Vital Signs: Status of Human Immunodeficiency Virus Testing, Viral Suppression, and HIV Preexposure Prophylaxis - United States, 2013-2018

Cannabis use and HIV among Black sexually minoritized men: a systematic review and narrative analysis

OBJECTIVE

We conducted a systematic review evaluating the extant literature examining the impacts of cannabis use on HIV-related outcomes among Black sexual minoritized men (BSMM).

DESIGN

A systematic review.

METHODS

We conducted a search in November 2024 of PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science using keywords related to BSMM, HIV, and cannabis. Study quality was assessed utilizing a tool developed for observational studies. One hundred eight unique articles were screened with 55 undergoing full-text review, and 20 met inclusion criteria. Results were synthesized and presented utilizing a narrative review process.

RESULTS

We identified 20 studies published between 1999 and 2024. Measures of cannabis use included any use (e.g., ever, past 30 days), daily/intermittent/heavy use, use before/during sex, and problematic use. Outcomes included HIV positivity/seroconversion, HIV Continuum of Care (CoC), PrEP CoC, and sex behavior strengths, vulnerabilities, and assets. Study findings were generally mixed, however positive associations between cannabis use and HIV seroconversion, inconsistent condom use, being HIV-positive and unaware of one's serostatus, and suboptimal ART adherence were reported.

CONCLUSION

This systematic review identified a growing literature on cannabis use and HIV among Black SMM. Conclusions that can be drawn from the evidence are limited. There is a critical need for studies that more rigorously measure cannabis use by considering contexts of cannabis use. In addition, there is a need for research that examines the pathways and mechanisms through which cannabis use may affect prevention and treatments outcomes related to HIV among Black SMM.

Association Between Dynamic Viral Rebound and Longitudinal Measures of Viral Load/CD4 Counts Among People with HIV in South Carolina

Monitoring HIV viral rebound (VR) is crucial, as it indicates an increased risk of infection, transmission, disease progression, and drug resistance. This study aims to identify the association between dynamic VR and historical viral load (VL)/CD4 count measures. Fifteen-year South Carolina population-based electronic health record data were used for the study. VR was defined as the return of detectable levels of VL (>200 copies/mL) after stable viral suppression (VS) (two consecutive VS, i.e., VL ≤200 copies/mL). A generalized linear mixed model was used to evaluate the association between dynamic VR and historical time-dependent predictors, such as nadir CD4 count and comorbidities, within a year prior to each VR. Subgroup analysis for men who have sex with men (MSM) was also conducted. Among 8,185 people with HIV (PWH), 1,173 (14.3%) had a history of VR. Lower nadir CD4 count (≥500 vs. <200 cells/µL; adjusted odds ratio [aOR]: 0.51, 95% confidence interval [CI]: [0.43, 0.60]), younger age (>60 years old vs. 18-30 years old; aOR: 0.43, 95% CI: [0.29, 0.63]), and being Black (Black vs. White; aOR: 1.58, 95% CI: [1.34, 1.85]) were associated with a higher risk of VR, while MSM (MSM vs. heterosexual; aOR: 0.81, 95% CI: [0.67, 0.96]) were associated with decreased VR risk. The rate of VR among PWH in South Carolina is significant. Within-1-year VL/CD4 test is critical for identifying PWH at risk for VR. Tailored interventions are needed for PWH at risk for VR to achieve sustained suppression and better health outcomes.

Co-creating strategies to promote uptake of HIV self-testing among young adults in Mecklenburg county, North Carolina: a protocol for a pilot implementation study

Background

HIV testing is the gateway to entering HIV care and prevention services. However, HIV testing rates remain low among young adults (18-29 years old) in Mecklenburg County, North Carolina (NC), an ending the HIV epidemic (EHE) priority jurisdiction. We aim to utilize community-engaged and participatory approaches to co-create implementation strategies to promote the reach and uptake of HIV self-testing (HIVST) among young adults in the region. This study protocol outlines the phases of the project and the proposed outcomes.

Methods

The Community-engaged Approaches to Expand HIV Self-Testing among Young Adults in Mecklenburg County, North Carolina (CATEST) project will be conducted in three phases, guided by the Consolidated Framework for Implementation Research (CFIR), Community-based Participatory Research (CBPR), and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks. The formative phase of the study, guided by CFIR, will focus on understanding the barriers, facilitators, and opportunities for implementing HIVST among young adults in Mecklenburg County, North Carolina. The second phase, guided by CBPR, will utilize participatory approaches such as crowdsourcing open calls and charrettes to co-create implementation strategies for HIVST. Then, the final pilot implementation phase, guided by CFIR and RE-AIM, will use mixed methods to evaluate the success of the co-created HIVST implementation strategies using a pre-post design. Participants in the study will complete a baseline survey and a follow-up survey immediately following intervention completion. In addition, a purposive sample of participants and representatives at the participating community organization will complete qualitative exit interviews within 1 month of intervention completion.

Discussion

This study protocol outlines the co-creation of implementation strategies, tests their feasibility, and explores preliminary effectiveness in promoting HIVST uptake among young adults in Mecklenburg County, NC. The study will yield insights on the feasibility of leveraging the capabilities of community and youth innovation to promote young adults-centered implementation strategies to advance the reach and adoption of HIVST among young adults.

Registration

Registered on Open Science Forum-DOI 10.17605/OSF.IO/2BZWV.

Acceptability and feasibility of HIV self-testing integration into publicly-funded HIV prevention services: Perspectives from HIV testing agency staff that provide HIV testing services to sexual and gender minority youth in Philadelphia County

BACKGROUND

Increasing HIV testing among priority populations is a primary strategy of the Ending the HIV Epidemic initiative. In October 2019, the Philadelphia Department of Public Health (PDPH) established a program to distribute publicly-funded HIV self-testing (HIVST) kits to Philadelphia County residents aged 16 years and older.

METHODS

Through a community-academic partnership, we used a cross-sectional sequential transformative mixed-methods design to examine perceived organizational factors, opportunities, and challenges to HIVST integration among agency staff at PDPH-funded agencies early in the COVID-19 pandemic due to decreased access to traditional in-person HIV testing services with a focus on agencies whose client populations included sexual and gender minority clients assigned male sex birth aged 13 to 24 years (not the sole population served at each agency). We integrated data from online surveys conducted with HIV testers (test counselors and testing leads), agency leaders (agency leads and directors), and care navigators (n =  42), and semi-structured interviews with HIV testers and agency leaders (n =  11) employed at PDPH-funded agencies.

