Demographic, psychological, and behavioral modifiers of the Antiretroviral Treatment Access Study (ARTAS) intervention

Latent Profile Patterns of Network-Level Norms and Associations with Individual-Level Sexual Behaviors: The N2 Cohort Study in Chicago

Individual-level behavior can be influenced by injunctive and descriptive social network norms surrounding that behavior. There is a need to understand how the influence of social norms within an individual's social networks may influence individual-level sexual behavior. We aimed to typologize the network-level norms of sexual behaviors within the social networks of Black sexual and gender minoritized groups (SGM) assigned male at birth. Survey data were collected in Chicago, Illinois, USA, between 2018 and 2019 from Black SGM. A total of 371 participants provided individual-level information about sociodemographic characteristics and HIV vulnerability from sex (i.e., condomless sex, group sex, use of alcohol/drugs to enhance sex) and completed an egocentric network inventory assessing perceptions of their social network members' (alters') injunctive and descriptive norms surrounding sexual behaviors with increased HIV vulnerability. We used Latent Profile Analysis (LPA) to identify network-level norms based on the proportion of alters' approval of the participant engaging in condomless sex, group sex, and use of drugs to enhance sex (i.e., injunctive norms) and alters' engagement in these behaviors (i.e., descriptive norms). We then used binomial regression analyses to examine associations between network-level norm profiles and individual-level HIV vulnerability from sex. The results of our LPA indicated that our sample experienced five distinct latent profiles of network-level norms: (1) low HIV vulnerability network norm, (2) moderately high HIV vulnerability network norm, (3) high HIV vulnerability network norm, (4) condomless sex dominant network norm, and (5) approval of drug use during sex dominant network norm. Condomless anal sex, group sex, and using drugs to enhance sex were positively and significantly associated with higher HIV vulnerability social network norm profiles, relative to low HIV vulnerability norm profiles. To mitigate Black SGM's HIV vulnerability, future HIV risk reduction strategies can consider using network-level intervention approaches such as opinion leaders, segmentation, induction, or alteration, through an intersectionality framework.

Enlaces Por La Salud: A Personal Health Navigator Intervention Grounded in the Transnational Framework

Despite the disproportionate burden of HIV among Latinxs, there is a paucity of culturally appropriate interventions that have shown efficacy at increasing their engagement and retention in HIV care. We describe the development and implementation of Enlaces, a six-session, individual-level intervention, guided by the transnational framework, to improve HIV care outcomes for newly diagnosed and out-of-care Mexican men and transgender women (TW). Descriptive statistics summarizing baseline data and implementation outcomes are provided. 91 participants enrolled between October 2014 and August 2017. Intervention engagement and satisfaction was high; 81.3% completed all six sessions and 100% were very satisfied/satisfied with their experience. Successful implementation of the ENLACES intervention was the result of establishing client trust and maintaining a flexible, supportive approach to intervention delivery. Use of the transnational framework provided a contextualized approach to engaging with Mexican men and TW living with HIV that can be adapted to other Latino populations.

Modified Antiretroviral Treatment Access Study (MARTAS): A Randomized Controlled Trial of the Efficacy of a Linkage-to-Care Intervention Among HIV-Positive Patients in Ukraine

Between October 2015 and March 2018, we conducted the Modified Antiretroviral Treatment Access Study (MARTAS), a nurse-delivered case management intervention to improve linkage-to-care for persons recently tested HIV positive. Adult participants from nine urban clinics in three regions of Ukraine were randomized to either MARTAS or standard of care (SOC) using individual, parallel, two-arm design. The main study outcome was linkage-to-care (defined as registration at an HIV clinic) within a 3-month period from enrollment in the study. Intention-to-treat analysis of MARTAS (n = 135) versus SOC (n = 139) showed intervention efficacy in linkage to HIV care (84.4% vs. 33.8%; adjusted RR 2.45; 95% CI 1.72, 3.47; p < 0.001). MARTAS is recommended for implementation in Ukraine and may be helpful in other countries with similar gaps in linkage-to-care. Clinicaltrials.gov registration number: NCT02338024.

Beyond Interpretation: The Unmet Need for Linguistically and Culturally Competent Care for Latinx People Living with HIV in a Southern Region with a Low Density of Spanish Speakers

Latinx people living with HIV (PLWH) experience disparities in health outcomes and face unique barriers to care related to language, intersectional stigma, and immigration status. We aimed to explore the lived experience of Spanish-speaking Latinx PLWH in the nonurban South to better understand how to improve care for this minority language population. We conducted semistructured interviews with 22 participants (10 men, 10 women, 2 transgender women) who were recruited from a Ryan White HIV/AIDS program (RWHAP) and a community-based organization. Almost all participants were foreign born. Emerging themes included language barriers, cultural differences, inadequate interpreter services, HIV-related and intersectional stigma, isolation, and relationships as a source of support. These barriers may contribute to disparities in outcomes for Latinx PLWH. New interventions are needed to overcome barriers, foster community, and ensure culturally tailored models of care. Potential clinic-level interventions include the development of specialized training for RWHAP interpreters and inclusion of interpreters in care teams.

