Barriers to care for rural people living with HIV: a review of domestic research and health care models

Telehealth Challenges, Opportunities, and Policy Recommendations for Rural Older Adults Living with HIV in the United States

Over one million people in the United States (U.S.) are living with HIV. People living with HIV in the rural South experience delayed HIV treatment and increased mortality risks. Access challenges and HIV stigma exacerbate care disengagement for rural people living with HIV (PLH). This study examines the applicability and feasibility of telehealth to provide HIV care for older adults in the rural U.S. South. Semi-structured interviews were conducted with 27 key informants with expertise in HIV care and community engagement in high rural HIV burden states. Results indicate that telehealth challenges exist for older rural PLH to receive HIV care, such as lack of internet access and low technology literacy. Phone calls can be a simple and effective telehealth option for older rural PLH, as they align with their care preferences, mitigate care barriers, and show promise increasing care engagement. When warranted, complex telehealth options for older rural PLH require tailored approaches, such as portable medical instruments allowing real-time data sharing during home visits or tablet distribution from the clinic. Findings suggest that policy makers and providers support the reimbursement and use of audio-only telehealth services, expand broadband infrastructure and affordability in rural areas, and implement tailored telehealth interventions.

Who wants long-Acting injectable antiretroviral therapy? Treatment preferences among adults with HIV in Florida

Long-acting injectable (LAI) antiretroviral therapy (ART) is available to people with HIV (PWH), but it is unknown which PWH prefer this option. Using the Andersen Behavioral Model this study identifies characteristics of PWH with greater preference for LAI ART. Cross-sectional data from the Florida Cohort, which enrolled adult PWH from community-based clinics included information on predisposing (demographics), enabling (transportation, income), and need (ART adherence <90%) factors. ART preference was assessed via a single question (prefer pills, quarterly LAI, or no preference). Confounder-adjusted multinomial logistic regressions compared those who preferred pills to the other preference options, with covariates identified using directed acyclic graphs. Overall, 314 participants responded (40% non-Hispanic Black, 62% assigned male, 63% aged 50+). Most (63%) preferred the hypothetical LAI, 23% preferred pills, and 14% had no preference. PWH with access to a car (aRRR 1.97 95%CI 1.05-3.71), higher income (aRRR 2.55 95%CI 1.04-6.25), and suboptimal ART adherence (aRRR 7.41 95% CI 1.52-36.23) were more likely to prefer the LAI, while those who reported having no social network were less likely to prefer the LAI (aRRR 0.32 95% CI 0.11-0.88). Overall LAI interest was high, with greater preference associated with enabling and need factors.

Spatial distribution and factors associated with HIV testing among adolescent girls and young women in Sierra Leone

BACKGROUND

Sierra Leone faces a significant challenge in addressing HIV/AIDS, particularly among adolescent girls and young women. This age group is considered highly vulnerable due to biological factors and social inequalities. Understanding the prevalence of HIV testing in this demographic is crucial for designing effective prevention and treatment strategies. This study investigated the spatial distribution of HIV testing and its associated factors among adolescent girls and young women in Sierra Leone.

METHODS

Data from the 2019 Sierra Leone Demographic and Health Survey was used for the study. The sample comprised 6,062 adolescent girls and young women between the ages of 15 and 24. Spatial autocorrelation and Moran's I statistic were employed to analyze the spatial distribution of HIV testing. An analysis utilising mixed-effect multilevel binary logistic regression was performed to determine the factors associated with HIV testing. The findings were presented as adjusted odds ratios (aOR) and a 95% confidence interval (CI).

RESULTS

The national prevalence of HIV testing among adolescents and young women in Sierra Leone was 42.1% [40.3,43.9]. Kailahun, Kambia, Tonkolil, some parts of the Western rural area, and Bonthe districts were found to be statistically significant hotspot for HIV testing. Whereas, Karene, Falaba, Bo, kenema, and some parts of Pujuhun were statistically cold spot districts. Adolescent girls and young women aged 20-24 [aOR = 1.63, 95% CI = 1.29, 2.07] had higher odds of HIV testing than those aged 15-19. Those with secondary/higher education [aOR = 1.87, 95% CI = 1.40, 2.51] had higher odds of HIV testing than those with no education. The odds of HIV testing was higher among adolescent girls and young women who use the Internet [aOR = 1.75, 95% CI = 1.32, 2.33] than those who did not use internet. Adolescent girls and young women with one [aOR = 16.56, 95% CI = 12.31, 22.29] and two or more parity [aOR = 16.37, 95% CI = 10.86, 24.68] had higher odds of HIV testing than those with no parity. The likelihood of HIV testing was higher among adolescent girls and young women who had sex below 18 [aOR = 4.54, 95% CI = 3.25, 6.34] and those who had sex at 18+ [aOR = 5.70, 95% CI = 3.84, 8.45] compared to those who had never had sex. Adolescent girls and young women who visited health facilities in the past 12 months [aOR = 1.82, 95% CI = 1.46, 2.26] had higher odds of HIV testing than those who did not.

CONCLUSION

Despite some positive trends, HIV testing rates among adolescent girls and young women in Sierra Leone remain moderate. Spatial autocorrelation analysis consistently revealed hotspots and cold spots for HIV testing, with Kailahun, Kambia, Tonkolil, some parts of the Western rural area, and Bonthe districts remaining persistent hotspots. Age, education, internet use, sexual history, parity, and healthcare access are significant factors influencing testing behaviour. To improve testing rates, the government and policymakers should prioritize educational campaigns, expand internet access, integrate HIV testing into routine healthcare, and address stigma associated with HIV.

Perceived risks and benefits of telePrEP interventions: An interview study with rural sexual minority men in Texas

PURPOSE

Many rural areas lack brick-and-mortar HIV prevention resources despite the increasing rates of HIV. Although online HIV pre-exposure prophylaxis (PrEP) programs can potentially increase uptake among rural sexual minority men (SMM), their attitudes and preferences regarding telehealth-based PrEP (telePrEP) programming are uncertain. This qualitative study examined rural SMM's perceived risks and benefits of participating in a hypothetical telePrEP program.

METHODS

Twenty rural SMM living in Texas completed a semi-structured online videoconferencing interview between April 12 and June 14, 2023. Data were analyzed with reflexive thematic analysis.

FINDINGS

Four themes were constructed: (1) telePrEP interventions increase accessibility but completely online services might be inadequate; (2) telePrEP and mail-order interventions are convenient but face challenges; (3) telePrEP interventions need to address confidentiality and privacy within the context of the sociopolitical climate; and (4) telePrEP interventions need to address trustworthiness and transparency.

CONCLUSIONS

Overall, our results indicate that rural SMM perceive telePrEP interventions that provide at-home and telehealth PrEP, HIV testing, and HIV care services as beneficial. However, overall utility and acceptability depend on perceptions of privacy, confidentiality, trustworthiness, and transparency. Given the HIV prevention and treatment service deserts in which many rural SMM live, telePrEP interventions must purposefully demonstrate how their operations and data will remain safe and secure. Further work should explore contextual or situational factors that influence the willingness and acceptability of rural SMM to participate in online HIV prevention intervention research studies.

Characterizing long-acting injectable antiretroviral therapy eligibility and initiation at a safety net academic medical center in the southeastern United States

Background: Long-acting injectable (LAI) cabotegravir/rilpivirine (CAB/RPV) extends dosing intervals from daily to every 8 weeks. Equitable implementation requires anticipating and addressing barriers to use. We described LAI-CAB/RPV eligibility and initiation among persons with HIV (PWH) receiving care at a Southeastern US academic medical center. Methods: We included PWH ≥18 years, in care 01/01/2020-12/31/2021, and participating in the UNC CFAR HIV Clinical Cohort. We characterized LAI-CAB/RPV eligibility, compared those with and without recent detectable viral load (VL), and described clinical outcomes on LAI-CAB/RPV. Results: Among 1672 PWH, 425 (25.4%) had LAI-CAB/RPV drug-resistance. Among 1238 LAI-eligible PWH, 8.9% had detectable VL. Median age was 53 (interquartile range 40, 61), 54.6% were non-Hispanic Black, and 73.6% male. Over one-third lived >50 miles from clinic, one-fifth were uninsured, and 7.4% reported hazardous alcohol use. Gaps in care (prior 12-month) were more common among PWH with detectable VL versus suppressed (23.1% vs 13.9%, p = 0.03). 6/47 initiated LAI-CAB/RPV had detectable VL prior to injection; >95% sustained suppression and those with detectable VL had a rapid decline in viremia. Conclusions: Three-quarters of PWH were eligible for LAI-CAB/RPV, but equitable implementation may require addressing challenges such as distance to care, inconsistent care engagement, and other comorbid conditions, particularly for PWH with viremia.