RESULTS

Many staff were familiar with HIVST (79%), and approximately two-thirds (64%) were likely to encourage HIVST to clients. In interviews, perceived benefits of HIVST integration were increased access to HIV testing, accommodation for client privacy, decreased risk of stigmatizing encounters, and testing program adaptability. Perceived challenges were loss of connection with clients, suboptimal linkage to HIV treatment and prevention services after self-testing, concerns regarding clients' correct use or interpretation of test results, and client preference.

CONCLUSIONS

Agency staff described HIVST as a useful tool for expanding low-barrier HIV testing services; however, staff foresaw potential implementation challenges. To optimize HIVST as a long-term strategy, resources are needed to increase familiarity and comfort with HIVST and enhance staff's capacity to establish meaningful client connections and link clients to post-test HIV treatment and pre-exposure prophylaxis services.

An Adaptive Antiretroviral Therapy Adherence Intervention for Youth with HIV Through Text Message and Cell Phone Support with and without Incentives: A Sequential Multiple Assignment Randomized Trial (SMART)

Youth living with HIV have low rates of medication adherence. Youth ages 15-24 years with adherence ≤ 80% or with HIV RNA PCRs (VL) ≥ 200 recruited through social media and clinical sites were randomized to brief weekday cell phone support (CPS) calls or daily, two-way, personalized text message (SMS) reminders for 3 months. Those with VL ≥ 200 or adherence ≤ 80% were rerandomized to receive SMS or CPS with monthly incentives for those utilizing the intervention at least 75% of days for 3 months. Those with VL < 200 or adherence > 80% after the initial 3 months were rerandomized to usual care or 3 months of tapered, 2x/week CPS or SMS. Self-reported adherence and VLs were collected every 3 months for one year. Eighty-three youth were recruited with 81% identifying as cisgender males, 55% Black, 22% Latine/x, and 76% gay, and 56% recruited from the Southern US. Both cohorts initially randomized to CPS and SMS demonstrated significant improvements in adherence over the 12-months (P <.001). Participants randomized to CPS had significant improvements in 7-day self-reported adherence over 12 months compared to those on SMS (P <.027). Those receiving a tapered intervention for an additional 3 months had improved self-reported adherence compared to those randomized to the standard of care arm (P <.001). Both SMS and CPS appear to be effective interventions for youth with poor antiretroviral adherence. Tapering the intervention for an additional 3 months is useful in maintaining adherence after the initial intervention. Additional research is required to determine how to best sequence these interventions, including the use of incentives.

Using Machine Learning Techniques to Predict Viral Suppression Among People With HIV

BACKGROUND

This study aims to develop and examine the performance of machine learning (ML) algorithms in predicting viral suppression among statewide people living with HIV (PWH) in South Carolina.

METHODS

Extracted through the electronic reporting system in South Carolina, the study population was adult PWH who were diagnosed between 2005 and 2021. Viral suppression was defined as viral load <200 copies/mL. The predictors, including sociodemographics, a historical information of viral load indicators (eg, viral rebound), comorbidities, health care utilization, and annual county-level factors (eg, social vulnerability), were measured in each 4-month windows. Using historic information in different lag time windows (1-, 3- or 5-lagged time windows with each 4-month window as a unit), both traditional and ML approaches (eg, Long Short-Term Memory Network) were applied to predict viral suppression. Comparisons of prediction performance between different models were assessed by area under curve (AUC), recall, precision, F1 score, and Youden index.

RESULTS

ML approaches outperformed the generalized linear mixed model. In all the 3 lagged analysis of a total of 15,580 PWH, the Long Short-Term Memory Network (Lag 1: AUC = 0.858; Lag 3: AUC = 0.877; Lag 5: AUC = 0.881) algorithm outperformed all the other methods in terms of AUC performance for predicting viral suppression. The top-ranking predictors that were common in different models included historical information of viral suppression, viral rebound, and viral blips in the Lag-1 time window. Inclusion of county-level variables did not improve the model prediction accuracy.

CONCLUSIONS

Supervised ML algorithms may offer better performance for risk prediction of viral suppression than traditional statistical methods.

Peer-Led Adjunctive Interventions for Increasing the Reach of HIV Prevention and Care Interventions to Latino/x/e Men Who Have Sex with Men: a Scoping Review

PURPOSE OF REVIEW

Latino/x/e men who have sex with men (LMSM) in the United States are disproportionately affected by HIV. Peer-led adjunctive interventions show promise for enhancing engagement in HIV prevention and care among LMSM, but their effectiveness and implementation remain underexplored. This scoping review aimed to map existing evidence on peer-led interventions, identify gaps, and inform future research for enhancing HIV prevention and care among LMSM.

RECENT FINDINGS

We followed PRISMA-ScR guidelines, covering literature from 2011 to 2022, using Covidence for systematic screening and data extraction. Articles were categorized by intervention aspects like delivery methods, outcomes, translational phases, theory-informed approaches, and cultural adaptation levels. The search yielded 613 records, with 22 meeting eligibility criteria, including 17 unique interventions. Interventions were delivered individually (57%), in groups (30%), to couples (4%), and via public campaigns (4%). Outcomes included HIV testing uptake (74%), treatment linkage (39%), PrEP uptake (22%), and PEP uptake (4%). Translational phases included formative (22%), pilot (26%), efficacy (22%), and effectiveness (22%). Cultural adaptations were surface (22%) and deep (13%). Findings indicate diverse peer-led interventions for LMSM, though many are in early stages of development. Further research is needed to move these interventions along the translational pathway to enhance their public health impact.

Designing a blockchain technology platform for enhancing the pre-exposure prophylaxis care continuum

Objectives

Pre-exposure prophylaxis (PrEP) is a key biomedical intervention for ending the HIV epidemic in the United States, but its uptake is impeded by systemic barriers, including fragmented workflows and ineffective data coordination. This study aims to design PrEPLinker, a blockchain-based, client-centered platform to enhance care to address these challenges by improving care coordination and enabling clients to securely manage their identity and PrEP-related data.

Materials and Methods

Using Houston, Texas, as a use case, we conducted a needs assessment with PrEP collaborators to evaluate existing workflows and identify barriers in the PrEP care continuum. Based on these findings, we designed PrEPinker, a blockchain-based identity framework and digital wallet using self-sovereign identity and verifiable credentials (VCs). These features enable clients to securirely control their identity data and facilitate efficient, privacy-serving data sharing across PrEP service points, such as community testing sites, clinics, and pharmacies.