Improving Care Outcomes for PLWH Experiencing Homelessness and Unstable Housing: a Synthetic Review of Clinic-Based Strategies

PURPOSE OF REVIEW

Singular interventions targeting vulnerable populations of people living with HIV (PLWH) are necessary for reducing new infections and optimizing individual-level outcomes, but extant literature for PLWH who experience homelessness and unstable housing (HUH) has not been compiled. To inform implementation of clinic-based programs that improve care outcomes in this population, we present a synthetic review of key studies examining clinic-based interventions, specifically case management, patient navigation, financial incentives, and the use of mobile technology.

RECENT FINDINGS

Results from unimodal interventions are mixed or descriptive, are limited by inability to address related multi-modal barriers to care, and do not address major challenges to implementation. Multi-component interventions are needed, but gaps in our knowledge base may limit widespread uptake of such interventions before further data are compiled. Future research evaluating interventions for PLWH experiencing HUH should include implementation outcomes in order to facilitate adaptation across diverse clinical settings.

Project Moxie: Results of a Feasibility Study of a Telehealth Intervention to Increase HIV Testing Among Binary and Nonbinary Transgender Youth

Transgender youth have low rates of engagement in HIV prevention, shaped in part by experiences of transphobia and lack of access to culturally competent care. Project Moxie tested the feasibility of an intervention that provides home-based HIV self-testing coupled with video-chat counseling. A diverse sample of 202 binary and nonbinary transgender youth (TY) were recruited online, and randomized 2:1 to receive the intervention or a control condition of only home-based HIV self-testing. TY were willing to order HIV self-testing kits and report their results. Half of those in the intervention arm opted to use the video-chat counseling and, among those who did, levels of satisfaction were high. Project Moxie demonstrates the ability to recruit TY online and provide them with access to home HIV testing. Further work is required to develop online interventions for youth who do not wish to receive counseling through video-chat formats.

Brief Report: Linking Depressive Symptoms to Viral Nonsuppression Among Women With HIV Through Adherence Self-Efficacy and ART Adherence

BACKGROUND

Depression plays a key role in suboptimal HIV outcomes, possibly mediated by adherence self-efficacy beliefs and antiretroviral treatment (ART) adherence behavior. Applying social-cognitive theory, we examined a longitudinal sequential path model of the association between depressive symptoms and viral nonsuppression in women with HIV (WWH) through these mediating mechanisms.

METHODS

This was an observational longitudinal study using data from the Women's Adherence and Visit Engagement substudy of the Women's Interagency HIV Study. WWH (N = 375) completed measures of depressive symptoms, adherence self-efficacy, and ART adherence. Viral load was measured through blood draw. We examined a longitudinal sequential path model spanning 3 time points at least 6 months apart between 2015 and 2017. Indirect effects were assessed of depressive symptoms at time 1 (T1) on viral nonsuppression at T3 through adherence self-efficacy at T2 and ART adherence at T3. Covariates included age, income, recreational drug use, race, and months on ART.

RESULTS

Depressive symptoms were associated with subsequent viral nonsuppression through its association with adherence self-efficacy and ART adherence [indirect effect: adjusted odds ratio = 1.004, 95% confidence interval: (1.001 to 1.008)]. Months on ART and recreational drug use were also significantly associated with viral nonsuppression at T3.

CONCLUSIONS

Our findings support depressive symptoms' association with adherence self-efficacy that in turn lead to suboptimal ART adherence and ultimately to viral nonsuppression for WWH. Tailoring of interventions aimed at addressing depressive symptoms, substance use, and adherence self-efficacy among WWH is needed to help close the gap between ART prescription and viral suppression on the HIV care continuum.

The impact of the housing status on clinical outcomes and health care utilization among individuals living with HIV

The lack of stable housing can impair access and continuity of care for patients living with human immunodeficiency virus (HIV). This study investigated the relationship between housing status assessed at multiple time points and several core HIV-related outcomes within the same group of HIV patients experiencing homelessness. Patients with consistently stable housing (CSH) during the year were compared to patients who lacked CSH (non-CSH group). The study outcomes included HIV viral load (VL), CD4 counts, and health care utilization. Multivariable and propensity weighted analyses were used to assess outcomes adjusting for potential group differences. Of 208 patients, 88 (42%) had CSH and 120 (58%) were non-CSH. Patients with CSH had significantly higher proportion of VL suppression and higher mean CD4 counts. The frequency of nurse visits in the CSH group was less than a half of that in the non-CSH group. Patients with CSH were less likely to be admitted to the medical respite facility, and if admitted, their length of stay was about a half of that for the non-CSH group. Our study findings show that patients with CSH had significantly better HIV virologic control and immune status as well as improved health care utilization.