A Qualitative Study of Transportation-Related Barriers to HIV Care in South Carolina

OBJECTIVES

Addressing structural barriers to care for people living with human immunodeficiency virus (HIV) in the southern United States is critical to increase rates of viral suppression and to reduce existing HIV disparities. This qualitative study aimed to describe transportation-related barriers experienced by people living with HIV in South Carolina, understand perceived effects of transportation vulnerability on HIV care, and explore strategies used by individuals to overcome transportation-related challenges.

METHODS

We conducted semistructured interviews with 20 people living with HIV from South Carolina who were either reengaging in HIV care after a prolonged absence (>9 months) or in care but with a detectable viral load (ie, >200 copies/mL). All people living with HIV reported transportation vulnerability. A deductive/inductive approach was used to identify transportation-related barriers perceived to negatively affect HIV care. We also identified strategies and resources described by people living with HIV as helpful in addressing transportation challenges.

RESULTS

Participants described a range of transportation-related barriers to HIV care, including lack of access to reliable, safe, and affordable transportation, as well as stigma due to HIV and socioeconomic statuses. These barriers were reported to negatively affect engagement in care and worsen both physical and mental health. Participants indicated flexible clinic policies and instrumental support from family and friends were useful in overcoming barriers.

CONCLUSIONS

This study offers insight for the development of transportation interventions to improve equitable access to HIV care for people living with HIV in South Carolina. It also calls attention to the ways in which transportation vulnerability, HIV-related stigma, and disability status intersect to create unique challenges for some people living with HIV.

Faith-based Community Engagement in HIV-Testing and Awareness of HIV Status in Southern, Rural, African American Communities

The Deep South is the epicenter of the HIV-epidemic in the United States, with rural AAs bearing the greatest burden. Traditional efforts to improve testing efforts have been largely unsuccessful due to their failure to recognize and leverage the sociopolitical and cultural factors that affect the uptake of HIV-screening interventions at the community level. The purpose of this study was to gain a deeper understanding of the socio-cultural contexts impacting HIV-testing in the rural South, and to assess strategies to increase testing in rural, Southern communities. Focus groups (n = 8) and semi-structured interviews (n = 31) were conducted among community and faith-based leaders in Alabama and Mississippi, to inform our understanding of local perceptions of HIV infection, barriers and facilitators impacting HIV-testing, and best strategies for improving testing efforts at the local level. Interviews and focus groups were audio-recorded, transcribed verbatim, and analyzed to extract major themes. While both faith-based and community leaders reported at least some stigmatizing attitudes towards HIV infection, faith-based leaders were more likely to report discomfort being around someone with HIV and were more likely to link the spread of HIV to immoral behaviors. The combination of the cultural importance of the Church, deep-seated religiosity among community members, and faith-based messages associating HIV infection with immorality directly impacted HIV stigma within the community-in turn, decreasing willingness to participate in HIV-testing, disclose positive HIV serostatus, or openly discuss transmission protection behaviors. The Church was identified as crucial to include to improve HIV-testing efforts in the rural South, due to their prominent sociopolitical roles within communities and ability to influence community members' perceptions of HIV stigma. Faith-based leaderships should be included in initiatives to increase improve HIV-testing and awareness of status and reduce HIV disparities in the Deep South.

Geographic disparities in late HIV diagnoses in Tennessee: Opportunities for interventions in the rural Southeast

PURPOSE

Incident HIV remains an important public health issue in the US South, the region leading the nation in HIV incidence, rural HIV cases, and HIV-related deaths. Late diagnoses drive incident HIV and understanding factors driving late diagnoses is critical for developing locally relevant HIV testing and prevention interventions, decreasing HIV transmission, and ending the HIV epidemic.

METHODS

Retrospective cohort study utilizing Tennessee Department of Health (TDH) surveillance data and US Census Bureau data. Adults of ≥18-year old with a new HIV diagnosis between January 1, 2015 and December 31, 2019 identified in the TDH electronic HIV/AIDS Reporting System were included. Individuals were followed from initial HIV diagnosis until death, 90 days of follow-up for outcome assessment, or administrative censoring 90 days after study enrollment closed.

FINDINGS

We included 3652 newly HIV-diagnosed individuals; median age was 31 years (IQR: 25, 42), 2909 (79.7%) were male, 2057 (56.3%) were Black, 246 (6.7%) were Hispanic, 408 (11.2%) were residing in majority-rural areas at diagnosis, and 642 (17.6%) individuals received a late HIV diagnosis. Residents of majority-rural counties (adjusted risk ratios [aRR] = 1.39, 95% confidence intervals [CI]: 1.16-1.67) and Hispanic individuals (aRR = 1.87, 95% CI: 1.50-2.33) had an increased likelihood of receiving a late diagnosis after controlling for race/ethnicity, age, and year of HIV diagnosis.

CONCLUSIONS

Rural residence and Hispanic ethnicity were associated with an increased risk of receiving a late HIV diagnosis in Tennessee. Future HIV testing and prevention efforts should be adapted to the needs of these vulnerable populations.

Prevalence and predictors of HIV testing among young men in Papua New Guinea: A cross-sectional analysis of a nationally representative sample

BACKGROUND

HIV testing is an important component of HIV prevention and serves as a gateway to other HIV-related services. However, the uptake remains suboptimal among young people, particularly in highly prevalent settings such as Papua New Guinea (PNG). This study aimed to assess the prevalence and determine the predictors of HIV testing uptake among young men aged 15-24 years in PNG.

METHODS

The 2016-2018 PNG Demographic and Health Survey (DHS) data was used. A total of 1,275 young men aged 15-24 years were included in the final analysis. Descriptive, bivariate, and multivariable logistic regression analyses were performed to determine independent predictors of HIV testing. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported. All analyses were adjusted using survey weights to account for unequal sampling probabilities.

RESULTS

The overall prevalence of HIV testing among young men was 17.1% (95% CI: 15-19). Of those who were tested for HIV, about one-third (32.9%) had experienced a sexual debut at age <15 years, and 33.9% inconsistently used condoms during sex. In multivariable analysis, men aged 20-24 years (AOR 1.18, 95% CI: 1.00-2.31), who owned mobile phones (AOR 1.43, 95% CI: 1.00-2.55), who were aware that consistent condom use during sex can reduce HIV risk (AOR 2.18, 95% CI: 1.18-4.04), who had paid for sex (AOR 1.75, 95% CI: 1.01-5.83), and who had two or more sexual partners (AOR 1.37, 95% CI: 1.01-3.14) had increased odds of HIV testing. However, decreased odds of HIV testing were found among men who were never married (AOR 0.51, 95% CI: 0.29-0.88), lived in rural areas (AOR 0.54, 95% CI: 0.32-0.92), and consistently used condoms during sex (AOR 0.59, 95% CI: 0.34-1.01).

CONCLUSION

The findings show that HIV testing is low among young men in PNG. To increase HIV testing uptake among young men, it is crucial to implement comprehensive youth-friendly HIV/STI education and tailored sensitization programs and enable more accessible and affordable HIV testing services. Also, outreach and community-based testing programs for young men in rural and prioritized areas requiring urgent prevention interventions are feasible options in PNG.

