Optimizing Community-Based HIV Testing and Linkage to Care for Young Persons in Metropolitan Atlanta

Vital Voices: HIV Prevention and Care Interventions Developed for Disproportionately Affected Communities by Historically Underrepresented, Early-Career Scientists

BACKGROUND

HIV prevention interventions which support engagement in care and increased awareness of biomedical options, including pre-exposure prophylaxis (PrEP), are highly desired for disproportionately affected Black/African American, Hispanic/Latinx and gay, bisexual, and other men who have sex with men (GBMSM) populations in the United States (US). However, in almost 40 years of HIV research, few interventions have been developed directly by and for these priority populations in domestic counties most at risk. We submit that interventions developed by early-career scientists who identify with and work directly with affected subgroups, and which include social and structural determinants of health, are vital as culturally tailored HIV prevention and care tools.

METHODS

We reviewed and summarized interventions developed from 2007 to 2020 by historically underrepresented early-career HIV prevention scientists in a federally funded research mentoring program. We mapped these interventions to determine which were in jurisdictions deemed as high priority (based on HIV burden) by national prevention strategies.

RESULTS

We summarized 11 HIV interventions; 10 (91%) of the 11 interventions are in geographic areas where HIV disparities are most concentrated and where new HIV prevention and care activities are focused. Each intervention addresses critical social and structural determinants of health disparities, and successfully reaches priority populations.

CONCLUSION

Focused funding that supports historically underrepresented scientists and their HIV prevention and care intervention research can help facilitate reaching national goals to reduce HIV-related disparities and end the HIV epidemic. Maintaining these funding streams should remain a priority as one of the tools for national HIV prevention.

At-Risk Groups of Men Who Have Sex With Men Can Be Reached Through Community-Based HIV Testing in Denmark

This study evaluates whether the community-based HIV testing clinic Checkpoint could reach at-risk groups of men who have sex with men (MSM) and link patients to care. A prospective observational study of all Checkpoint visits during 2013-2016 and a retrospective registry study of all MSM diagnosed with HIV in Denmark during the same period were conducted. One percent of the 9,074 tests in Checkpoint were HIV-positive, accounting for 19% of all new HIV diagnoses among MSM in Denmark. Checkpoint testers reported frequent condomless anal sex. Two percent of migrant Checkpoint testers were HIV-positive compared to 1 % among Danish MSM. HIV-positive MSM identified through Checkpoint were significantly younger, more of them were migrant, and a smaller proportion were late testers compared to those testing through the conventional health care system. Checkpoint reaches at-risk populations of MSM and links patients successfully to care.

Cascade Analysis of Anonymous Voluntary HIV Counseling and Testing Among Patients with HIV Infection in Taiwan

Despite successful implementation of anonymous voluntary human immunodeficiency virus (HIV) counseling and testing (aVCT) in Taiwan, the trend of late HIV presentation in sexually active populations has remained unchanged in Taiwan over the past decade. We evaluated the effect and acceptance of an aVCT cascade program among Taiwanese individuals by surveying 572 participants (mean age: 29.6 years; 99.3% men; and 79.5% same-sex sexual contact) diagnosed with HIV/acquired immune deficiency syndrome (AIDS) from 2015 to 2019. We designed a five-stage continuum based on acceptance of the program before HIV diagnosis: at high risk of HIV infection (Stage 1), heard of aVCT (Stage 2), wants to receive aVCT (Stage 3), has received aVCT (Stage 4), and regularly receives aVCT (Stage 5). Four domains established from exploratory factor analysis described reasons for inability to reach the next aVCT stage: low perceived HIV risk, fear of testing positive because of discrimination/stigmatization, and structural barriers to aVCT. Regular aVCT (vs. never receiving aVCT) protected against AIDS on diagnosis (p < 0.001). There were no significant differences in program acceptance across 2015-2019. However, uptake reduced markedly across the program; the largest reduction (37.4.0-61.0%) occurred from Stage 4 to Stage 5. Fear of testing positive because of discrimination/stigmatization was the main reason for not proceeding to the next aVCT stage. Although the findings indicate the benefits of regular aVCT for early HIV diagnosis, additional strategies to reduce fear of negative social consequences of HIV infection are prioritized to optimize aVCT in Taiwan.

Factors Associated with HIV Seroconversion Among Women Attending an Urban Health Clinic in the South: A Matched Case-Control Study

Compared to knowledge about HIV risk factors among men in the south, less is known about risk factors for women. We conducted an individually matched case-control study to identify factors associated with HIV seroconversion among women. Cases had a clinician-assisted visit (CAV) between 2011 and 2016 at an Atlanta-based public health clinic before HIV diagnosis. Controls were women who visited the clinic but remained HIV negative. Controls were matched to cases in a 2:1 ratio on race, age at first CAV, and date of first CAV. Conditional logistic regression was used to develop a best-fitting model for characterizing HIV risk. Of 18,281 women who were HIV negative at their first visit, 110 (0.6%) seroconverted before 2019. Of these, 80 (73%) had a CAV before HIV diagnosis. Having multiple gonorrhea episodes, a syphilis episode, a greater number of sex partners in the past 2 months, anal sex, history of drug use, history of exchanging drugs or money for sex, and heterosexual sex with >1 sex partner in the last month were individually associated with HIV seroconversion. In multivariate analyses, having a syphilis episode [odds ratio (OR) = 4.7, 95% confidence interval (CI): 1.3-16.3], anal sex (OR = 2.8, 95% CI: 1.0-8.1), and injection drug or crack cocaine use (OR = 33.5, 95% CI: 3.6-313.3) remained associated with HIV. Women having all three risk factors were six times more likely to seroconvert compared to women without these factors. Our results offer insights into which women in a southern HIV "hotspot" may be at greatest risk for HIV.