Results

The needs assessment identified significant gaps in data exchange for PrEP referrals and follow-up appointments. In response, PrEPLinker was designed to incorporate decentralized identifiers-unique, secure digital identifiers that are not linked to any centralized authority-and VCs for ensuring seamless transfer of digital medical records. Preliminary usability testing with 15 participants showed that over 70% rated the interactive design positively, finding it easy to use, learn, and navigate without technical support. Additionally, more than 80% expressed confidence in using the blockchain based platform to manage sensitive health information securely.

Discussion and Conclusion

Blockchain technology offers a promising, client-centered solution for addressing systemic barriers in PrEP care by improving data cordination, security, and client control over personal health information. The design of PrEPLinker demorates the potential to streamline PrEP referrals, follow-up processes, and data managent. These advancements in data coordination and secruity could improve PrEP uptake and adherence, supporting efforts to reduce HIV transmission in Houston and beyond.

Assessing Knowledge, Practices, and Barriers to PrEP and nPEP Prescription Among Texas Healthcare Providers

BACKGROUND

The effectiveness of pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP) in preventing HIV is well-established, yet their use in clinical practice remains low. Healthcare providers, especially those in primary and emergency care settings, play a crucial role in adopting and implementing these prevention strategies. We conducted a statewide survey with 519 healthcare providers in Texas to assess their knowledge, practices, and barriers related to prescribing PrEP and nPEP.

METHODS

The survey collected data on demographics, clinical experience, practice type, awareness of recommended guidelines, knowledge of PrEP and nPEP, prescribing practices, and challenges encountered to prescribe these medications. We used multiple regression analysis to identify factors associated with PrEP and nPEP prescribing behavior.

RESULTS

While most providers were familiar with CDC and/or USPSTF-recommended PrEP guidelines, fewer had adequate knowledge of nPEP. Key challenges identified by providers included concerns about cost (48%), limited time (40% for PrEP and 51% for nPEP), and insufficient education or training (40% for PrEP and 35% for nPEP). Providers who were more familiar with the recommended guidelines and had greater experience in sexual health assessment were more likely to prescribe both PrEP and nPEP.

CONCLUSIONS

This study highlights the need for enhanced education and training to boost providers' knowledge and confidence in prescribing PrEP and nPEP. It also underscores the importance of addressing cost-related barriers and simplifying care processes to better integrate these HIV prevention strategies into primary and emergency care settings.

PrEP your step: Implementing an online crowdsourcing contest to engage young people in HIV prevention in Washington DC, USA

HIV incidence among young people (Black and Latinx women and men who have sex with men ages 16-24 years), in the United States is high. Traditional top-down approaches for pre-exposure prophylaxis (PrEP) social marketing are not effectively reaching this population. Crowdsourcing is a promising approach to engaging young people in the development of innovative solutions to raise awareness and use of PrEP among those at highest risk of HIV. This study engaged young people in the design and evaluation of an online crowdsourcing contest to promote PrEP among Washington, DC youth. The contest used standard methods recommended by the World Health Organization and feedback from our community partners. Online recruitment using social media elicited online votes and survey responses. We analyzed cross-sectional surveys using descriptive statistics, and semi-structured interviews with contest participants using thematic coding to explore barriers and facilitators to contest engagement. Approximately 82% of entries were from young people in DC. A convenience sample of 181 people voted on their favorite crowdsourced PrEP messages and shared their awareness and attitudes about PrEP. The contest website received 2,500 unique visitors and 4,600 page views. Themes from semi-structured interviews (n = 16) included the need for more community engagement in developing PrEP messaging and positive attitudes towards crowdsourcing. Survey data (n = 887) showed that the crowdsourced messages were well-liked and resonated with the community. Most preferred to see PrEP messages in social media (23%), email (17%) and videos (14%). Approximately 70% of survey participants reported that after viewing the crowdsourced message they would talk to their sexual partner or medical provider (63%) about PrEP, use PrEP (58%), and learn more about PrEP (56%). Crowdsourced messages solicit substantial online viewership. More implementation research is needed to understand the public health impact of integrating social media, crowdsourcing, and community engagement to develop PrEP promotional messages.

Complexity and Variation in Infectious Disease Birth Cohorts: Findings from HIV+ Medicare and Medicaid Beneficiaries, 1999-2020

The impact of uncertainty in information systems is difficult to assess, especially when drawing conclusions from human observation records. In this study, we investigate survival variation in a population experiencing infectious disease as a proxy to investigate uncertainty problems. Using Centers for Medicare and Medicaid Services claims, we discovered 1,543,041 HIV+ persons, 363,425 of whom were observed dying from all-cause mortality. Once aggregated by HIV status, year of birth and year of death, Age-Period-Cohort disambiguation and regression models were constructed to produce explanations of variance in survival. We used Age-Period-Cohort as an alternative method to work around under-observed features of uncertainty like infection transmission, receiver host dynamics or comorbidity noise impacting survival variation. We detected ages that have a consistent, disproportionate share of deaths independent of study year or year of birth. Variation in seasonality of mortality appeared stable in regression models; in turn, HIV cases in the United States do not have a survival gain when uncertainty is uncontrolled for. Given the information complexity issues under observed exposure and transmission, studies of infectious diseases should either include robust decedent cases, observe transmission physics or avoid drawing conclusions about survival from human observation records.

Associations of stigma, loneliness, and treatment self-regulation with HIV medication adherence among individuals with substance use disorder using a mobile health application

Introduction

Medication adherence contributes to poor HIV outcomes, especially among people with HIV and Substance use disorder (SUD). Mobile health applications have been leveraged to improve behavioral health outcomes among this population. Our cross-sectional study examined the relationship between medication adherence with factors such as treatment self-regulation, isolation, and internalized stigma, among people with HIV and SUD using the Addiction Comprehensive Health Enhancement Support System (A-CHESS) mobile app.

Methods

A sample of 208 participants using A-CHESS to improve treatment adherence completed a survey. Adherence was measured using the Four-item Morisky Medication Adherence Scale and dichotomized (maximum score of 20 points considered as adherent). Positive and negative affect was measured separately using Positive Affect Negative Affect Schedule and loneliness was measured using UCLA three-item Loneliness Scale. Internalized stigma was measured using Internalized AIDS-Related Stigma Scale. Competence/Treatment self-regulation was measured using Treatment Self-regulation Questionnaire. Multivariable logistic regression was used to assess the associations of affect, treatment self-regulation, isolation, and internalized stigma, with adherence to antiretroviral therapy adjusting for age, education, and gender.

Results

Among 208 participants in this study, most were Black (n = 137; 66%), male (n = 156; 75%) and had a mean age of 46 (standard deviation = 11.3). The most reported substances associated with missing HIV medication were alcohol (27%) and cocaine/crack (20%). Logistic regression analysis revealed that internalized stigma was significantly associated with HIV medication adherence (OR = 0.82; 95% CI: 0.70-0.99; p = 0.034).