Investigating the Determinants of Mortality before CD4 Count Recovery in a Cohort of Patients Initiated on Antiretroviral Therapy in South Africa Using a Fine and Gray Competing Risks Model

CD4 count recovery is the main goal for an HIV patient who initiated ART. Early ART initiation in HIV patients can help restore immune function more effectively, even when they have reached an advanced stage. Some patients may respond positively to ART and attain CD4 count recovery. Meanwhile, other patients failing to recover their CD4 count due to non-adherence, treatment resistance and virological failure might lead to HIV-related complications and death. The purpose of this study was to find the determinants of death in patients who failed to recover their CD4 count after initiating antiretroviral therapy. The data used in this study was obtained from KwaZulu-Natal, South Africa, where 2528 HIV-infected patients with a baseline CD4 count of <200 cells/mm3 were initiated on ART. We used a Fine-Gray sub-distribution hazard and cumulative incidence function to estimate potential confounding factors of death, where CD4 count recovery was a competing event for failure due to death. Patients who had no tuberculosis were 1.33 times at risk of dying before attaining CD4 count recovery [aSHR 1.33; 95% CI (0.96-1.85)] compared to those who had tuberculosis. Rural patients had a higher risk of not recovering and leading to death [aSHR 1.97; 95% CI (1.57-2.47)] than those from urban areas. The patient's tuberculosis status, viral load, regimen, baseline CD4 count, and location were significant contributors to death before CD4 count recovery. Intervention programs targeting HIV testing in rural areas for early ART initiation and promoting treatment adherence are recommended.

Labor Pains: Work-Related Barriers to Access to Health Care for People Living with HIV in Hyderabad, India

To explore themes regarding work-related barriers to access to health care, we conducted 32 interviews, 16 with third gender people and 16 with cisgender women, all of whom were all living with HIV in Hyderabad, India. Most respondents were members of Dalit castes and had been living with HIV for several years at the time of the interview. Using thematic content analysis, interviews were coded by two researchers using a social determinants of health conceptual framework. Themes highlighted in this study include the burden of taking time off from work, the loss of pay associated with missing work, and the interruption of gendered care work responsibilities that respondents faced when seeking treatment. Findings from this study support the claim that equitable work policies and practices for marginalized laborers can increase access to medical care for people living with HIV.

Socio-Behavioural Barriers to Viral Suppression in the Older Adult Population in Rural South Africa

South Africa has the largest share of people living with HIV in the world and this population is ageing. The social context in which people seek HIV care is often ignored. Apart from clinical interventions, socio-behavioural factors impact successful HIV care outcomes for older adults living with HIV. We use cross-sectional data linked with demographic household surveillance data, consisting of HIV positive adults aged above 40, to identify socio-behavioural predictors of a detectable viral load. Older adults were more likely to have a detectable viral load if they did not disclose their HIV positive status to close family members (aOR 2.56, 95% CI 1.89-3.46), resided in the poorest households (aOR 1.98, 95% CI 1.23-3.18), or were not taking medications other than ART (aOR 1.83, 95% CI 1.02-1.99) likely to have a detectable. Clinical interventions in HIV care must be supported by understanding the socio-behavioural barriers that occur outside the health facility. The importance of community health care workers in bridging this gap may offer more optimum outcomes for older adults ageing with HIV.

Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study

BACKGROUND

In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or 'rural' areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States.

METHODS

We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes.

RESULTS

Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to "get things in order" before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration.

CONCLUSION

Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.

Depression and Anxiety Symptoms and Treatment Utilization, and Associated HIV Outcomes among Adults with HIV in Rural Florida

Persons living with HIV (PLWH) and depression or anxiety in the rural South may have suboptimal HIV outcomes. We sought to examine the proportion of PLWH from rural Florida with symptoms of depression or anxiety, the proportion who received depression or anxiety treatment, and the relationship between untreated and treated symptoms of depression or anxiety and HIV outcomes. Cross-sectional survey data collected between 2014 and 2018 were analyzed. Among 187 PLWH residing in rural Florida (median age 49 years, 61.5%, male 45.5% Black), 127 (67.9%) met criteria for symptoms of depression and/or anxiety. Among these 127 participants, 60 (47.2%) were not on depression or anxiety treatment. Participants with untreated symptoms of depression and anxiety (OR 3.2, 95% CI 1.2-9.2, p = 0.03) and treated depression and anxiety with uncontrolled symptoms (OR 1.4, 95% CI 0.5-4.0, p = 0.52) were more likely to have viral non-suppression compared to those without depression or anxiety in an unadjusted bivariate analysis. Only the association between untreated symptoms of depression and anxiety and viral non-suppression was statistically significant, and when adjusting for social and structural confounders the association was attenuated and was no longer statistically significant. This suggests that social and structural barriers impact both mental health and HIV outcomes. Our findings support the need for increased mental health services and resources that address the social and structural barriers to care for PLWH in the rural South.

Predictors of Viral Suppression Among People Living with HIV in Rural Oregon

With recent outbreaks of HIV in rural areas of the United States, it has become increasingly important to understand the factors affecting health outcomes of people with HIV living in rural areas. We assessed predictors of durable HIV viral suppression among rural participants using a pooled 7-year dataset from the Medical Monitoring Project (MMP), a cross-sectional, representative sample of individuals receiving HIV medical care in Oregon. Only 77.3% of rural participants achieved durable HIV viral suppression, while 22.7% had at least one detectable HIV viral load measurement within the past 12 months. The primary predictors of viral suppression were ARV adherence, poverty, and reported heavy drinking in the past 30 days. These results highlight the influence of social factors on health outcomes for persons with HIV living in rural areas and inform areas for policy and program change.

Urban-rural disparities in geographic accessibility to care for people living with HIV

In the United States, people living with HIV (PLWH) in rural areas fare worse along the HIV care continuum than their urban counterparts; this may be due in part to limited geographic access to care. We estimated drive time to care for PLWH, focusing on urban-rural differences. Adult Medicaid enrollees living with HIV and their usual care clinicians were identified using administrative claims data from 14 states (Medicaid Analytic eXtract, 2009-2012). We used geographic network analysis to calculate one-way drive time from the enrollee's ZIP code tabulation area centroid to their clinician's practice address, then examined urban-rural differences using bivariate statistics. Additional analyses included altering the definition of rurality; examining subsamples based on the state of residence, services received, and clinician specialty; and adjusting for individual and county characteristics. Across n = 49,596 PLWH, median drive time to care was 12.8 min (interquartile range 26.3). Median drive time for rural enrollees (43.6 (82.0)) was nearly four times longer than for urban enrollees (11.9 (20.6) minutes, p < 0.0001), and drive times exceeded one hour for 38% of rural enrollees (versus 12% of urban, p < 0.0001). Urban-rural disparities remained in all additional analyses. Sustained efforts to circumvent limited geographic access to care are critical for rural areas.

Socioeconomic inequality and contributors in accepting attitudes toward people living with HIV among adults in Ethiopia from 2005 to 2016: a population-based cross-sectional study

INTRODUCTION

The public's accepting attitude toward people living with HIV is crucial in reducing HIV-related stigma and discrimination, increasing people's access to HIV service. This study examines the inequalities in accepting attitudes toward people living with HIV in Ethiopia from 2005 to 2016.

METHODS

This cross-sectional study was based on the 2005, 2011 and 2016 Ethiopian Demographic Health Surveys. A total of 17 075, 28 478 and 25 542 adults were included in the 2005, 2011 and 2016 surveys, respectively. Socioeconomic inequality was investigated using the concentration curve and Erreygers' concentration index (ECI), which is scaled from -1 (pro-poor) to +1 (pro-rich). The ECI was decomposed to identify the contributors to socioeconomic inequality using generalised linear regression with the logit link function.

RESULTS

Accepting attitude toward people living with HIV was 17.9% (95% CI: 16.6%, 19.3%) in 2005, which increased to 33.5% (95% CI: 31.8%, 35.3%) in 2011 and 39.6% (95% CI: 37.6%, 41.9%) in 2016. ECI was 0.342 (p<0.001), 0.436 (p<0.001) and 0.388 (p<0.001), respectively, for 2005, 2011 and 2016. The trend line illustrates socioeconomic inequality seems diverging over time, with an increasing ECI of 0.005 every year (r=0.53; p=0.642; slope=0.005).

CONCLUSIONS

The current study found that there was pro-rich inequality from 2005 to 2016. People with higher socioeconomic status had a better attitude toward people living with HIV. Comprehensive knowledge about HIV/AIDS, education status, residence, and access to electronic and paper-based media, as well as HIV testing, contribute to a better accepting attitude toward people living with HIV. It is of utmost importance for the country to enhance accepting attitude toward people living with HIV to reduce stigma and discrimination. This requires whole-system response according to the primary healthcare approach toward ending the epidemic of HIV/AIDS in the country.