The Intersection Between Women's Reproductive Desires and HIV Care Providers' Reproductive Health Practices: A Mixed Methods Analysis

Background HIV-positive women in the United States can have healthy pregnancies and avoid transmitting HIV to their children. Yet, little is known about the extent to which HIV care providers' reproductive health practices match women's pregnancy desires. Accordingly, we explored young HIV-positive women's pregnancy desires and reproductive health behaviors and examined reproductive health information offered by HIV care clinics. Methods A mixed-method analysis was conducted using data from a 14-site Adolescent Medicine Trials Network (ATN) study. We conducted descriptive statistics on data from 25 HIV-positive women (e.g., demographics, pregnancy desires, and sexual- and health-related behaviors). Qualitative interviews with 58 adolescent and adult clinic providers were analyzed using the constant comparative method. Results About half of the women reported using reproductive health care services (i.e., contraception and pregnancy tests) (n = 12) and wanted a future pregnancy (n = 13). Among women who did not desire a future pregnancy (n = 5), three used dual methods and two used condoms at last sexual encounter. Qualitative themes related to clinics' approaches to reproductive health (e.g., "the emphasis…is to encourage use of contraceptives") and the complexity of merging HIV and reproductive care (e.g., "We [adolescent clinic] transition pregnant moms from our care back and forth to adult care"). Discussion Despite regular HIV-related medical appointments, HIV-positive women may have unaddressed reproductive health needs (e.g., pregnancy desire with providers focused on contraceptive use). Findings from this study suggest that increased support for young HIV-positive women's reproductive health is needed, including supporting pregnancy desires (to choose when, how, and if, to have children).

A Critical Review and Commentary on the Challenges in Engaging HIV-Infected Latinos in the Continuum of HIV Care

Antiretroviral therapy for treatment of HIV infection has become increasingly effective. Persistent poor HIV outcomes in racial and ethnic minority populations in the US call for a closer examination into why Latinos are at significant risk for acquiring and dying from HIV. To improve clinical outcomes and achieve an AIDS-free generation, HIV research must address disparities in HIV outcomes in Latinos, the largest ethnic/racial minority population in the US. Immigrant status as well as cultural factors influence HIV care utilization and are essential to highlight for effective intervention development in Latinos. A better understanding of these individual and contextual factors is critical to developing tailored approaches to engaging Latinos in HIV care. Based on a comprehensive literature review, we offer a framework for understanding what is needed from clinical practice and research to improve engagement in HIV care for US-based Latinos. These findings may have implications for other minority populations.

Patient and provider perspectives inform an intervention to improve linkage to care for HIV patients in Ukraine

BACKGROUND

Engagement with HIV medical care is critical to successful HIV treatment and prevention efforts. However, in Ukraine, delays in the timely initiation of HIV treatment hamper viral suppression. By January 01, 2016, only 126,604 (57.5%) of the estimated 220,000 people living with HIV (PLWH) had registered for HIV care, and most (55.1%) of those who registered for HIV care in 2015 did that at a late stage of infection. In the US, Anti-Retroviral Treatment and Access to Services (ARTAS) intervention successfully linked newly diagnosed PLWH to HIV services using strengths-based case management with a linkage coordinator. To tailor the ARTAS intervention for Ukraine, we conducted a qualitative study with patients and providers to understand barriers and facilitators that influence linkage to HIV care.

METHODS

During September-October 2014, we conducted 20 in-depth interviews with HIV-positive patients and two focus groups with physicians in infectious disease, sexually transmitted infection (STI), and addiction clinics in Dnipropetrovsk Region of Ukraine. Interviews and focus groups were audio-recorded and transcribed verbatim. We translated illustrative quotes into English. We used thematic analysis for the data analysis.

RESULTS

Participants (20 patients and 14 physicians) identified multiple, mostly individual-level factors influencing HIV care initiation. Key barriers included lack of HIV knowledge, non-acceptance of HIV diagnosis, fear of HIV disclosure, lack of psychological support from health providers, and HIV stigma in community. Responsibility for one's health, health deterioration, and supportive provider communication were reported as facilitators to linkage to care. Expected benefits from the case management intervention included psychological support, HIV education, and help with navigating the segmented health system.

CONCLUSIONS

The findings from the study will be used to optimize the ARTAS for the Ukrainian context. Our findings can also support future linkage-to-care strategies in other countries of Eastern Europe and Central Asia.

Providing Home-Based HIV Testing and Counseling for Transgender Youth (Project Moxie): Protocol for a Pilot Randomized Controlled Trial

Background

Transgender and gender nonconforming people experience some of the highest human immunodeficiency virus (HIV) rates in the United States, and experience many structural and behavioral barriers that may limit their engagement in HIV testing, prevention, and care. Evidence suggests that transgender and gender nonconforming youth (TY) are especially vulnerable to acquiring HIV, yet there is little research on TY and few services are targeted towards HIV testing, prevention, and care for this population. Telehealth presents an opportunity to mitigate some structural barriers that TY experience in accessing HIV testing, allowing TY to engage in HIV testing and counseling in a safe and nonjudgmental space of their choosing. Project Moxie is an HIV prevention intervention that pairs the use of HIV self-testing with remote video-based counseling and support from a trained, gender-affirming counselor. This study aims to offer a more positive HIV testing and counseling experience, with the goal of improving HIV testing frequency.

Objective

Project Moxie involves a pilot randomized controlled trial (RCT) of 200 TY aged 15-24 years, who are randomized on a 1:1 basis to control or intervention arms. The aim is to examine whether the addition of counseling provided via telehealth, coupled with home-based HIV testing, can create gains in routine HIV testing among TY over a six-month follow-up period.