Conclusion

Internalized stigma was significantly associated with HIV medication adherence. Further research is needed to better understand this relationship and develop interventions addressing stigma in people with HIV and SUD.

Hospital readmissions among adults living with and without HIV in the US: findings from the Nationwide Readmissions Database

Background

Thirty-day hospital readmission measures quality of care, but there are limited data among people with HIV (PWH) and people without HIV (PWoH) in the era of universal recommendation for antiretroviral therapy. We descriptively compared 30-day all-cause, unplanned readmission risk between PWH and PWoH.

Methods

A retrospective cohort study was conducted using the 2019 Nationwide Readmissions Database (2019/01/01-2019/12/31), an all-payer database that represents all US hospitalizations. Index (initial) admissions and readmissions were determined using US Centers for Medicare & Medicaid Services definitions. Crude and age-adjusted risk ratios (aRR) comparing the 30-day all-cause, unplanned readmission risk between PWH to PWoH were estimated using random effect logistic regressions and predicted marginal estimates. Survey weights were applied to all analyses.

Findings

We included 24,338,782 index admissions from 18,240,176 individuals. The median age was 52(IQR = 40-60) years for PWH and 61(IQR = 38-74) years for PWoH. The readmission risk was 20.9% for PWH and 12.2% for PWoH (age-adjusted-RR:1.88 [95%CI = 1.84-1.92]). Stratified by age and sex, young female (age 18-29 and 30-39 years) PWH had a higher readmission risk than young female PWoH (aRR = 3.50 [95%CI = 3.11-3.88] and aRR = 4.00 [95%CI = 3.67-4.32], respectively). While the readmission risk increased with age among PWoH, the readmission risk was persistently high across all age groups among PWH. The readmission risk exceeded 30% for PWH admitted for hypertensive heart disease, heart failure, and chronic kidney disease.

Interpretation

PWH have a disproportionately higher risk of readmission than PWoH, which is concerning given the aging profile of PWH. More efforts are needed to address readmissions among PWH.

Funding

US National Institutes of Health.

Results From a Pilot Study of an Automated Directly Observed Therapy Intervention Using Artificial Intelligence With Conditional Economic Incentives Among Young Adults With HIV

BACKGROUND

Despite improvements in antiretroviral therapy (ART) availability, suboptimal adherence is common among youth with HIV (YWH) and can increase drug resistance and poor clinical outcomes. Our study examined an innovative mobile app-based intervention that used automated directly observed therapy (aDOT) using artificial intelligence, along with conditional economic incentives (CEIs) to improve ART adherence and enhance viral suppression among YWH.

SETTING

We conducted a pilot study of the aDOT-CEI intervention, informed by the operant framework of Key Principles in Contingency Management Implementation, to improve ART adherence among YWH (18-29) in California and Florida who had an unsuppressed HIV viral load.

METHODS

We recruited 28 virally unsuppressed YWH from AIDS Healthcare Foundation clinics, who used the aDOT platform for 3 months. Study outcomes included feasibility and acceptability, self-reported ART adherence, and HIV viral load.

RESULTS

Participants reported high satisfaction with the app (91%), and 82% said that it helped them take their medication. Comfort with the security and privacy of the app was moderate (55%), and 59% indicated the incentives helped improve daily adherence.

CONCLUSIONS

Acceptability and feasibility of the aDOT-CEI intervention were high with potential to improve viral suppression, although some a priori metrics were not met. Pilot results suggest refinements which may improve intervention outcomes, including increased incentive amounts, provision of additional information, and reassurance about app privacy and security. Additional research is recommended to test the efficacy of the aDOT-CEI intervention to improve viral suppression in a larger sample.

HIV PrEP Coverage Among Black Adults: A Concept Analysis of the Inequities, Disparities, and Implications

Background

Significant racial disparities exist in HIV pre-exposure prophylaxis (PrEP) coverage in the United States (U.S), with Black individuals experiencing seven times higher new HIV infection rates compared to their White counterparts. Despite being the highest priority population at risk for HIV, Black adults have the lowest PrEP coverage, impacting the overall progress toward meeting the ending the HIV epidemic (EHE) goals in the U.S.

Methods

Utilizing the Walker and Avant method, this concept analysis examined existing literature and U.S. Centers for Disease Control and Prevention resources to explore HIV PrEP coverage.

Results

Findings highlighted a lack of clarity in the concept, resulting in four operational definitions. To address this ambiguity, a conceptual definition of HIV PrEP coverage was proposed, focusing on equitable access to PrEP medication among sexually active individuals aged 18-64 years, particularly those traditionally underserved and would benefit from PrEP. This inclusive definition aims to align with the dynamics of sexual behavior in racial minority groups. Key attributes of this conceptual definition include estimates of PrEP use, access, need, cost, side effects, frequency of HIV testing, and self-efficacy. Antecedents entail HIV status, testing behaviors, transmission risks, and communication with health care providers. Consequences involve perceptions of risk, screening routines, provider biases, stigma, and potential HIV transmission reduction.

Conclusion

Analyzing HIV PrEP coverage offers useful insights into social and structural factors exacerbating health inequities in the field of HIV prevention and control. This concept analysis underscores the importance of unified sexual health communication, diverse approaches to PrEP access for racial minorities, and improved sexual health policies for Black adults. Moreover, understanding and advocating for equity in HIV PrEP coverage is crucial for addressing the existing racial disparities and achieving the EHE objectives in the U.S.

Intersectional stigma and the non-communicable disease syndemic in the context of HIV: protocol for a multisite, observational study in the USA

INTRODUCTION

The increasing burden of non-communicable diseases, such as hypertension, diabetes and dyslipidaemia, presents key challenges to achieving optimal HIV care outcomes among ageing people living with HIV. These diseases are often comorbid and are exacerbated by psychosocial and structural inequities. This interaction among multiple health conditions and social factors is referred to as a syndemic. In the USA, there are substantial disparities by social position (ie, racial, ethnic and socioeconomic status) in the prevalence and/or control of non-communicable diseases and HIV. Intersecting stigmas, such as racism, classism and homophobia, may drive these health disparities by contributing to healthcare avoidance and by contributing to a psychosocial syndemic (stress, depression, violence victimisation and substance use), reducing success along the HIV and non-communicable disease continua of care. Our hypothesis is that marginalised populations experience disparities in non-communicable disease incidence, prevalence and control, mediated by intersectional stigma and the psychosocial syndemic.

