offered diverse perspectives on improving the violence screening process, including recommendations on how, where, by whom, when, and how frequently screenings should occur.

Conclusion

Multiple forms of violence are highly prevalent among CWLH, with several found to be associated with mental health and HIV outcomes. This highlights the necessity for a trauma-informed approach within HIV care settings. Healthcare professionals should consider the unique needs and preferences of CWLH when screening for violence and providing support services. Doing so may improve mental, physical, and overall well-being throughout the HIV care continuum.

Long-Term Outcomes of a Health Information System-Based Feedback Intervention Study of Antimicrobial Prescriptions in Primary Care Institutions: Follow-Up of a Randomized Cross-Over Controlled Trial

Purpose

To evaluate the long-term impacts of the feedback intervention on controlling inappropriate use of antimicrobial prescriptions in primary care institutions in China, as a continuation of the previous feedback intervention trial.

Methods

After the intervention ended, we conducted a 12-month follow-up study. The prescription data were collected from the baseline until the end of the follow-up period. The generalized estimation equation was employed to analyze the differences among four representative time points: at the baseline point, at 3 months, at 6 months, and at 18 months. The time-intervention interaction was utilized to evaluate the changing trends of group A and group B. Our primary outcome variable is the monthly inappropriate antimicrobial prescription rate (IAPR).

Results

After adjusting for covariates, the IAPRs in group A decreased by 1.00% on average from the baseline point to the 3 months, 5.00% from the 3 months to the 6 months, -0.92% from the 6 months to the 18 months, and 0.39% from the baseline point to the 18 months. During the corresponding four periods in group B, the average decline was 2.33%, 3.67%, -0.42%, and 0.72%, respectively. As for antimicrobial prescription rates (APRs), the average decline for group A was 1.33%, 3.67%, and 0.17% during the three periods: from the baseline point to the 3 months, from the 3 months to the 6 months, and from the 6 months to the 18 months, respectively. Accordingly in group B, the average decline was 1.00%, 3.67%, and 0.08%, respectively.

Conclusion

Our feedback intervention generated limited long-term impacts. Although the IAPRs and the APRs consistently remained below the baseline point, both rates experienced a rebound within a certain range following the stop of the intervention in the two groups. It is reasonable to think that the desired effects will be difficult to maintain without sustained implementation of feedback intervention.

The impact of intimate partner violence on PrEP adherence among U.S. Cisgender women at risk for HIV

BACKGROUND

Cisgender women account for 1 in 5 new HIV infections in the United States, yet remain under-engaged in HIV prevention. Women experiencing violence face risk for HIV due to biological and behavioral mechanisms, and barriers to prevention, such as challenges to Pre-Exposure Prophylaxis for HIV Prevention (PrEP) adherence. In this analysis, we aim to characterize intimate partner violence (IPV) among cisgender heterosexual women enrolled in a PrEP demonstration project and assess the associations with PrEP adherence.

METHODS

Adherence Enhancement Guided by Individualized Texting and Drug Levels (AEGiS) was a 48-week single-arm open-label study of PrEP adherence in HIV-negative cisgender women in Southern California (N = 130) offered daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC). From 6/2016 to 10/2018, women completed a survey reporting HIV risk behavior and experiences of any IPV (past 90-days) and IPV sub-types (past-year, lifetime) and biological testing for HIV/STIs at baseline, and concentrations of tenofovir-diphosphate (TFV-DP) in dried blood spots at weeks 4, 12, 24, 36, and 48. Outcomes were TFV-DP concentrations consistent with ≥ 4 or ≥ 6 doses/week at one or multiple visits. Multivariable logistic regression models were conducted to examine associations.

RESULTS

Past-90-day IPV was reported by 34.4% of participants, and past-year and lifetime subtypes reported by 11.5-41.5%, and 21.5-52.3%, respectively. Women who engaged in sex work and Black women were significantly more likely to report IPV than others. Lifetime physical IPV was negatively associated with adherence at ≥ 4 doses/week at ≥ 3 of 5 visits, while other relationships with any IPV and IPV sub-types were variable.

CONCLUSION

IPV is an indication for PrEP and important indicator of HIV risk; our findings suggest that physical IPV may also negatively impact long-term PrEP adherence.

CLINICAL TRIALS REGISTRATION

NCT02584140 (ClinicalTrials.gov), registered 15/10/2015.