Methods

This study implements a prospective pilot RCT of 200 TY recruited online. Participants in the control arm will receive one HIV self-testing kit and will be asked to report their results via the study’s website. Participants in the experimental arm will receive one HIV self-testing kit and will test with a remotely-located counselor during a prescheduled video-counseling session. Participants are assessed at baseline, and at three and six months posttesting.

Results

Project Moxie was launched in June 2017 and recruitment is ongoing. As of August 21, 2017, the study had enrolled 130 eligible participants.

Conclusions

Combining home-based HIV testing and video-based counseling allows TY, an often stigmatized and marginalized population, to test for HIV in a safe and nonjudgmental setting of their choosing. This approach creates an opportunity to reduce the high rate of HIV among TY through engagement in care, support, and linkage to the HIV treatment cascade for those who test positive.

Trial Registration

ClinicalTrials.gov NCT03185975; https://clinicaltrials.gov/ct2/show/NCT03185975 (Archived by WebCite at http://www.webcitation.org/6vIjHJ93s)

Transitioning HIV-infected adolescents to adult care at 14 clinics across the United States: using adolescent and adult providers' insights to create multi-level solutions to address transition barriers

HIV-infected adolescents have disproportionately low rates of care retention and viral suppression. Approximately half disengage from care while transitioning to adult clinics, in part due to fragmented care systems and lack of streamlined protocols. We conducted 58 qualitative interviews with social service and health care providers across 14 Adolescent Trials Network clinics (n = 28) and 20 adult clinics that receive transitioning adolescents (n = 30) from August 2015-June 2016. We used the constant comparative approach to examine processes, barriers, and facilitators of adult care transition. Transition barriers coalesced around three levels. Structural: insurance eligibility, transportation, and HIV-related stigma; Clinical: inter-clinic communication, differences in care cultures, and resource/personnel limitations; and Individual: adolescents' transition readiness and developmental capacity. Staff-initiated solutions (e.g., grant-funded transportation) were often unsustainable and applied individual-level solutions to structural-level barriers. Comprehensive initiatives, which develop collaborative policies and protocols that support providers' ability to match the solution and barrier level (i.e., structural-to-structural), are sorely needed. These initiatives should also support local systematic planning to facilitate inter-clinic structures and communication. Such approaches will help HIV-infected adolescents transition to adult care and improve long-term health outcomes.

Effect of point-of-care CD4 cell count results on linkage to care and antiretroviral initiation during a home-based HIV testing campaign: a non-blinded, cluster-randomised trial

BACKGROUND

HIV disease staging with referral laboratory-based CD4 cell count testing is a key barrier to the initiation of antiretroviral treatment (ART). Point-of-care CD4 cell counts can improve linkage to HIV care among people living with HIV, but its effect has not been assessed with a randomised controlled trial in the context of home-based HIV counselling and testing (HBCT).

METHODS

We did a two-arm, cluster-randomised, controlled efficacy trial in two districts of western Kenya with ongoing HBCT. Housing compounds were randomly assigned (1:1) to point-of-care CD4 cell counts (366 compounds with 417 participants) or standard-of-care (318 compounds with 353 participants) CD4 cell counts done at one of three referral laboratories serving the study catchment area. In each compound, we enrolled people with HIV not engaged in care in the previous 6 months. All participants received post-test counselling and referral for HIV care. Point-of-care test participants received additional counselling on the result, including ART eligibility if CD4 was less than 350 cells per μL, the cutoff in Kenyan guidelines. Participants were interviewed 6 months after enrolment to ascertain whether they sought HIV care, verified through chart reviews at 23 local clinics. The prevalence of loss to follow-up at 6 months (LTFU) was listed as the main outcome in the study protocol. We analysed linkage to care at 6 months (defined as 1-LTFU) as the primary outcome. All analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT02515149.

FINDINGS

We enrolled 770 participants between July 1, 2013, and Feb 28, 2014. 692 (90%) had verified linkage to care status and 78 (10%) were lost to follow-up. Of 371 participants in the point-of-care group, 215 (58%) had linked to care within 6 months versus 108 (34%) of 321 in the standard-of-care group (Cox proportional multivariable hazard ratio [HR] 2·14, 95% CI 1·67-2·74; log rank p<0·0001).

INTERPRETATION

Point-of-care CD4 cell counts in a resource-limited HBCT setting doubled linkage to care and thereby improved ART initiation. Given the substantial economic and logistic hindrances to providing ART for all people with HIV in resource-limited settings in the near term, point of care CD4 cell counts might have a role in prioritising care and improving linkage to care.

FUNDING

US Centers for Disease Control and Prevention.

Factors associated with psychological distress among young women in Kisumu, Kenya

BACKGROUND

Attention to mental health issues is growing globally. In many countries, including Kenya, however, assessment of psychological distress, especially in rural areas, is limited.

METHODS

We analyzed data from young women screened for a longitudinal contraceptive ring study in Kisumu, Kenya. Multivariable regression analysis was used to assess factors associated with recent moderate and high psychological distress, as measured by the Kessler (K-6) psychological distress scale.