Predictors of Treatment Adherence and Virological Failure Among People Living with HIV Receiving Antiretroviral Therapy in a South African Rural Community: A Sub-study of the ITREMA Randomised Clinical Trial

A large proportion of people living with HIV (PLHIV) in sub-Saharan Africa reside in rural areas. Knowledge of enablers and barriers of adherence to antiretroviral treatment (ART) in these populations is limited. We conducted a cohort study of 501 adult PLHIV on ART at a rural South African treatment facility as a sub-study of a clinical trial (ClinicalTrials.gov NCT03357588). Socio-economic, psychosocial and behavioral characteristics were assessed as covariates of self-reported adherence difficulties, suboptimal pill count adherence and virological failure during 96 weeks of follow-up. Male gender was an independent risk factor for all outcomes. Food insecurity was associated with virological failure in males. Depressive symptoms were independently associated with virological failure in both males and females. Household income and task-oriented coping score were protective against suboptimal pill-count adherence. These results underscore the impact of low household income, food insecurity and depression on outcomes of ART in rural settings and confirm other previously described risk factors. Recognition of these factors and targeted adherence support strategies may improve patient health and treatment outcomes.

A qualitative assessment of barriers to healthcare and HIV prevention services among men who have sex with men in non-metropolitan areas of the south

HIV cases are increasing in the rural Southern United States, especially among men who have sex with men (MSM). To facilitate healthcare access and encourage HIV prevention for non-metropolitan MSM, it is essential to examine their barriers to care. This qualitative study conducted semi-structured interviews with 20 MSM living in non-metropolitan areas of the South. Analysis revealed that MSM experience multiple barriers accessing healthcare in non-metropolitan areas such as finding knowledgeable and affirming providers with desired characteristics and beliefs and communicating with providers about sexual health and HIV prevention. To aid in identification, many respondents expressed a desire for providers to publicly signal that they provide care for sexual and gender minority patients and are an inclusive clinical space. Overall, results suggest that MSM face unique healthcare-related challenges, beyond those typically experienced by the broader population in non-metropolitan areas, because of tailored identity-based needs. To better support MSM in non-metropolitan areas, especially in the South where increased experiences of stigma are found, providers should seek further training regarding sexual health communication and HIV prevention, indicate on websites and in offices that they support sexual and gender minority patients, and provide telehealth services to MSM living in more geographically isolated areas.

Telemedicine for unhealthy alcohol use in adults living with HIV in Alabama using common elements treatment approach: A hybrid clinical efficacy-implementation trial protocol

Background

Unhealthy alcohol use is an unaddressed barrier to achieving and maintaining control of the human immunodeficiency virus (HIV) epidemic. Integrated screening, treatment of common behavioral and mental health comorbidities, and telemedicine can improve alcohol treatment and HIV clinical and quality of life outcomes for rural and underserved populations.

Objective

In a randomized controlled clinical trial, we will evaluate the effectiveness and implementation of telephone-delivered Common Elements Treatment Approach (T-CETA), a transdiagnostic cognitive behavioral therapy protocol, on unhealthy alcohol use, HIV, other substance use and mental health outcomes among predominantly rural adults with HIV receiving care at community clinics in Alabama.

Methods

Adults with HIV receiving care at four selected community clinics in Alabama will receive a telephone-delivered alcohol brief intervention (BI), and then be assigned at random (stratified by clinic and sex) to no further intervention or T-CETA. Participants will be recruited after screening positively for unhealthy alcohol use or when referred by a provider. The target sample size is 308. The primary outcome will be change in the Alcohol Use Disorder Identification Test (AUDIT) at six- and 12-months post-enrollment. Additional outcomes include HIV (retention in care and viral suppression), patient-reported mental health (anxiety, depression, posttraumatic stress), and quality of life. A range of implementation measures be evaluated including T-CETA provider and client acceptability, feasibility, cost and cost-effectiveness.

Conclusions

This trial will inform alcohol treatment within HIV care programs, including the need to consider comorbidities, and the potential impact of alcohol interventions on HIV and quality of life outcomes.

Injectable Long-Acting Cabotegravir-Rilpivirine Therapy for People Living With HIV/AIDS: Addressing Implementation Barriers From the Start

ABSTRACT

Injectable cabotegravir and rilpivirine (CAB/RPV), administered bimonthly by a medical provider, is convenient and improves privacy and medication management. One year after approval, myriad implementation barriers threaten the access and sustainability of this life-saving innovation: (1) eligibility issues (viral suppression, drug resistance, and failed oral regimens); (2) injection requires medical provider and transportation to facility; (3) strict medication adherence; (4) life challenges-mental health, homelessness, joblessness; and (5) lack of insurance and high cost. Universal implementation of CAB/RPV calls for social, human, and health organizations to partner and provide HIV continuum of care and prevention services to facilitate CAB/RPV access and maintenance and for transparent health insurance billing practices to abate uncertainty concerning CAB/RPV's classification as a pharmaceutical or medical benefit and related cost implications.

Factors associated with quality of life, depressive symptoms, and perceived stress among rural older adults living with HIV in the United States

PURPOSE

Rural older people living with HIV (PLH) in the United States are a population of growing size and significance. A better understanding of factors associated with quality of life (QOL), depressive symptoms, and stress in this population-especially modifiable factors-could inform future interventions.

METHODS

Online or on paper, we surveyed 446 PLH aged 50+ residing in rural counties across the United States (Mage = 56, 67% male, 67% White, and 23% Black). Associations between social support, HIV stigma, satisfaction with medical care, discrimination in health care settings, and structural barriers and health-related QOL, depressive symptoms, and perceived stress were assessed using multiple linear regressions.

FINDINGS

Controlling for demographics, greater social support was associated with better QOL, fewer depressive symptoms, and less stress. Greater HIV stigma was associated with more depressive symptoms and stress. Satisfaction with care was associated with better QOL and less stress. Discrimination in medical settings was associated with lower QOL and more depressive symptoms and stress. Finally, experiencing more structural barriers was associated with lower QOL and more depressive symptoms and stress.

CONCLUSIONS

In addition to engagement in care and viral suppression, QOL and mental health are also critical considerations for rural older PLH. Increasing social support, reducing or providing skills to cope with HIV stigma, improving quality of care, reducing discrimination and stigma in medical settings, and reducing or mitigating the impact of structural barriers present potential targets for interventions aiming to improve the well-being of older rural PLH.

The lived experiences of rural HIV social workers

HIV service providers are the primary implementers of HIV care services, but rural HIV service providers are under researched. We used an interpretative phenomenological analysis to explore rural HIV service providers' lived experiences of working in HIV care, who work in a rural region of a Midwestern state in the United States. From July to August 2019, 15 HIV service providers participated in a one-hour semi-structured telephone interview that elicited their experiences working in the rural HIV care continuum. Participants were tired of constantly educating and working to reduce HIV stigma; however, they received support from family and friends once they educated them about HIV. Participants felt they lacked control over systems and they developed emotional-based coping to address constant occupational stressors. Findings highlight the importance of resiliency and advocacy research and practice across ecological levels.

Factors Associated with Retention in HIV Care Among HIV-Positive Adolescents in Public Antiretroviral Therapy Clinics in Ibanda District, Rural South Western Uganda

Background

Retention in antiretroviral therapy (ART) care is a key indicator of Human Immunodeficiency Virus (HIV) treatment success as it improves adherence, critical for better treatment outcomes and prevention of drug resistance. HIV treatment among adolescents living with HIV (ALHIV) is characterized by loss to follow-up, poor ART adherence, and eventual death. This study assessed retention in ART care and the associated factors among ALHIV in Ibanda district, rural South Western Uganda.

Methods

This was a retrospective cohort study using clinical data from ALHIV enrolled from 2019 to 2020 in eight health facilities in Ibanda district. Data from the Electronic Medical Record (EMR) system was extracted to assess the associated factors and participants' status two years after enrollment. Data were analyzed using EPIdata version 3.1 in which Univariate and multivariate cox proportional hazard regression analyses were determined. A hazard ratio (HR) at a 95% confidence interval was obtained, and a P-value <0.05 was considered statistically significant.