Experiences of childhood, intimate partner, non-partner, and hate crime-related violence among a sample of people living with HIV in the epicenter of the U.S. HIV epidemic

Introduction

Experiences of violence among people living with HIV (PLWH) are thought to be highly prevalent but remain inadequately captured. As a first step toward acceptable, trauma informed practices that improve engagement and retention in care for PLWH, we must acquire more comprehensive understanding of violence experiences. We examined experiences of various forms of lifetime violence: adverse childhood experiences (ACES), intimate partner violence (IPV), non-partner violence (NPV), and hate crimes among diverse sample of PLWH in Atlanta, Georgia.

Methods

Cross sectional data collected from in- and out-of-care PLWH (N = 285) receiving care/support from Ryan White Clinics (RWCs), AIDS Service Organizations (ASOs), or large safety-net hospital, February 2021-December 2022. As part of larger study, participants completed interviewer-administered survey and reported on experiences of violence, both lifetime and past year. Participant characteristics and select HIV-related variables were collected to further describe the sample. Univariate and bivariate analyses assessed participant characteristics across types of violence.

Results

High prevalence of past violence experiences across all types (ACES: 100%, IPV: 88.7%, NPV: 97.5%, lifetime hate crimes 93.2%). People assigned male at birth who identified as men experienced more violence than women, with exception of non-partner forced sex. Participants identifying as gay men were more likely to have experienced violence.

Conclusion

Among our sample of PLWH at the epicenter of the United States HIV epidemic, histories of interpersonal and community violence are common. Findings emphasize need for RWCs, ASOs, and hospital systems to be universally trained in trauma-informed approaches and have integrated onsite mental health and social support services.

Implementation of trauma-informed care and trauma-responsive services in clinical settings: a latent class regression analysis

Introduction

Engagement and retention in health care is vital to sustained health among people living with HIV (PLWH), yet clinical environments can deter health-seeking behavior, particularly for survivors of interpersonal violence. PLWH face disproportionate rates of interpersonal violence; clinical interactions can provoke a re-experiencing of the sequalae of trauma from violence, called re-traumatization. Trauma-informed care (TIC) is a strengths-based approach to case that minimizes potential triggers of re-traumatization and promotes patient empowerment, increasing acceptability of care. Yet, Ryan White HIV/AIDS clinics, at which over 50% of PLWH received care, have struggled to IMPLEMENT TIC. In this analysis, we sought to (1) identify unique sub-groups of HIV clinics based on clinical attributes (i.e., resources, leadership, culture, climate, access to knowledge about trauma-informed care) and (2) assess relationships between sub-group membership and degree of implementation of TIC and trauma-responsive services offered.

Methods

A total of 317 participants from 47 Ryan White Federally-funded HIV/AIDS clinics completed a quantitative survey between December 2019 and April 2020. Questions included assessment of inner setting constructs from the Consolidated Framework for Implementation Research (CFIR), perceived level of TIC implementation, and trauma-responsive services offered by each respondent's clinic. We employed latent class analysis to identify four sub-groups of clinics with unique inner setting profiles: Weak Inner Setting (n = 124, 39.1%), Siloed and Resource Scarce (n = 80, 25.2%), Low Communication (n = 49, 15.5%), and Robust Inner Robust (n = 64, 20.2%). We used multilevel regressions to predict degree of TIC implementation and provision of trauma-responsive services.

Results

Results demonstrate that clinics can be distinctly classified by inner setting characteristics. Further, inner setting robustness is associated with a higher degree of TIC implementation, wherein classes with resources (Robust Inner Setting, Low Communication) are associated with significantly higher odds reporting early stages of implementation or active implementation compared to Weak class membership. Resourced class membership is also associated with availability of twice as many trauma-responsive services compared to Weak class membership.

Discussion

Assessment of CFIR inner setting constructs may reveal modifiable implementation setting attributes key to implementing TIC and trauma-responsive services in clinical settings. Introduction.

The REACH (Resiliency, Engagement, and Accessibility for Comorbid HIV/PTSD/SUD populations) Protocol: Using a Universal Screener to Improve Mental Health and Enhance HIV Care Outcomes