RESULTS

Among the 461 women screened, most (58.4%) were categorized as having moderate psychological distress, 20.8% were categorized as having low or no psychological distress, and 20.8% were categorized as having high psychological distress. Moderate psychological distress (vs low/no) was significantly more likely among women who reported a history of forced sex and were concerned about recent food insecurity. High (vs low/no) psychological distress was significantly more likely among women who reported a history of forced sex, who were concerned about recent food insecurity, and who self-reported a sexually transmitted infection.

CONCLUSION

To reduce psychological distress, a focus on prevention as well as care methods is needed. Girls need a path toward a healthy and productive adulthood with a focus on education, which would help them gain skills to avoid forced sex. Women would benefit from easy access to social services and supports that would help them with basic needs like food security among other things. A holistic or ecological approach to services that would address mental, educational, social, health, and economic issues may have the highest chance of having a long-term positive impact on public health.

Creating Systems Change to Support Goals for HIV Continuum of Care: The Role of Community Coalitions to Reduce Structural Barriers for Adolescents and Young Adults

Routine population-wide HIV screening, early linkage and long-term retention in healthcare for HIV-infected individuals are key nodes of the HIV continuum of care and are essential elements of the National HIV/AIDS Strategy. Despite this, up to 80% of youth are unaware of their HIV infection status and only 29% are linked to HIV healthcare; less than half are engaged in long-term HIV healthcare, and far fewer maintain viral suppression. To fill this gap and to address the national call to action to establish a seamless system for immediate linkage to continuous and coordinated quality healthcare after diagnosis, this paper describes the processes and mechanisms by which the SMILE Program worked within the infrastructure of the ATN-affiliated Connect to Protect^® (C2P) community coalitions to address structural barriers that hindered youth in their communities from being tested for HIV infection or linked and engaged in healthcare after an HIV positive diagnosis.

Using a Multitest Algorithm to Improve the Positive Predictive Value of Rapid HIV Testing and Linkage to HIV Care in Nonclinical HIV Test Sites

BACKGROUND

Use of a rapid HIV testing algorithm (RTA) in which all tests are conducted within one client appointment could eliminate off-site confirmatory testing and reduce the number of persons not receiving confirmed results.

METHODS

An RTA was implemented in 9 sites in Los Angeles and San Francisco; results of testing at these sites were compared with 23 sites conducting rapid HIV testing with off-site confirmation. RTA clients with reactive results on more than 1 rapid test were considered HIV+ and immediately referred for HIV care. The positive predictive values (PPVs) of a single rapid HIV test and the RTA were calculated compared with laboratory-based confirmatory testing. A Poisson risk regression model was used to assess the effect of RTA on the proportion of HIV+ persons linked to HIV care within 90 days of a reactive rapid test.

RESULTS

The PPV of the RTA was 100% compared with 86.4% for a single rapid test. The time between testing and receipt of RTA results was on average 8 days shorter than laboratory-based confirmatory testing. For risk groups other than men who had sex with men, the RTA increased the probability of being in care within 90 days compared with standard testing practice.

CONCLUSIONS

The RTA increased the PPV of rapid testing to 100%, giving providers, clients, and HIV counselors timely information about a client's HIV-positive serostatus. Use of RTA could reduce loss to follow-up between testing positive and confirmation and increase the proportion of HIV-infected persons receiving HIV care.

Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review

BACKGROUND

Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide.

OBJECTIVES

We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation.

SEARCH METHODS

We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature.

SELECTION CRITERIA

We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure.

DATA COLLECTION AND ANALYSIS

Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding.

RESULTS

Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics.

CONCLUSIONS

Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

Factors affecting linkage to care and engagement in care for newly diagnosed HIV-positive adolescents within fifteen adolescent medicine clinics in the United States

Early linkage to care and engagement in care are critical for initiation of medical interventions. However, over 50 % of newly diagnosed persons do not receive HIV-related care within 6 months of diagnosis. We evaluated a linkage to care and engagement in care initiative for HIV-positive adolescents in 15 U.S.-based clinics. Structural and client-level factors (e.g. demographic and behavioral characteristics, clinic staff and location) were evaluated as predictors of successful linkage and engagement. Within 32 months, 1,172/1,679 (69.8 %) of adolescents were linked to care of which 1,043/1,172 (89 %) were engaged in care. Only 62.1 % (1,043/1,679) of adolescents were linked and engaged in care. Linkage to care failure was attributed to adolescent, provider, and clinic-specific factors. Many adolescents provided incomplete data during the linkage process or failed to attend appointments, both associated with failure to linkage to care. Additional improvements in HIV care will require creative approaches to coordinated data sharing, as well as continued outreach services to support newly diagnosed adolescents.