Results

Eighty-four ALHIV comprising 86.9% (N = 73) females were enrolled. The majority 63.1% (N = 53) resided in semi/peri-urban, and 44.0% (N = 37) stayed less than 5 km from the facility. Only 35.7% (N = 30) were active on ART, while 17 (20.2%) and 36 (42.9%) were lost to follow-up and transfer-outs, respectively. Factors associated with low retention were: ALHIV that moved 5-10Km (HR = 5.371; 95% CI: 1.227-23.5050, p = 0.026), used differential service delivery model was Facility-Based Group (FBG) (HR = 12.419; 95% CI: 4.034-38.236, p < 0.001) and those enrolled on the Young Adolescent Program Support (YAPs) (HR = 4.868; 95CI:1.851-12.803; p = 0.001). Retention reduced with increasing ART duration, ALHIV on (TDF/3TC/EFV) (p < 0.001), lived more than 10Km (p = 0.043) and did not benefit from any intervention (p < 0.001).

Conclusion

Results showed low retention in care and the urgent need to strengthen individual case management strategies for ALHIV, thus interventions focusing on peer support are desired.

Shifting the narrative: equity, evidence, effectiveness, and innovation in the era of Ending the HIV Epidemic

BACKGROUND

The use of evidence-based (EB) and evidence-informed (EI) criteria in determining the effectiveness of health interventions has been widely adopted by national and international agencies in their attempt to address health gaps, particularly around Ending the HIV Epidemic (EHE) initiatives. Utilization of these rigorous standards has proven critical in making progress towards achieving EHE goals, yet many communities remain unreached and underserved despite widespread adoption of EB/EI standards in public health research and practice. Although a crucial tool for innovative healthcare delivery, emphasis on the use of EB/EI parameters has created bias within the cycle of knowledge creation that favors well-resourced institutions given their capacity to meet the rigorous evaluation standards required of EB/EI science. This bias can systematically exclude institutions more aligned with community needs, such as community-based organizations and other grass-roots initiatives, which may have long-standing interventions that more effectively engage marginalized groups but do not have the capacity to meet EB/EI standards.

MAIN BODY

This paper will explore the manifestation of systematic bias and research inequity in the process of identifying and assessing EB/EI HIV care interventions through the lens of a Health Resources and Services Administration funded initiative, coined the Center for Innovation and Engagement, which supports people living with HIV in the United States. An overview of the initiative is provided along with examples of how promising interventions with positive outcomes for members of marginalized communities are excluded in place of interventions that meet traditional standards of scientific rigor but are not novel or particularly innovative. Themes around academic imperialism and power hierarchies will be considered along with key barriers, lessons learned, and recommendations for promoting more equitable EB/EI research practice.

CONCLUSIONS

It is crucial for entities supporting public health interventions to prioritize equity and inclusion in all stages of funding, design, and implementation. This is particularly true for conditions, such as HIV, that disproportionally impact the most marginalized. This will require approaching EB/EI research with a critical lens towards power and a willingness to dismantle historical dynamics that perpetuate inequities as a way of encouraging truly innovative solutions to support those who need it most.

Acceptability and Feasibility of Online, Asynchronous Photovoice with Key Populations and People Living with HIV

Photovoice is an action-oriented qualitative method involving photography and story-telling. Although photovoice yields a powerful form of data that can be leveraged for research, intervention, and advocacy, it has arguably been underutilized within HIV research. Online, asynchronous photovoice methods represent a promising alternative to traditional in-person methods, yet their acceptability and feasibility with key populations and people living with HIV (PLWH) have yet to be explored. The current study describes the methods and evaluation of an online, asynchronous photovoice project conducted with 34 members of key populations and PLWH in Malaysia in 2021. A HIPAA-compliant website incorporating a series of instructional videos was created to facilitate participant engagement and data collection. Quantitative and qualitative indicators suggest that participants found the project to be highly acceptable and feasible. Online, asynchronous photovoice methods hold potential for increasing the scale of this powerful and versatile qualitative research method with key populations and PLWH.

Challenges to meeting the HIV care needs of older adults in the rural South

People living with HIV in rural parts of the Southern United States face poor outcomes along the HIV care continuum. Additionally, over half of people with diagnosed HIV are age 50 and older. Older adults living with HIV in the rural South often have complex health and social needs associated with HIV, aging, and the rural environment. Research is needed to understand what support organizations and clinics need in providing care to this population. This qualitative study examines the challenges health and social service providers face in caring for older patients living with HIV. In 2020-2021, we interviewed 27 key informants who work in organizations that provide care to older adults with HIV in the seven states with high rural HIV burden: Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina. Our findings highlight how racism and poverty; culture, politics, and religion; and a lack of healthcare infrastructure collectively shape access to HIV care for older adults in the South. Rural health and social service providers need structural-level changes to improve their care and services.

Access of People Living with HIV to Testing Services in Greece: A Challenge for Equity in Care

(1) Background: Access to laboratory testing services for HIV in Greece is persistently challenged and this impacts both the continuum of care and, potentially, equity in access. (2) Methods: A cross-sectional study with two parts (first part: HIV-positive people/PLWHIV; second part: HIV clinicians) was conducted in Greece to quantify challenges regarding access to laboratory testing for HIV. Data were collected through online surveys, during a one-month period, between 2019 and 2020. The total sample consisted of 153 PLWHIV and 26 HIV clinicians. (3) Results: Access to viral load testing varied significantly according to place of residence (p = 0.029) and year of diagnosis (p = 0.054). Patients diagnosed after 2015 reported worse access to viral load testing (72.7% vs. 85.9%). Over one third of respondents perceived viral load tests as being not at all accessible (11.4%) or somewhat accessible, only after facing multiple systemic obstacles (24.2%). Equally, most of HIV clinicians reported barriers or no access to baseline viral load testing (80%) and baseline genotype resistance tests (96%). (4) Conclusions: Access of people diagnosed with HIV to CD4 lymphocyte tests and genotype resistance screening is significantly challenged in Greece, especially after 2015. Addressing this challenge is critical in removing access barriers and achieving the UNAIDS 95-95-95 HIV elimination goals.

Telehealth Services: Implications for Enhancing Sexually Transmitted Infection Prevention

ABSTRACT

In the United States, sexually transmitted infections (STIs) are among the most persistent threats to health equity. Increasing access to STI prevention and control services through the provision of Remote Health and Telehealth can improve sexual health outcomes. Telehealth has been shown to increase access to care and even improve health outcomes. The increased flexibility offered by Telehealth services accommodates both patient and provider. Although both Telehealth and Remote Health strategies are important for STI prevention, share common attributes, and, in some circumstances, overlap, this article will focus more specifically on considerations for Telehealth and how it can contribute to increasing health equity by offering an important complement to and, in some cases, substitute for in-person STI services for some populations. Telehealth assists a variety of different populations, including those experiencing STI disparities; however, although the Internet offers a promising resource for many American households and increasing percentages of Americans are using its many resources, not all persons have equal access to the Internet. In addition to tailoring STI programs to accommodate unique patient populations, these programs will likely be faced with adapting services to fit reimbursement and licensing regulations.

Association between the geographic accessibility of PrEP and PrEP use among MSM in nonurban areas

PURPOSE

The US HIV epidemic has become a public health issue that increasingly affects men who have sex with men (MSM), including those residing in nonurban areas. Increasing access to pre-exposure prophylaxis (PrEP) in nonurban areas will prevent HIV acquisition and could address the growing HIV epidemic. No studies have quantified the associations between PrEP access and PrEP use among nonurban MSM.

METHODS

Using 2020 PrEP Locator data and American Men's Internet Survey data, we conducted multilevel log-binomial regression to examine the association between area-level geographic accessibility of PrEP-providing clinics and individual-level PrEP use among MSM residing in nonurban areas in the United States.

FINDINGS

Of 4,792 PrEP-eligible nonurban MSM, 20.1% resided in a PrEP desert (defined as more than a 30-minute drive to access PrEP), and 15.2% used PrEP in the past 12 months. In adjusted models, suburban MSM residing in PrEP deserts were less likely to use PrEP in the past year (adjusted prevalence ratio [aPR] = 0.35; 95% confidence interval [CI] = 0.15, 0.80) than suburban MSM not residing in PrEP deserts, and other nonurban MSM residing in PrEP deserts were less likely to use PrEP in the past year (aPR = 0.75; 95% CI = 0.60, 0.95) than other nonurban MSM not residing in PrEP deserts.