Metropolitan Atlanta Community Adolescent Rapid Testing Initiative: The impact of motivational interviewing and intensive case management on the psychosocial and clinical care outcomes of adolescents and young adults with HIV

Early diagnosis and treatment are critical to preventing HIV-related complications and transmission for adolescents and young adults with HIV. The Metropolitan Atlanta Community Adolescent Rapid Testing Initiative (MACARTI) was a single-center, prospective, nonrandomized, interventional control group study incorporating motivational interviewing psychotherapy strategies with community outreach, HIV testing, and intensive case management. This substudy of MACARTI examined how the motivational interviewing and case management components influenced psychological distress, proactive coping, HIV/AIDS stress, and HIV stigma in association with HIV disease markers (HIV viral load and CD4⁺ T-cell counts). Ninety-eight adolescents and young adults with HIV (M_age = 21.5 ± 1.8, range 18-24) were allocated to either the standard of care (n = 49) or MACARTI (n = 49) arms, and results were compared between these two groups. Baseline and follow-up surveys measured psychological distress, proactive coping, HIV/AIDS stress, and HIV stigma. MACARTI arm assignment was associated with statistically significant reductions in psychological distress (p = .016), HIV/AIDS stress (p = .023), and the use of more reflective coping (p = .016) and strategic planning strategies (p = .001) during the first 6 months. These results did not remain significant at 1-year follow-up but may still provide support for the integration of psychotherapy strategies into HIV identification, linkage, and retention efforts in the future. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Predicting HIV testing in low threshold community contexts among young African American women living in the Southern United States

Southern U.S. African American women have disproportionately high HIV infection rates, and increasing HIV testing is a prevention priority. Research suggests that optimal testing conditions involve reaching out to community members and offering free tests in private, supportive contexts with minimal delays for results. These conditions were implemented with young African American women (N = 223, M age = 20.4 years) living in disadvantaged areas of a Southern U.S. city to identify participant characteristics associated with test choice. Participants were recruited using Respondent Driven Sampling. Structured field interviews assessed personal and social network characteristics, sexual practices, substance use, and behavioral impulsivity (assessed by a delay discounting task). A free HIV test was then offered, and test choice was the outcome variable. Testing was accepted by 69%, which exceeded the national lifetime test rate for this population by 7.4% (p < .05). All were sero-negative. Test refusal (31%) was associated with poorer educational performance, greater impulsivity (discounting), less social network encouragement to use birth control (ps < .05), and lower engagement in sexual risk behaviors (p < .10). Test choice did not differ by substance involvement. Thus, low threshold community testing promoted acceptance among this priority population, although a minority with specific characteristics likely need additional incentives for test acceptance.

Jail-Based Case Management Improves Retention in HIV Care 12 Months Post Release

Continuous and coordinated HIV care is essential for persons living with HIV to benefit from the advances in medical treatment of the disease. Approximately one in seven individuals living with HIV pass through correctional facilities annually. While sentenced individuals may receive discharge planning services, detainees in local jails usually do not. The multisite evaluation of the EnhanceLink initiative demonstrated that jail based services including discharge planning were associated with high rates of linkage to community HIV care upon release. Follow up for the multisite evaluation was limited to 6 months. This paper extends follow up to 12 months at one site and demonstrates that clients who were linked by the jail based case manager to a Ryan White community based case manager were more than nine times more likely to be retained in care at 12 month post release. (OR 9.39, CI 1.11-79.12).

Reasons for Accepting and Declining Free HIV Testing and Counseling Among Young African American Women Living in Disadvantaged Southern Urban Communities

Advancing HIV prevention and treatment among at-risk Southern communities of color requires understanding why voluntary HIV testing is accepted or declined. Reasons for testing decisions were investigated among young African American women (n = 223, mean age = 20.4 years) recruited from disadvantaged areas in a Southern US city. A free HIV test was offered following field interviews that assessed HIV risk behaviors and personal and social network characteristics; 69.1% accepted testing, and all were seronegative. After their decision, participants rated reasons for their choice, which were factor analyzed. A four-factor solution showed that test acceptance was related to (1) current sexual relationships and HIV risk concerns, (2) knowledge of HIV medical treatment benefits, (3) awareness of persons living with HIV, and (4) health protection and HIV test convenience. A three-factor solution showed that test refusal was related to (1) negative consequences of a positive test and privacy concerns, (2) low perception of HIV risk, and (3) anticipated social rejection if the test was positive. Comparisons of factor-based average item scores showed that health protection/HIV test convenience was rated as most influential in test acceptance decisions, whereas low perception of HIV risks was rated as most influential in test rejection decisions. The findings suggest that test acceptance can be promoted by offering free, convenient HIV testing as a health check in a testing context that assesses and provides feedback about participants' HIV risk levels.