Linking HIV-positive adolescents to care in 15 different clinics across the United States: creating solutions to address structural barriers for linkage to care

Linkage to care is a critical corollary to expanded HIV testing, but many adolescents are not successfully linked to care, in part due to fragmented care systems. Through a collaboration of the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC) and the Adolescent Trials Network (ATN), a linkage to care outreach worker was provided to ATN clinics. Factors related to linkage were explored to better understand how to improve retention rates and health outcomes for HIV-positive adolescents. We conducted 124 interviews with staff at 15 Adolescent Trials Network clinics to better understand linkage to care processes, barriers, and facilitators. Content analysis was conducted focusing on structural barriers to care and potential solutions, specifically at the macro-, meso-, and micro-levels. Macro-level barriers included navigating health insurance policies, transportation to appointments, and ease of collecting and sharing client-level contact information between testing agencies, local health departments and clinics; meso-level barriers included lack of youth friendliness within clinic space and staff, and duplication of linkage services; micro-level barriers included adolescents' readiness for care and adolescent developmental capacity. Staff initiated solutions included providing transportation for appointments and funding clinic visits and tests with a range of grants and clinic funds while waiting for insurance approval. However, such solutions were often ad hoc and partial, using micro-level solutions to address macro-level barriers. Comprehensive initiatives to improve linkage to care are needed to address barriers to HIV-care for adolescents, whose unique developmental needs make accessing care particularly challenging. Matching the level of structural solution to the level of structural barriers (i.e., macro-level with macro-level), such as creating policy to address needed youth healthcare entitlements versus covering uninsured patients with clinic funds is imperative to achieving the goal of increasing linkage to care rates for newly diagnosed adolescents.

"Taking a half day at a time:" patient perspectives and the HIV engagement in care continuum

The HIV treatment continuum, or "cascade," outlines key benchmarks in the successful treatment of HIV-infected individuals. However, the cascade fails to capture important dimensions of the patient experience in that it has been constructed from a provider point of view. In order to understand meaningful steps in the HIV care cascade for individuals diagnosed with HIV through expanded, more routine testing, we conducted in-depth interviews (n=34) with three groups of individuals: those diagnosed with HIV in the emergency department/urgent care clinic who linked to HIV care and exhibited 100% appointment adherence in the first 6 months of HIV care; those diagnosed in the emergency department/urgent care clinic who linked to HIV care and exhibited sporadic appointment adherence in the first 6 months of HIV care, and; hospitalized patients with no outpatient HIV care for at least 6 months. This last group was chosen to supplement data from in-care patients. The engagement in care process was defined by a changing perspective on HIV, one's HIV identity, and the role of health care. The linkage to care experience laid the groundwork for subsequent retention. Interventions to support engagement in care should acknowledge that patient concerns change over time and focus on promoting shifts in perspective.

Linking HIV+ adolescents into care: The effects of relationships between local health departments and adolescent medicine clinics

BACKGROUND

The fragmentation of HIV-related diagnostic and treatment services, especially for youth, is a significant barrier for transitioning to care. The study identified key elements that affected care linkage efforts.

METHODS

We conducted 64 interviews across 15 clinical sites. The constant comparative method was used.

RESULTS

Primary linkage to care processes are illustrated through three geographically diverse case studies. Factors included: inter-agency relationships, data sharing protocols, and service duplication concerns. Program improvement strategies were discussed.

CONCLUSIONS

A strong, citywide network is helpful in coordinating care linkage services. These partnerships will be critical in effectively realizing the goals of the National HIV/AIDS.

Linkage to care for HIV-positive adolescents: a multisite study of the adolescent medicine trials units of the adolescent trials network

PURPOSE

To understand linkage to care practices at sites providing clinical services to newly diagnosed HIV-positive adolescents.

METHODS

Qualitative analysis of detailed interviews conducted with 28 personnel involved in linkage to care at 15 sites providing specialty care to HIV-positive adolescents.

RESULTS

We showed that multiple models exist for linkage to care, and that both formal and informal community relationships are important for successful linkage to care. Stigma was seen as a universal issue, enhancing the importance of the balance of confidentiality and social support. Barriers to care, such as mental health issues, substance use, and transportation, are common.

CONCLUSIONS

We conclude that the complexity of linkage to care requires thought and planning as HIV testing is expanded to lower-risk populations.

Using the HIV surveillance system to monitor the National HIV/AIDS Strategy

OBJECTIVES

To report on indicators of the National HIV/AIDS Strategy, we analyzed data collected through the national HIV surveillance system.

METHODS

We analyzed data from adults and adolescents aged 13 years or older diagnosed with HIV in 13 US jurisdictions that have laboratory reporting of CD4+ T-lymphocyte (CD4) and viral load (VL) test results and enter CD4 and VL test results into the national surveillance system.

RESULTS

Of 4899 people diagnosed in 2009, 81.7% had at least 1 CD4 or VL test performed within 3 months of diagnosis. A higher proportion of Whites (86.2%) than Blacks (78.4%) and Hispanics (82.6%) had a CD4 or VL test. Of 53,642 people diagnosed through 2008 and living with HIV at the end of 2009 who had a VL test, 69.4% had a most recent VL of 200 copies per milliliter or less. The proportion of people with suppressed VLs differed among Blacks (60.2%), Hispanics (70.3%), and Whites (77.4%) and among people aged 13 to 24 years (44.3%) compared with people aged 65 years or older (84.2%). Of men who have sex with men, 74.2% had a suppressed VL.

CONCLUSIONS

The findings highlight disparities in access to and success of care.