Among people living with HIV (PLWH), 50% report substance use disorders (SUDs), and 30-61% report posttraumatic stress disorder (PTSD). Comorbid PTSD/SUD/HIV has been linked to faster HIV progression and twice the rate of death, lower medical adherence and retention, and increased viral load compared to PLWH without co-occurring PTSD or SUD. A critical first step in establishing comprehensive mental health services for PLWH is the implementation of an evidence-based screening protocol for PTSD and SUDs to facilitate referrals to specialty mental health providers. Guided by the Consolidated Framework for Implementation Research, this mixed-methods study aimed to examine the feasibility of delivering the REACH (Resiliency, Engagement, and Accessibility for Comorbid HIV/PTSD/SUD populations) Screening protocol. Three case managers were instructed to provide the REACH screening electronically to all patients that they saw for enrollment or re-enrollment appointments over 3 months (n=102). Of the 70 patients who completed the screener, 27% had clinically significant PTSD symptoms and 48.6% had SUD concerns. Qualitative feedback revealed themes related to beliefs about SU and PTSD, attitudes toward screening, comfort in the discussion of SU and PTSD, and referral and treatment considerations. Discussion includes lessons learned for implementation of this assessment of PTSD/SUD in PLWH as a novel approach to increase mental health engagement and promote health equity, with the potential long-term impact of improving HIV care outcomes via ameliorating mental health/SUD, and implications for prevention of HIV transmission. Implementation science can be leveraged to understand the gap in the utilization of existing evidence-based screening tools in HIV care settings.

A scoping review of outer context constructs in dissemination and implementation science theories, models, and frameworks

Many studies have explored organizational factors that facilitate implementation. However, there is still a limited understanding of determinants external to the implementing organization and their effects on evidence-based intervention (EBI) adoption, implementation, and outcomes. The purpose of this scoping review was to assess definitions of context and identify salient determinants of outer context found in dissemination and implementation theories, models, and frameworks. We employed a compilation of dissemination and implementation frameworks from two reviews as the data source. We abstracted the following information: type of article, outcomes of the framework, presence of a context definition, presence of any outer setting definition and the definition, number and domains of outer setting mentioned, definitions of outer context constructs, and any quantitative measures of outer setting. We identified 19 definitions of outer context. Forty-seven (49%) frameworks reported one or more specific constructs of the outer setting. While the outer context domains described in the frameworks varied, the most common domains were policy (n = 24), community (n = 20), partnerships (n = 13), and communications (n = 12). Based on our review of the frameworks, more conceptualization and measurement development for outer context domains are needed. Few measures were found and definitions of domains varied across frameworks. Expanding outer context construct definitions would advance measure development for important factors external to the organizations related to EBI implementation.

Abuse in the Continua: HIV Prevention and Care Outcomes and Syndemic Conditions Associated with Intimate Partner Violence Among Black Gay and Bisexual Men in the Southern United States

Intimate partner violence (IPV) has been implicated in HIV acquisition and worse HIV outcomes. Limited research focuses on the experiences of Black gay and bisexual men. Using data from cross-sectional surveys in Baltimore, Maryland, and Jackson, Mississippi, we analyzed the association between IPV victimization and HIV-related outcomes among 629 adult Black gay and bisexual men, among whom 53% self-reported a negative result at last HIV test. 40% of participants reported lifetime physical, sexual, and/or psychological IPV victimization, and 24% past-year victimization. Recent and lifetime IPV were associated with recent clinical diagnosis of STI (adjPrR: 1.44; 95%CI: 1.08-1.92) and ART medication interruptions (adjPrR: 1.59; 95%CI: 1.25-2.01), respectively. Physical IPV was inversely associated with current PrEP use (adjPrR: 0.35; 95%CI: 0.13-0.90). Recent IPV was independently correlated with depression symptomatology (adjPrR: 2.36; 95%CI: 1.61-3.47) and hazardous alcohol use (adjPrR: 1.93; 95%CI: 1.42-2.61), with evidence of interactions. IPV-HIV relationships were intersected by internalized stigma, housing instability, poverty, and lack of insurance. Tailored IPV services are urgently needed for comprehensive HIV services for Black gay and bisexual men in the U.S.

Trauma-Informed HIV Care Interventions: Towards a Holistic Approach

PURPOSE OF REVIEW

The prevalence of trauma is higher among people living with HIV compared to the general population and people living without HIV. Trauma may be a major barrier in attaining HIV treatment outcomes, such as linkage to HIV care, engagement in HIV care, adherence to antiretroviral therapy (ART), and viral suppression. The purpose of this review was to highlight trauma-informed interventions that are geared towards improving treatment outcomes among people living with HIV.

RECENT FINDINGS

Recent studies suggest that a trauma-informed approach to developing interventions may help to improve treatment outcomes, such as engagement in care and adherence to ART. However, studies have also shown that depending on the operationalization of usual care, a trauma-informed approach may result in similar outcomes. Very few studies have examined the impact of trauma-informed interventions on HIV care and treatment outcomes. Additional research is needed on the acceptability, feasibility, and efficacy of trauma-informed interventions among affected populations such as older adults, and racial/ethnic and sexual minorities living with HIV.