METHODS AND ANALYSIS

Collecting data over a 4 year period, we will recruit sexual minority men (planned n=1800) enrolled in the MACS/WIHS Combined Cohort Study, a long-standing mixed-serostatus observational cohort in the USA, to investigate the following specific aims: (1) assess relationships between social position, intersectional stigma and the psychosocial syndemic among middle-aged and ageing sexual minority men, (2) assess relationships between social position and non-communicable disease incidence and prevalence and (3) assess relationships between social position and HIV and non-communicable disease continua of care outcomes, mediated by intersectional stigma and the psychosocial syndemic. Analyses will be conducted using generalised structural equation models using a cross-lagged panel model design.

ETHICS AND DISSEMINATION

This protocol is approved as a single-IRB study (Advarra Institutional Review Board: Protocol 00068335). We will disseminate results via peer-reviewed academic journals, scientific conferences, a dedicated website, site community advisory boards and forums hosted at participating sites.

Application of elastic net regression for modeling COVID-19 sociodemographic risk factors

OBJECTIVES

COVID-19 has been at the forefront of global concern since its emergence in December of 2019. Determining the social factors that drive case incidence is paramount to mitigating disease spread. We gathered data from the Social Vulnerability Index (SVI) along with Democratic voting percentage to attempt to understand which county-level sociodemographic metrics had a significant correlation with case rate for COVID-19.

METHODS

We used elastic net regression due to issues with variable collinearity and model overfitting. Our modelling framework included using the ten Health and Human Services regions as submodels for the two time periods 22 March 2020 to 15 June 2021 (prior to the Delta time period) and 15 June 2021 to 1 November 2021 (the Delta time period).

RESULTS

Statistically, elastic net improved prediction when compared to multiple regression, as almost every HHS model consistently had a lower root mean square error (RMSE) and satisfactory R2 coefficients. These analyses show that the percentage of minorities, disabled individuals, individuals living in group quarters, and individuals who voted Democratic correlated significantly with COVID-19 attack rate as determined by Variable Importance Plots (VIPs).

CONCLUSIONS

The percentage of minorities per county correlated positively with cases in the earlier time period and negatively in the later time period, which complements previous research. In contrast, higher percentages of disabled individuals per county correlated negatively in the earlier time period. Counties with an above average percentage of group quarters experienced a high attack rate early which then diminished in significance after the primary vaccine rollout. Higher Democratic voting consistently correlated negatively with cases, coinciding with previous findings regarding a partisan divide in COVID-19 cases at the county level. Our findings can assist regional policymakers in distributing resources to more vulnerable counties in future pandemics based on SVI.

HIV preexposure prophylaxis and postexposure prophylaxis in women: a comprehensive guide for healthcare providers

Great disparities and inequities in the delivery and acceptance of human immunodeficiency virus (HIV) prevention exist globally among women. Various barriers, such as societal stigma, low perceived risk, relationship dynamics, and lack of education on routes of HIV transmission can cause low utilization in HIV preexposure prophylaxis (PrEP) adoption and use. In addition, socioeconomic and structural factors, such as financial burden, lack of provider knowledge and willingness to prescribe, absence of insurance coverage, and limited access to healthcare services are additional barriers to PrEP use among cisgender women. The goal of this review is to highlight current and prospective PrEP options, attitudes, and views of PrEP use among cisgender women and healthcare providers, and the role of PrEP in special populations of cisgender women.

HIV Prevention and Care Among Black Cisgender Sexual Minority Men and Transgender Women: Protocol for an HIV Status-Neutral Cohort Study Using an Observational-Implementation Hybrid Approach

BACKGROUND

Black cisgender gay, bisexual, and other sexual minority men (SMM) and transgender women (TW) continue to be heavily affected by HIV. Further research is needed to better understand HIV prevention and care outcomes in this population. In particular, there is a need for research examining the impact of substance use and sleep health on HIV prevention and treatment outcomes among Black SMM and TW.

OBJECTIVE

This paper outlines the study methods being used in the recently launched follow-up study to the Neighborhoods and Networks (N2) study, which we refer to as N2 Part 2 (N2P2). N2P2 aims to address this gap in the literature, build off the findings of the original N2 study, and identify socioenvironmental determinants of health, including whether neighborhood and network factors mediate and moderate these relationships.

METHODS

Building on the N2 cohort study in Chicago from 2018 to 2022, N2P2 used a prospective longitudinal cohort design and an observational-implementation hybrid approach. With sustained high levels of community engagement, we aim to recruit a new sample of 600 Black SMM and TW participants residing in the Chicago metropolitan statistical area. Participants are asked to participate in 3 study visits across an 18-month study period (1 visit every 9 months). Four different forms of data are collected per wave: (1) an in-person survey, (2) biological specimen collection, (3) a daily remote ecological momentary assessment for 14 days after each study visit, and (4) data from electronic health records. These forms of data collection continue to assess neighborhood and network factors and specifically explore substance use, sleep, immune function, obesity, and the implementation of potential interventions that address relevant constructs (eg, alcohol use and pre-exposure prophylaxis adherence).

RESULTS

The N2P2 study was funded in August 2021 by the National Institute of Drug Abuse (R01DA054553 and R21DA053156) and National Heart, Lung, and Blood Institute (R01HL160325). This study was launched in November 2022. Recruitment and enrollment for the first wave of data collection are currently ongoing.

CONCLUSIONS

The N2P2 study is applying innovative methods to comprehensively explore the impacts of substance use and sleep health on HIV-related outcomes among an HIV status-neutral cohort of Black SMM and TW in Chicago. This study is applying an observational-implementation hybrid design to help us achieve findings that support rapid translation, a critical priority among populations such as Black SMM and TW that experience long-standing inequities with regard to HIV and other health-related outcomes. N2P2 will directly build off the findings that have resulted from the original N2 study among Black SMM and TW in Chicago. These findings provide a better understanding of multilevel (eg, individual, network, and neighborhood) factors that contribute to HIV-related outcomes and viral suppression among Black SMM and TW.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48548.

Implementation strategies to screen, refer and link women involved in the carceral system to PrEP for HIV prevention

PURPOSE

Women involved in the carceral system (CS) experience several conditions that increase their risk for HIV (e.g. high rates of substance use, psychiatric disorders, histories of victimization). The purpose of this study is to explore perspectives on potential strategies to connect women in the CS to pre-exposure prophylaxis (PrEP) services.

DESIGN/METHODOLOGY/APPROACH

This study conducted in-depth interviews with 27 women involved in the CS eligible for PrEP. Using vignettes, interviews explored attitudes, barriers and facilitators toward PrEP screening, referral and linkage facilitated via a CS stakeholder, an mHealth application or providing PrEP service referrals during detention via a navigator.