An exploratory study to examine intentions to adopt an evidence-based HIV linkage-to-care intervention among state health department AIDS directors in the United States

BACKGROUND

Widespread dissemination and implementation of evidence-based human immunodeficiency virus (HIV) linkage-to-care (LTC) interventions is essential for improving HIV-positive patients' health outcomes and reducing transmission to uninfected others. To date, however, little work has focused on identifying factors associated with intentions to adopt LTC interventions among policy makers, including city, state, and territory health department AIDS directors who play a critical role in deciding whether an intervention is endorsed, distributed, and/or funded throughout their region.

METHODS

Between December 2010 and February 2011, we administered an online questionnaire with state, territory, and city health department AIDS directors throughout the United States to identify factors associated with intentions to adopt an LTC intervention. Guided by pertinent theoretical frameworks, including the Diffusion of Innovations and the "push-pull" capacity model, we assessed participants' attitudes towards the intervention, perceived organizational and contextual demand and support for the intervention, likelihood of adoption given endorsement from stakeholder groups (e.g., academic researchers, federal agencies, activist organizations), and likelihood of enabling future dissemination efforts by recommending the intervention to other health departments and community-based organizations.

RESULTS

Forty-four participants (67% of the eligible sample) completed the online questionnaire. Approximately one-third (34.9%) reported that they intended to adopt the LTC intervention for use in their city, state, or territory in the future. Consistent with prior, related work, these participants were classified as LTC intervention "adopters" and were compared to "nonadopters" for data analysis. Overall, adopters reported more positive attitudes and greater perceived demand and support for the intervention than did nonadopters. Further, participants varied with their intention to adopt the LTC intervention in the future depending on endorsement from different key stakeholder groups. Most participants indicated that they would support the dissemination of the intervention by recommending it to other health departments and community-based organizations.

CONCLUSIONS

Findings from this exploratory study provide initial insight into factors associated with public health policy makers' intentions to adopt an LTC intervention. Implications for future research in this area, as well as potential policy-related strategies for enhancing the adoption of LTC interventions, are discussed.

Community HIV treatment advocacy programs may support treatment adherence

Treatment advocacy (TA) programs, based in AIDS service organizations and clinics, aim to engage clients into care and support antiretroviral treatment (ART) adherence through client-centered counseling; advocate for patients with providers; and provide social service referrals. Systematic evaluations of TA are lacking. We conducted a non-randomized evaluation examining relationships of TA participation to adherence, care engagement, social services utilization, unmet needs, patient self-advocacy, and adherence self-efficacy among 121 HIV-positive clients (36 in TA, 85 not in TA; 87% male, 34% African American, 31% White, 19% Latino). In multivariate models, TA participants (vs. non-TA participants) showed higher electronically monitored [85.3% vs. 70.7% of doses taken; b(SE) = 13.16(5.55), p < .05] and self-reported [91.1% vs. 75.0%; b(SE) = 11.60(5.65), p < .05] adherence; utilized more social service programs [Ms = 5.2 vs. 3.4; b(SE) = 1.97(0.48), p < .0001]; and had fewer unmet social-service needs [Ms = 1.8 vs. 2.7; b(SE) = -1.06(0.48), p < .05]. Findings suggest the need for a randomized controlled trial of TA.

A community-based study of barriers to HIV care initiation

Timely treatment of HIV infection is a public health priority, yet many HIV-positive persons delay treatment initiation. We conducted a community-based study comparing HIV-positive persons who received an HIV diagnosis at least 3 months ago but had not initiated care (n=100) with a reference population of HIV-positive persons currently in care (n=115) to identify potential barriers to treatment initiation. Study participants were mostly male (78.0%), and persons of color (54.9% Latino, 26.3% black), with median age 37.8 years. Median time since HIV diagnosis was 3.7 years. Univariate analysis revealed that those never in care differed substantially from those currently in care with regard to sociodemographics; HIV testing and counseling experiences; perceived barriers to care; and knowledge, attitudes, and beliefs regarding HIV. Factors independently associated with never initiating HIV care were younger age (adjusted odds ratio [AOR]=0.93; 95% confidence interval [CI]: 0.88, 0.99), shorter time since diagnosis (AOR=0.87; 95% CI: 0.77, 0.98), lacking insurance (AOR=0.11; 95% CI: 0.03, 0.35), not knowing someone with HIV/AIDS (AOR=0.09; 95% CI: 0.03, 0.30) not disclosing HIV status (AOR=0.13; 95% CI: 0.02, 0.70), not receiving help making an HIV care appointment after diagnosis (AOR=0.04; 95% CI: 0.01, 0.14), and not wanting to think about being HIV positive (AOR=3.57; 95% CI: 1.22, 10.46). Our findings suggest that isolation and stigma remain significant barriers to initiating HIV care in populations consisting primarily of persons of color, and that direct linkages to HIV care at the time of diagnosis are critical to promoting timely care initiation in these populations.