CONCLUSIONS

Structural interventions designed to decrease barriers to PrEP access that are unique to nonurban areas in the United States are needed to address the growing HIV epidemic in these communities.

Time to occurrence, predictors, and patterns of opportunistic infections incidence among HIV-positive patients attending Antiretroviral Therapy Clinic of Salale University Comprehensive Specialized Hospital: A retrospective cohort study

Opportunistic infections (OIs) in HIV patients are infections that are more common or more severe as a result of HIV-mediated immunosuppression. The advances in the capacity of antiretroviral therapy (ART) have diminished the incidence of OIs. However, even in the ART era, HIV-related OIs continue to be major causes of hospitalization and mortality. Therefore, this study aims to identify time to occurrence, predictors, and patterns of OIs incidence among HIV-positive patients attending ART clinic of Salale University Comprehensive Specialized Hospital, Ethiopia. A retrospective cohort study was conducted between 1st September 2016 and 1st September 2021. All 419 patients diagnosed during the study period were recruited. Data were extracted from both patient medical records and ART logbooks. Stata-16 was used for data analysis. Follow-up time was calculated from the date of HIV diagnosis to the date of OIs occurrence or censoring. Cox proportional hazards regression model was used to identify the predictors of OIs incidence. The total person-time of the follow-up was 8656 person-months of observation. During the follow-up time, 199 (47.49%) of the patients had developed OIs. The incidence rate of OIs was 23 (95%CI: 20, 26) per 1000 person-months of observation. The median OIs free survival time was 36 (95%CI: 31, 40) months. Predictors such as residence, cd4 category, baseline hemoglobin level, ART side effects, isoniazid preventive therapy, and chronic disease comorbidity were significantly predicted OIs incidence. The study area's OIs incidence remained high, requiring prompt action. To reduce the morbidity and mortality associated with OIs, HIV-positive patients with the predictors of rural residence, low CD4 category, low baseline hemoglobin level, ART side effects, not taking IPT, and baseline chronic disease comorbidity necessitate close follow-up and monitoring. Thus, we recommend focused and evidence-informed strategies to address OIs burden and improve outcomes.

ASSOCIATION OF SOCIAL NEEDS WITH UNCONTROLLED VIREMIA IN PEOPLE WITH HIV

Using a tool integrated into the electronic health record, we determined prevalence of 10 social needs among 377 people with HIV (PWH) and 27,833 patients without HIV receiving care in the Montefiore Health System. PWH (median age 53) were 55% women, 41% Black, 44% Hispanic. 33% of PWH reported at least one social need vs. 18% among patients without HIV, with healthcare transportation and housing needs significantly higher among PWH in adjusted analyses. PWH reporting transportation needs were 27% less likely to be virologically suppressed (< 200 copies/mL, adjusted prevalence ratio 0.73, 95% CI 0.55-0.96) compared with PWH without transportation needs.

Longitudinal analysis of HIV outcomes for persons living with HIV in non-urban areas in southern Alberta, Canada

BACKGROUND

Many challenges remain in successfully engaging people with HIV (PWH) into lifelong HIV care. Living in non-urban or rural areas has been associated with worse outcomes. Uncertainties remain regarding how to provide optimal HIV care in non-urban areas.

METHODS

Using a retrospective descriptive analysis framework, we compared multiple measurable HIV care metrics over time on the basis of urban versus non-urban residency, under a centralized HIV care model. We examined rates of HIV diagnosis, access to and retention in HIV care, and longitudinal outcomes for all newly diagnosed PWH between January 1, 2008, and January 1, 2020, categorized by their home location at the time of HIV diagnosis in southern Alberta.

RESULTS

Of 719 newly diagnosed PWH, 619 (86%) lived in urban areas and 100 (14%) lived in non-urban areas. At HIV diagnosis, the groups had no significant differences in initial CD4 count or clinical characteristics (p = 0.73). Non-urban PWH, however, had slightly longer times to accessing HIV care and initiating antiretroviral therapy (ART) (p < 0.01). Non-urban PWH showed trends toward slightly lower retention in care and lower sustained ART use, with higher rates of unsuppressed viral loads at 12, 24, and 36 months after diagnosis (p < 0.01). However, by 2020 both cohorts had suppression rates above 90%.

CONCLUSIONS

Sustained retention in care was more challenging for non-urban PWH; however, adherence to ART and viral suppression rates were more than 90%. Although encouraging, challenges remain in identifying and reducing unique barriers for optimal care of PWH living in non-urban areas.

The Meaning and Perceptions of HIV-Related Stigma in African American Women Living With HIV in Rural Florida: A Qualitative Study

ABSTRACT

African Americans are disproportionally affected by HIV/AIDS compared with other races/ethnicities, yet few studies have examined the cultural and/or attitudinal precursors that can make African American women vulnerable to HIV-related stigma in the rural South. This study qualitatively explored the meaning and perceptions of HIV-related stigma among African American women in Florida. Thirteen semi-structured interviews were conducted using an empirical phenomenological approach. Five observer perspectives and 26 participant perspectives emerged. Participants described stigma through self-conceptualizations (e.g., ignorance), experiences (e.g., judgments), psychological dysfunction (e.g., mental health), intersectionality (e.g., race, disability), and overcoming stigma (e.g., advocacy). Our findings reveal that HIV-related stigma is unpleasant for African American women. However, over time, women in this study developed strategies to combat stigma. Elements of stigma reduction described in this study may be an important starting point for designing a culturally targeted intervention for African American women living with HIV.

Assessing the Health Outcomes of the Food Access Pilot Project: An Evaluation of a Medically Supportive Food Support Program for People Living with HIV in Rural California Counties

Food insecurity disproportionately affects rural communities and people living with HIV (PLHIV). The Food Access Pilot Project (FAPP) was a California state-funded program that provided home-delivered, medically supportive meals via online meal vendors to food-insecure PLHIV in three rural counties. We performed longitudinal, retrospective analyses of FAPP participant data (n = 158; 504 and 460 person-time observations for viral load and CD4 count, respectively) over 36 months from a Ryan White client management database. Pre-post analyses demonstrated increased prevalence of food security and CD4 ≥ 500 between baseline and 12 months. Population-averaged trends using generalized estimating equations adjusted for participant demographics demonstrated increased odds of viral suppression and CD4 ≥ 500, and increased CD4 count (cells/mm³) for every six months of program enrollment. Home-delivered, medically supportive meals may improve food security status, HIV viral suppression, and immune health for low-income PLHIV in rural settings.

A cross-sectional survey of potential factors, motivations, and barriers influencing research participation and retention among people who use drugs in the rural USA

BACKGROUND

Despite high morbidity and mortality among people who use drugs (PWUD) in rural America, most research is conducted within urban areas. Our objective was to describe influencing factors, motivations, and barriers to research participation and retention among rural PWUD.

METHODS

We recruited 255 eligible participants from community outreach and community-based, epidemiologic research cohorts from April to July 2019 to participate in a cross-sectional survey. Eligible participants reported opioid or injection drug use to get high within 30 days and resided in high-needs rural counties in Oregon, Kentucky, and Ohio. We aggregated response rankings to identify salient influences, motivations, and barriers. We estimated prevalence ratios to assess for gender, preferred drug use, and geographic differences using log-binomial models.

RESULTS

Most participants were male (55%) and preferred methamphetamine (36%) over heroin (35%). Participants reported confidentiality, amount of financial compensation, and time required as primary influential factors for research participation. Primary motivations for participation include financial compensation, free HIV/HCV testing, and contribution to research. Changed or false participant contact information and transportation are principal barriers to retention. Respondents who prefer methamphetamines over heroin reported being influenced by the purpose and use of their information (PR = 1.12; 95% CI: 1.00, 1.26). Females and Oregonians (versus Appalachians) reported knowing and wanting to help the research team as participation motivation (PR = 1.57; 95% CI: 1.09, 2.26 and PR = 2.12; 95% CI: 1.51, 2.99).