FINDINGS

Most women were, on average, 41.3 years, from racial and ethnic minority groups (56% black/African American; 19% Latinx). Inductive thematic analysis revealed CS involved women expressed mostly positive attitudes toward CS-based PrEP implementation. Younger women were more accepting of and interested in mHealth interventions. Implementation facilitators included leveraging relationships with trusted allies (e.g. "peers") and existing systems collaborations. Recommended implementation strategies included providing HIV and PrEP-specific education and training for system stakeholders and addressing issues related to privacy, system mistrust and stigma.

ORIGINALITY/VALUE

Results provide a critical foundation for the implementation of interventions to improve PrEP access for women involved in the CS and have important implications for implementation strategies for all adults involved in the CS. Improving access to PrEP among this population may also support progress toward addressing national disparities in PrEP uptake, where women, black and Latinx populations have substantial unmet need.

Uptake and Discontinuation of Pre-Exposure Prophylaxis Among Uninsured Transgender and Cisgender Women: A Public-Private Partnership Model in North Carolina

HIV pre-exposure prophylaxis (PrEP) remains underutilized among cis and trans women. The PrEP Initiative Program (PIP) is a novel public-private partnership implemented at 12 local clinics in North Carolina. PIP provides HIV/sexually transmitted infection (STI) testing and clinical and laboratory monitoring for PrEP to uninsured/underinsured clients. We sought to understand service-related differences among both cis and trans women enrolled in PIP, including STIs diagnoses, clinic type, sources of referral, services needed, and reasons for PrEP discontinuation. The Kaplan-Meier curves display retention on PrEP over the duration of the program. Since 2018, 142 women (cis n = 113; trans n = 29) enrolled, and 136 started PrEP. The majority were ages 25-34 years (31.7%) or 18-24 years (29.6%), Black (57.8%) or Latinx (24.7%). Approximately 20.6% of recipients reported at least one STI while enrolled. Overall, trans women requested fewer services than cis women. After accounting for the amount of time each patient was taking PrEP, there were higher rates of trans women diagnosed with syphilis than cis women. Rates of persons with other STIs were not notably different between trans and cis women. Clinic access varied by gender: 69% of trans women were enrolled at only one site. Trans women were retained significantly longer: The Kaplan-Meier adjusted median time to discontinuation was 560 and 238 days for trans and cis women, respectively. PIP successfully reached historically marginalized and uninsured cis and trans women who may benefit from PrEP. Further investigations into factors contributing to recruitment and retention of women in HIV prevention programs are needed.

iVY: protocol for a randomised clinical trial to test the effect of a technology-based intervention to improve virological suppression among young adults with HIV in the USA

INTRODUCTION

Young adults with HIV (YWH) experience worse clinical outcomes than adults and have high rates of substance use (SU) and mental illness that impact their engagement in care and adherence to antiretroviral therapy (ART). The intervention for Virologic Suppression in Youth (iVY) aims to address treatment engagement/adherence, mental health (MH) and SU in a tailored manner using a differentiated care approach that is youth friendly. Findings will provide information about the impact of iVY on HIV virological suppression, MH and SU among YWH who are disproportionately impacted by HIV and at elevated risk for poor health outcomes.

METHODS AND ANALYSIS

The iVY study will test the effect of a technology-based intervention with differing levels of resource requirements (ie, financial and personnel time) in a randomised clinical trial with an adaptive treatment strategy among 200 YWH (18-29 years old). The primary outcome is HIV virological suppression measured via dried blood spot. This piloted and protocolised intervention combines: (1) brief weekly sessions with a counsellor via a video-chat platform (video-counselling) to discuss MH, SU, HIV care engagement/adherence and other barriers to care; and (2) a mobile health app to address barriers such as ART forgetfulness, and social isolation. iVY has the potential to address important, distinct and changing barriers to HIV care engagement (eg, MH, SU) to increase virological suppression among YWH at elevated risk for poor health outcomes.

ETHICS AND DISSEMINATION

This study and its protocols have been approved by the University of California, San Francisco Institutional Review Board. Study staff will work with a Youth Advisory Panel to disseminate results to YWH, participants and the academic community.

TRIAL REGISTRATION NUMBER

NCT05877729.

Prevention, treatment and cure of HIV infection

The development of antiretroviral therapy for the prevention and treatment of HIV infection has been marked by a series of remarkable successes. However, the efforts to develop a vaccine have largely failed, and efforts to discover a cure are only now beginning to gain traction. In this Review, we describe recent progress on all fronts - pre-exposure prophylaxis, vaccines, treatment and cure - and we discuss the unmet needs, both current and in the coming years. We describe the emerging arsenal of drugs, biologics and strategies that will hopefully address these needs. Although HIV research has largely been siloed in the past, this is changing, as the emerging research agenda is marked by multiple cross-discipline synergies and collaborations. As the limitations of antiretroviral drugs as a means to truly end the epidemic are becoming more apparent, there is a great need for continued efforts to develop an effective preventative vaccine and a scalable cure, both of which remain formidable challenges.

The associations of income and Black-White racial segregation with HIV outcomes among adults aged ≥18 years-United States and Puerto Rico, 2019

OBJECTIVE(S)

To examine associations between Index of Concentration at the Extremes (ICE) measures for economic and racial segregation and HIV outcomes in the United States (U.S.) and Puerto Rico.

METHODS

County-level HIV testing data from CDC's National HIV Prevention Program Monitoring and Evaluation and census tract-level HIV diagnoses, linkage to HIV medical care, and viral suppression data from the National HIV Surveillance System were used. Three ICE measures of spatial polarization were obtained from the U.S. Census Bureau's American Community Survey: ICEincome (income segregation), ICErace (Black-White racial segregation), and ICEincome+race (Black-White racialized economic segregation). Rate ratios (RRs) for HIV diagnoses and prevalence ratios (PRs) for HIV testing, linkage to care within 1 month of diagnosis, and viral suppression within 6 months of diagnosis were estimated with 95% confidence intervals (CIs) to examine changes across ICE quintiles using the most privileged communities (Quintile 5, Q5) as the reference group.

RESULTS

PRs and RRs showed a higher likelihood of testing and adverse HIV outcomes among persons residing in Q1 (least privileged) communities compared with Q5 (most privileged) across ICE measures. For HIV testing percentages and diagnosis rates, across quintiles, PRs and RRs were consistently greatest for ICErace. For linkage to care and viral suppression, PRs were consistently lower for ICEincome+race.