The impact of retention in early HIV medical care on viro-immunological parameters and survival: a statewide study

Current literature on retention in HIV care fails to account for patients who continually/simultaneously access different providers. This statewide study examined retention in early HIV medical care and its impact on viro-immunological improvement and survival outcomes. It was a retrospective study of South Carolina residents ≥13 years old who were diagnosed with HIV infection in 2004-2007 and initially entered in care. CD4 count/percent and viral load (VL) tests that must be reported to the South Carolina HIV surveillance database were used as a proxy for a clinical visit. Retention was defined as at least one visit in each of four 6-month periods over 2 years postlinkage. Retention rates were categorized as "optimal" (visits in four intervals), "suboptimal" (visits in three intervals), sporadic (visits in two or one intervals), and "dropout" (no visits). Logistic regression and Cox proportional analyses were used to examine retention. Of the 2197 persons, about 50% failed to maintain optimal retention in care postlinkage. Male gender, nonwhite race/ethnicity, younger age, delayed linkage, and HIV-only status were significant predictors of lower rate of retention. Mean decrease in baseline log(10) VL was greater among those with optimal compared to suboptimal (-1.81 vs. -1.42; p < 0.001) and sporadic retention (-1.81 vs. -0.70; p < 0.001). Mean increase in baseline CD4 count was greater in optimal retention compared to suboptimal (169.70 vs. 107.5; p < 0.001) and sporadic retention (169.70 vs. 2.43; p < 0.001). Increased risk of mortality was associated with sporadic retention (aHR 2.91; 95% CI 1.54-5.50) and "dropout" (aHR 4.00; 95% CI 1.50-10.65). Rate of poor retention in early HIV medical care was relatively higher than reported in clinic-based data. Increasing the rate of retention in early HIV care could substantially improve viro-immunological parameters and survival outcomes.

Predictors of time to enter medical care after a new HIV diagnosis: a statewide population-based study

Public health benefits of expanded HIV screening will be adequately realized only if an early diagnosis is followed by prompt linkage to care. We characterized rates and factors associated with failure to enter into medical care within three months of HIV diagnosis and assessed the predictors of time to enter care over a follow-up period of up to 60 months. The study cohort included 3697 South Carolina (SC) residents' ≥13 years who were newly HIV-diagnosed in 2004-2008. Date of first laboratory report of CD4(+) T-cell count or viral load (VL) test after 30 days of confirmatory HIV diagnosis was used to define time to linkage to care. Results showed that of the total 3697 persons, 1768 (48%) entered care within three months, 1115 (30%) in four-12 months after diagnosis, and 814 (22%) failed to initiate care within 12 months of HIV diagnosis. At the end of study follow-up period of up to 60 months from the date of HIV diagnosis, 472/3697 (13%) individuals remained out of care. Multivariable Cox proportional hazards analysis showed that compared with hospitals, time to enter care was shorter in those diagnosed at state mental health/correctional facilities (adjusted hazards ratio [aHR] 1.16; 95% confidence interval [CI] 1.02-1.34) and longer in those diagnosed at county health departments (aHR 0.87; 95% CI 0.80-0.96) and at "Other/unknown" facilities (aHR 0.79; 95% CI 0.70-0.89). Time to entry into care was longer for men (aHR 0.82; 95% CI 0.75-0.89) compared with women, blacks (aHR 0.91; 95% CI 0.83-0.98) compared with whites, and males who have sex with males (MSM) (aHR 0.89; 95% CI 0.80-0.98) compared with heterosexual exposure. Delayed entry into HIV care remains a challenge in controlling HIV transmission in SC. Better integration of testing and care facilities could improve the proportion of newly HIV-diagnosed persons who enter care in a timely manner.

Intensive case management before and after prison release is no more effective than comprehensive pre-release discharge planning in linking HIV-infected prisoners to care: a randomized trial

Imprisonment provides opportunities for the diagnosis and successful treatment of HIV, however, the benefits of antiretroviral therapy are frequently lost following release due to suboptimal access and utilization of health care and services. In response, some have advocated for development of intensive case-management interventions spanning incarceration and release to support treatment adherence and community re-entry for HIV-infected releasees. We conducted a randomized controlled trial of a motivational Strengths Model bridging case management intervention (BCM) beginning approximately 3 months prior to and continuing 6 months after release versus a standard of care prison-administered discharge planning program (SOC) for HIV-infected state prison inmates. The primary outcome variable was self-reported access to post-release medical care. Of the 104 inmates enrolled, 89 had at least 1 post-release study visit. Of these, 65.1% of BCM and 54.4% of SOC assigned participants attended a routine medical appointment within 4 weeks of release (P > 0.3). By week 12 post-release, 88.4% of the BCM arm and 78.3% of the SOC arm had at attended at least one medical appointment (P = 0.2), increasing in both arms at week 24-90.7% with BCM and 89.1% with SOC (P > 0.5). No participant without a routine medical visit by week 24 attended an appointment from weeks 24 to 48. The mean number of clinic visits during the 48 weeks post release was 5.23 (SD = 3.14) for BCM and 4.07 (SD = 3.20) for SOC (P > 0.5). There were no significant differences between arms in social service utilization and re-incarceration rates were also similar. We found that a case management intervention bridging incarceration and release was no more effective than a less intensive pre-release discharge planning program in supporting health and social service utilization for HIV-infected individuals released from prison.