CONCLUSIONS

Beyond financial compensation, researchers should emphasize confidentiality, offer testing and linkage with care, use several contact methods, aid transportation, and accommodate demographic differences to improve research participation and retention among rural PWUD.

Frameworks, measures, and interventions for HIV-related internalised stigma and stigma in healthcare and laws and policies: systematic review protocol

INTRODUCTION

There is strong global commitment to eliminate HIV-related stigma. Wide variation exists in frameworks and measures, and many strategies to prevent, reduce or mitigate stigma have been proposed but critical factors determining success or failure remain elusive.

METHODS AND ANALYSIS

Building on existing knowledge syntheses, we designed a systematic review to identify frameworks, measures and intervention evaluations aiming to address internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level. The review addresses four key questions (KQ): KQ1: Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? KQ2: Which measures of stigma have been proposed and what are their descriptive properties? KQ3: Which interventions have been evaluated that aimed to reduce these types of stigma and discrimination or mitigate their adverse effects and what are the effectiveness and unintended consequences? KQ4: What common 'critical factors for success or failure' can be identified across interventions that have been evaluated? We will search PubMed, PsycINFO, Web of Science, Universal Human Rights Index, HeinOnline, PAIS, HIV Legal Network, CDSR, Campbell Collaboration, PROSPERO and Open Science Framework. Critical appraisal will assess the source, processes and consensus finding for frameworks; COnsensus-based Standards for the selection of health Measurement Instruments criteria for measures; and risk of bias for interventions. Quality of evidence grading will apply . A gap analysis will provide targeted recommendations for future research. We will establish a compendium of frameworks, a comprehensive catalogue of available measures, and a synthesis of intervention characteristics to advance the science of HIV-related stigma.

PROSPERO REGISTRATION NUMBER

CRD42021249348.

Syringe Coverage Among People Who Inject Drugs in West Virginia, USA

Ensuring people who inject drugs (PWID) have ≥ 100% sterile syringe coverage (i.e., persons have access to a sterile syringe for all injections) is optimal for HIV prevention. Existing syringe coverage literature is informative, yet little work has examined syringe coverage among PWID in rural communities. Using data from a 2018 PWID population estimation study conducted in a rural county in West Virginia, we used logistic regression to identify correlates of adequate sterile syringe coverage (at least 100%). A minority (37%) of PWID reported having adequate syringe coverage. Factors inversely associated with adequate syringe coverage included having recently (past 6 months): engaged in transactional sex work, shared syringes, and injected fentanyl. Having exclusively acquired syringes from a syringe services program was associated with increased odds of adequate syringe coverage. Rural PWID may benefit from tailored interventions designed to increase sterile syringe access.

Randomized Community Trial Comparing Telephone versus Clinic-Based Behavioral Health Counseling for People Living with HIV in a Rural Setting

PURPOSE

To test the efficacy of a theory-based behavioral intervention delivered via telephone versus clinic-based counseling to improve HIV outcomes and reduce alcohol consumption for people at-risk for treatment failure in a rural setting.

METHODS

Patients receiving HIV care (N = 240) were randomized using a computer-generated scheme to one of three conditions: (a) telephone behavioral health counseling, (b) clinic-based behavioral health counseling, or (c) attention control nutrition education. Behavioral counseling was delivered by either a community nurse or a paraprofessional patient navigator, with differences examined. Participants were followed for 12 months to assess medication adherence using unannounced pill counts and alcohol use measured by electronic daily text message assessments, and 18 months for HIV viral load and retention in care extracted from medical records.

FINDINGS

There was evidence for telephone and office-based counseling demonstrating greater medication adherence than the control condition but only in the short term. Clinic-based behavioral counseling significantly reduced alcohol use to a greater degree than telephone counseling and the control condition. There were no other differences between conditions. There were also no discernable differences between counseling delivered by the community nurse and the patient navigator.

CONCLUSIONS

Telephone and clinic-based counseling demonstrated improved medication adherence in the short term, while clinic-based counseling demonstrated reductions in alcohol use. The modest outcomes suggest that intensive intervention strategies are needed for patients that clinicians identify as at-risk for treatment discontinuation and treatment failure.

Community Legal Systems: Targeting PrEP and HIV Education to Decrease Risk of HIV Transmission

The southern U.S. has both high HIV and incarceration rates in comparison to its population. As in the rest of the country, HIV prevention is based on education, behavior change, and biomedical efforts, such as pre-exposure prophylaxis (PrEP). This study examined the implementation of an educational intervention and supportive services to obtain PrEP in a population of individuals (N = 218) involved in an Adult Drug Court (ADC) or on probation or parole (P-P). Nearly all ADC and P-P participants self-reported risk behaviors linked to HIV acquisition. Results supported the acceptance and usefulness of the intervention as rated by participants. Participants showed increased knowledge of HIV risks and testing post-education. In multivariate analysis, predictors of interest in using PrEP included low stigma beliefs, specifically their level of prejudice views, high depressive symptoms, and white race. The intervention shows promise. Given the high risk documented for ADC and P-P individuals, HIV prevention is a critical component for increased protective behaviors.

Knowledge, awareness and use of HIV services among the youth from nomadic and agricultural communities in Tanzania

BACKGROUND

Nomadic life not only prevents the community from accessing and utilising HIV services but also deters them from obtaining reliable information on HIV.

METHODS

We conducted a cross-sectional study of youth aged 10-24 years from the Kilindi and Ngorongoro Districts in Tanzania to assess knowledge, accessibility and utilisation of HIV/AIDS services among nomadic and agricultural youths.

RESULTS

Of 518 youths interviewed, 279 (53.9%) were males, and 276 (53.3%) were from agricultural communities. A significant proportion of youths from agricultural communities had correct knowledge of AIDS (n = 126, 45.8%; P = 0.002), HIV transmission (n = 273, 98.9%; P = 0.001) and comprehensive knowledge of HIV/AIDS (n = 78, 28.5%; P = 0.009) compared to nomads. Youths from agricultural communities were two times (OR 1.8, 95% CI 1.2-2.6) more likely to be aware of the availability of formal HIV services. Awareness of the availability of HIV services was higher among married individuals than in unmarried ones (OR 3.8, 95% CI 2.0-7.4), and significantly higher among youths with secondary/college education than in those who did not have formal education (OR 5.3, 95% CI 2.3-12.4). The uptake of HIV services was lower among nomadic youths.

CONCLUSION

Knowledge, awareness and utilisation of HIV/AIDS transmission services were low in general, and even lower among nomadic youths, calling for more targeted interventions.

Effect of Case Management on HIV Outcomes for Community Corrections Population: Results of an 18-Month Randomized Controlled Trial

BACKGROUND

Evidence-based interventions that engage community-dwelling, justice-involved, people living with HIV (PLWH) in care are urgently needed. Project Bridge, an intensive case management intervention, has demonstrated efficacy for linking PLWH to care transitioning from prison to the community. We assessed whether a modified Project Bridge model was effective for increasing rates of HIV treatment engagement, antiretroviral therapy receipt, and adherence for community-dwelling individuals supervised on probation and parole.

SETTING

Baltimore, Maryland.

METHODS

In this study, the 18-month outcomes of a randomized controlled trial in which PLWH were also on probation or parole received either Project Bridge (n = 50) or treatment as usual (n = 50) were assessed. HIV treatment engagement (primary outcome), antiretroviral therapy prescription, and adherence (secondary outcomes) are evaluated using the intent-to-treat approach.

RESULTS

There were no statistically significant differences in rates of HIV treatment engagement, antiretroviral therapy prescription receipt, or adherence between groups over the 18-month study period. Across groups, participants were 5.6 times more likely to receive HIV care, 5.8 times more likely to receive an antiretroviral therapy prescription, and 4 times more likely to report antiretroviral therapy adherence at each follow-up period.

CONCLUSIONS

Future research is needed to identify potentially less-intensive interventions that target the unique needs of PLWH under community supervision.