CONCLUSIONS

We found that poor HIV outcomes and disparities were associated with income, racial, and economic segregation as measured by ICE. These ICE measures contribute to poor HIV outcomes and disparities by unfairly concentrating certain groups (i.e., Black persons) in highly segregated and deprived communities that experience a lack of access to quality, affordable health care. Expanded efforts are needed to address the social/economic barriers that impede access to HIV care among Black persons. Increased partnerships between government agencies and the private sector are needed to change policies that promote and sustain racial and income segregation.

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Costs of Providing Preexposure Prophylaxis for HIV Prevention at Community Health Centers in the United States

OBJECTIVE

Preexposure prophylaxis (PrEP) is recommended for people at risk of acquiring HIV. We assessed billable costs associated with PrEP delivery at community health centers.

METHODS

The Sustainable Health Center Implementation PrEP Pilot (SHIPP) study is an observational cohort of people receiving daily oral PrEP at participating federally qualified health centers and other community health centers. We assessed health care utilization and billable costs of providing PrEP at 2 health centers, 1 in Chicago, Illinois, and 1 in Washington, DC, from 2014 to 2018. The health centers followed the clinical practice guidelines for PrEP provision, including regular visits with health care providers and ongoing laboratory monitoring. Using clinic billing records and Current Procedural Terminology (CPT) coding, we retrospectively extracted data on the frequency and costs (in 2017 US dollars) of PrEP clinic visits and laboratory screening, for each patient, for 12 months since first PrEP prescription.

RESULTS

The average annual number of PrEP clinic visits and associated laboratory screens per patient was 5.1 visits and 25.2 screens in Chicago (n = 482 patients) and 5.4 visits and 24.8 screens in Washington, DC (n = 56 patients). The average annual PrEP billable cost per patient was $583 for clinic visits and $1070 for laboratory screens in Chicago and $923 for clinic visits and $1018 for laboratory screens in Washington, DC. The average annual total cost per patient was $1653 (95% CI, $1639-$1668) in Chicago and $1941 (95% CI, $1811-$2071) in Washington, DC.

CONCLUSIONS

Our analysis, which provides PrEP billable cost estimates based on empirical data, may help inform health care providers who are considering implementing this HIV prevention strategy.

A high-throughput screening assay for silencing established HIV-1 macrophage infection identifies nucleoside analogs that perturb H3K9me3 on proviral genomes

HIV-infected macrophages are long-lived cells that represent a barrier to functional cure. Additionally, low-level viral expression by central nervous system (CNS) macrophages contributes to neurocognitive deficits that develop despite antiretroviral therapy (ART). We recently identified H3K9me3 as an atypical epigenetic mark associated with chronic HIV infection in macrophages. Thus, strategies are needed to suppress HIV-1 expression in macrophages, but the unique myeloid environment and the responsible macrophage/CNS-tropic strains require cell/strain-specific approaches. Here, we generated an HIV-1 reporter virus from a CNS-derived strain with intact auxiliary genes expressing destabilized luciferase. We employed this reporter virus in polyclonal infection of primary human monocyte-derived macrophages (MDM) for a high-throughput screen (HTS) to identify compounds that suppress virus expression from established macrophage infection. Screening ~6,000 known drugs and compounds yielded 214 hits. A secondary screen with 10-dose titration identified 24 meeting criteria for HIV-selective activity. Using three replication-competent CNS-derived macrophage-tropic HIV-1 isolates and viral gene expression readout in MDM, we confirmed the effect of three purine analogs, nelarabine, fludarabine, and entecavir, showing the suppression of HIV-1 expression from established macrophage infection. Nelarabine inhibited the formation of H3K9me3 on HIV genomes in macrophages. Thus, this novel HTS assay can identify suppressors of HIV-1 transcription in established macrophage infection, such as nucleoside analogs and HDAC inhibitors, which may be linked to H3K9me3 modification. This screen may be useful to identify new metabolic and epigenetic agents that ameliorate HIV-driven neuroinflammation in people on ART or prevent viral recrudescence from macrophage reservoirs in strategies to achieve ART-free remission. IMPORTANCE Macrophages infected by HIV-1 are a long-lived reservoir and a barrier in current efforts to achieve HIV cure and also contribute to neurocognitive complications in people despite antiretroviral therapy (ART). Silencing HIV expression in these cells would be of great value, but the regulation of HIV-1 in macrophages differs from T cells. We developed a novel high-throughput screen for compounds that can silence established infection of primary macrophages, and identified agents that downregulate virus expression and alter provirus epigenetic profiles. The significance of this assay is the potential to identify new drugs that act in the unique macrophage environment on relevant viral strains, which may contribute to adjunctive treatment for HIV-associated neurocognitive disorders and/or prevent viral rebound in efforts to achieve ART-free remission or cure.

Successful Integration of HIV PrEP in Primary Care and Women's Health Clinical Practice: A Model for Implementation

Ending the HIV Epidemic is contingent upon the increased utilization of pre-exposure prophylaxis (PrEP). The majority of PrEP in the United States is prescribed in specialty care settings; however, to achieve national implementation goals, it is necessary to expand PrEP services in primary care and women's health clinics. To this end, a prospective cohort study was conducted of health care providers participating in one of three rounds of a virtual program aimed at increasing the number of PrEP prescribers in primary care and women's health clinics within the NYC Health and Hospitals network, the public healthcare system of New York City. Provider prescribing behavior was compared at pre-intervention (August 2018-September 2019) and post-intervention (October 2019-February 2021). Among 104 providers, the number prescribing PrEP increased from 12 (11.5%) to 51 (49%) and the number of individual patients on PrEP increased from 19 to 128. The program utilized clinical integration models centering on existing STI management workflows and was associated with increased numbers of PrEP prescribers and volume of prescriptions in primary care and women's health clinics. The dissemination of similar programs could support national scale-up of PrEP.

Readiness to Provide Oral and Injectable PrEP for Sexual and Gender Minority Youth Among Healthcare Providers and Clinics in the U.S. Northeast

PURPOSE

To examine readiness to provide oral and injectable pre-exposure prophylaxis (PrEP) for sexual and gender minority youth (SGMY) and to explore decision-making for HIV prevention strategies (e.g., condom use, daily and event-driven oral PrEP, and injectable PrEP) among healthcare providers.

METHODS

Between February and April 2022, we recruited 31 prescribing providers (M.Ds, D.Os, P.As, and N.Ps) practicing in primary care and specialized clinics in the U.S. Northeast for focus groups or individual interviews. Focus groups and interview transcripts were analyzed using thematic analysis.