Willingness to Participate in At-Home HIV Testing Among Young Adults Who Use Opioids in Rural Appalachia

New HIV infections associated with injection drug use are of major concern in rural US communities. This study explores acceptability of, consent for, and uptake of free at-home HIV testing among people who use drugs (PWUD) in one of the nation’s epicenters for drug-related harms and HIV vulnerability: Rural Central Appalachia. Eligible participants were 18–35 years old, lived in Appalachian Kentucky, and reported using opioids to get high in the previous 30 days. A majority reported being likely (63.6%, 96/151) to take a free at-home HIV tests and 66.9% (101/151) consented to receive one. Among those who were randomly selected to receive a Home Access HIV-1 test kit (n = 37), 37.8% mailed in blood spots and 21.6% called to receive results. This study provides evidence that PWUD may be willing to take an at-home test, but other barriers may inhibit actual completion.

A Qualitative Study of Community-Based HIV/AIDS Prevention Interventions, Programs, and Projects for Rural and Remote Regions in Canada: Implementation Challenges and Lessons Learned

CONTEXT

Fifteen percent to 20% of the Canadian and American populations live outside urban areas, and despite growing regional HIV/AIDS-related health disparities, there is little published research specific to rural or remote (rural/remote) HIV/AIDS prevention programming.

OBJECTIVE

To document implementation challenges, lessons learned, and evaluation approaches of promising and proven HIV/AIDS prevention programs and interventions developed and delivered by organizations with rural/remote catchment areas in Canada to provide a foundation for information sharing among agencies.

DESIGN

Qualitative study design, using a community-based participatory research approach. We screened Canadian community-based organizations with an HIV/AIDS prevention mandate to determine whether they offered services for rural/remote populations and invited organizational representatives to participate in semistructured telephone interviews. Interviews were audio-recorded and transcribed. Content analysis was used to identify categories in the interview data.

SETTING

Canada, provinces (all except Prince Edward Island), and territories (all except Nunavut).

PARTICIPANTS

Twenty-four community-based organizations.

RESULTS

Screening calls were completed with 74 organizations, of which 39 met study criteria. Twenty-four (62%) interviews were conducted. Populations most frequently served were Indigenous peoples (n = 13 organizations) and people who use drugs (n = 8 organizations) (categories not mutually exclusive). Key lessons learned included the importance of involving potential communities served in program development; prioritizing community allies/partnerships; building relationships; local relevancy and appropriateness; assessing community awareness or readiness; program flexibility/adaptability; and addressing stigma. Evaluation activities were varied and used for funder reporting and organizational learning.

CONCLUSIONS

Rural/remote HIV/AIDS programs across Canada expressed similar challenges and lessons learned, suggesting that there is potential for knowledge exchange, and development of a community of practice. Top-down planning and evaluation models may fail to capture program achievements in rural/remote contexts. The long-term engagement practices that render rural/remote programs promising do not always conform to planning and implementation requirements of limited funding.

HIV Stigma and Viral Suppression Among People Living With HIV in the Context of Universal Test and Treat: Analysis of Data From the HPTN 071 (PopART) Trial in Zambia and South Africa

BACKGROUND

The impact of HIV stigma on viral suppression among people living with HIV (PLHIV) is not well characterized.

SETTING

Twenty-one communities in Zambia and South Africa, nested within the HPTN 071 (PopART) trial.

METHODS

We analyzed data on viral suppression (<400 copies HIV RNA/mL) among 5662 laboratory-confirmed PLHIV aged 18-44 years who were randomly sampled within the PopART trial population cohort 24 months after enrolment (PC24). We collected data on experiences and internalization of stigma from those PLHIV who self-reported their HIV status (n = 3963/5662) and data on perceptions of stigma from a 20% random sample of all PLHIV (n = 1154/5662). We also measured stigma at the community-level among PLHIV, community members, and health workers. We analyzed the association between individual- and community-level measures of HIV stigma and viral suppression among PLHIV, adjusting for confounding.

RESULTS

Of all 5662 PLHIV, 69.1% were virally suppressed at PC24. Viral suppression was highest among those 3963 cohort participants who self-reported living with HIV and were on ART (88.3%), and lower among those not on treatment (37.5%). Self-identifying PLHIV who reported internalized stigma were less likely to be virally suppressed (75.0%) than those who did not (80.7%; adjusted risk ratio, 0.94 95% CI: 0.89 to 0.98). Experiences, perceptions, and community-level measures of stigma were not associated with viral suppression.

CONCLUSION

Internalized stigma among PLHIV was associated with a lower level of viral suppression; other dimensions of stigma were not. Stigma reduction approaches that address internalized stigma should be an integral component of efforts to control the HIV epidemic.

Assessing clinical quality performance and staffing capacity differences between urban and rural Health Resources and Services Administration-funded health centers in the United States: A cross sectional study

BACKGROUND

In the United States, there are nearly 1,400 Health Resources and Services Administration-funded health centers (HCs) serving low-income and underserved populations and more than 600 of these HCs are located in rural areas. Disparities in quality of medical care in urban vs. rural areas exist but data on such differences between urban and rural HCs is limited in the literature. We examined whether urban and rural HCs differed in their performance on clinical quality measures before and after controlling for patient, organizational, and contextual characteristics.

METHODS AND FINDINGS

We used the 2017 Uniform Data System to examine performance on clinical quality measures between urban and rural HCs (n = 1,373). We used generalized linear regression models with the logit link function and binomial distribution, controlling for confounding factors. After adjusting for potential confounders, we found on par performance between urban and rural HCs in all but one clinical quality measure. Rural HCs had lower rates of linking patients newly diagnosed with HIV to care (74% [95% CI: 69%, 80%] vs. 83% [95% CI: 80%, 86%]). We identified control variables that systematically accounted for eliminating urban vs. rural differences in performance on clinical quality measures. We also found that both urban and rural HCs had some clinical quality performance measures that were lower than available national benchmarks. Main limitations included potential discrepancy of urban or rural designation across all HC sites within a HC organization.

CONCLUSIONS

Findings highlight HCs' contributions in addressing rural disparities in quality of care and identify opportunities for improvement. Performance in both rural and urban HCs may be improved by supporting programs that increase the availability of providers, training, and provision of technical resources.

MAVSCOT: A fuzzy logic-based HIV diagnostic system with indigenous multi-lingual interfaces for rural Africa

HIV still constitutes a major public health problem in Africa, where the highest incidence and prevalence of the disease can be found in many rural areas, with multiple indigenous languages being used for communication by locals. In many rural areas of the KwaZulu-Natal (KZN) in South Africa, for instance, the most widely used languages include Zulu and Xhosa, with only limited comprehension in English and Afrikaans. Health care practitioners for HIV diagnosis and treatment, often, cannot communicate efficiently with their indigenous ethnic patients. An informatics tool is urgently needed to facilitate these health care professionals for better communication with their patients during HIV diagnosis. Here, we apply fuzzy logic and speech technology and develop a fuzzy logic HIV diagnostic system with indigenous multi-lingual interfaces, named Multi-linguAl HIV indigenouS fuzzy logiC-based diagnOstic sysTem (MAVSCOT). This HIV multilingual informatics software can facilitate the diagnosis in underprivileged rural African communities. We provide examples on how MAVSCOT can be applied towards HIV diagnosis by using existing data from the literature. Compared to other similar tools, MAVSCOT can perform better due to its implementation of the fuzzy logic. We hope MAVSCOT would help health care practitioners working in indigenous communities of many African countries, to efficiently diagnose HIV and ultimately control its transmission.

Preferred Methods of HIV and Sexually Transmissible Infection Screening Delivery Among a Rural Sample of Men Who Have Sex with Men

Despite the national HIV and sexually transmissible infection (STI) rates growing in rural areas, rural populations-particularly men who have sex with men (MSM), have limited access to secondary (i.e., HIV/STI screening) prevention activities compared with their urban counterparts. We conducted semistructured in-depth interviews with 23 rural MSM residing in Oklahoma and Arkansas to assess their (1) experiences with HIV and STI testing; (2) perceptions of at-home testing; and (3) preferences for receiving results and care. Barriers to accessing HIV/STI screening included lack of medical providers within rural communities, privacy and confidentiality concerns, and perceived stigma from providers and community members. To overcome these barriers, all participants recognized the importance of screening paradigms that facilitated at-home screening, medical consultation, and care. This included the ability to request a testing kit and receive results online, to access affirming and competent providers utilizing telemedicine technology, as well as prompt linkage to treatment. These narratives highlight the need for systems of care that facilitate HIV and STI screening within rural communities, which do not require participants to access services at traditional physical venues.