RESULTS

Most providers specialized in Pediatrics (42%) or Adolescent Medicine (23%) and 58% had previously prescribed PrEP. Main barriers to PrEP readiness were low PrEP knowledge, limited time for visits, and competing clinical priorities. Organizational factors such as routine HIV/STI testing, PrEP-specific electronic health records templates, and specialized staff (e.g., PrEP navigators) promoted PrEP readiness. Providers held positive attitudes toward injectable PrEP to promote adherence among SGMY, yet barriers to implementation of this modality were identified (e.g., patient anxiety about needles, additional staffing needs). Providers described event-driven oral PrEP as an option for SGMY with episodic HIV risk. Assurances of conditional confidentiality, including preventing disclosure of sensitive information through insurance forms, and shared decision-making facilitated conversations about HIV prevention with SGMY.

DISCUSSION

Future PrEP implementation efforts for SGMY should consider combined efforts targeting provider knowledge about PrEP modalities (e.g., decision aids) and clinic organizational factors (e.g., routine HIV/STI testing, resources to assist providers and patients in navigating the multiple steps between prescription and adherence to PrEP).

HIV Pre-exposure Prophylaxis Persistence and Adherence Among Men Who Have Sex With Men in Four US Cities

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) persistence and adherence are critical to ending the HIV epidemic in the United States.

SETTING

In 2017 National HIV Behavioral Surveillance, HIV-negative men who have sex with men (MSM) in 4 US cities completed a survey, HIV testing, and dried blood spots at recruitment.

METHODS

We assessed 3 PrEP outcomes: persistence (self-reported PrEP use at any time in the past 12 months and had tenofovir, emtricitabine, or tenofovir diphosphate detected in dried blood spots), adherence at ≥4 doses/week (self-reported past-month PrEP use and tenofovir diphosphate concentration ≥700 fmol/punch), and adherence at 7 doses/week (self-reported past-month PrEP use and tenofovir diphosphate concentration ≥1250 fmol/punch). Associations with key characteristics were examined using log-linked Poisson regression models with generalized estimating equations.

RESULTS

Among 391 MSM who took PrEP in the past year, persistence was 80% and was lower among MSM who were younger, had lower education, and had fewer sex partners. Of 302 MSM who took PrEP in the past month, adherence at ≥4 doses/week was 80% and adherence at 7 doses/week was 66%. Adherence was lower among MSM who were younger, were Black, and had fewer sex partners.

CONCLUSIONS

Although persistence and adherence among MSM were high, 1 in 5 past-year PrEP users were not persistent and 1 in 5 past-month PrEP users were not adherent at levels that would effectively protect them from acquiring HIV (ie, ≥4 doses/week). Efforts to support PrEP persistence and adherence should include MSM who are young, are Black, and have less education.

Provider Perspectives on Barriers to Routine HIV Testing of Adolescent and Young Adult Patients in Emergency Department Settings

HIV testing rates among US youth aged 13-24 years are sub-optimal, with high rates of missed testing opportunities in emergency departments (EDs). We assessed barriers to routine HIV testing of youth in urban ED settings from the perspective of healthcare providers. Ten physicians and nurses were recruited from the pediatric and adult EDs at a high-volume hospital in New York City, USA to complete in-depth interviews to provide their perspectives on barriers to routine HIV testing of youth ages 13 to 24 in EDs. Interviews were conducted using a semi-structured interview guide with questions and probes. All interviews were conducted via Zoom due to the COVID-19 pandemic and were audio-recorded and transcribed verbatim. Transcripts were coded independently by two researchers using an inductive thematic analysis approach. Participants often offered HIV testing to youth in the ED based on their perceptions of patients' HIV risk, with pediatric providers sometimes discouraging adolescents they perceived to be at low HIV risk from testing. Participants cited other priorities, logistics of blood-based testing, and discomfort discussing HIV as other reasons for not offering HIV testing to all youth in the ED. Efforts are needed to encourage providers to offer HIV testing to all youth regardless of perceived risk, as the ED often serves as youths' only point of contact with the healthcare system. Emphasis on this and the importance of early detection, along with institutional change, clear guidance, and support for the testing process may help increase youth testing and avoid missed HIV diagnosis opportunities.

Estimated Uncovered Costs For HIV Preexposure Prophylaxis In The US, 2018

The cost of HIV preexposure prophylaxis (PrEP) medication and care is a key barrier to PrEP use. Using population-based surveys and published information, we estimated the number of people with uncovered costs for PrEP care among US adults with PrEP indications, stratified by HIV transmission risk group, insurance status, and income. Accounting for existing PrEP payer mechanisms, we estimated annual uncovered costs for PrEP medication, clinical visits, and laboratory testing based on the 2021 PrEP clinical practice guideline. Of 1.2 million US adults with PrEP indications in 2018, we estimated that 49,860 (4 percent) of them had PrEP-related uncovered costs, including 32,350 men who have sex with men, 7,600 heterosexual women, 5,070 heterosexual men, and 4,840 people who inject drugs. Of those 49,860 people with uncovered costs, 3,160 (6 percent) incurred $18.9 million in uncovered costs for PrEP medication, clinical visits, and lab testing, and 46,700 (94 percent) incurred $83.5 million in uncovered costs for only clinical visits and lab testing. The total annual uncovered costs for adults with PrEP indications were $102.4 million in 2018. The proportion of people with uncovered costs for PrEP is less than 5 percent among adults with PrEP indications, but the magnitude of costs is significant.

Integrative Review of Methods From Youth Risk Behavior Survey Secondary Data Analyses Examining HIV Syndemic Factors Among Adolescent Gay and Bisexual Men

BACKGROUND

Adolescent gay/bisexual men exhibit the highest prevalence of undiagnosed HIV infections. Ascertaining antecedents of behaviorally acquired HIV infections among adolescent gay/bisexual men can be challenging; however, these challenges can be overcome through the utilization of secondary data, such as the Youth Risk Behavior Survey.

OBJECTIVE

Syndemics theory suggests that HIV infections are not a singular phenomenon; instead, many infections occur at the intersection of syndemic factors, such as substance use, violence, and mental health. Our objective is to describe and synthesize research methods of secondary data analyses that examine syndemic factors in relation to HIV risk behavior outcomes among subsamples of adolescent gay/bisexual men.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo were systematically searched. Inclusion criteria were (a) peer-reviewed Youth Risk Behavior Survey secondary data analyses conducted in the United States after 1991, (b) subsamples with adolescent gay/bisexual men, (c) one or more syndemic factor(s), and (d) one or more HIV risk behavior outcome(s). We used the National Institutes of Health Quality Assessment Tools for quality appraisal.

RESULTS

Of 1,036 citations retrieved, nine studies met inclusion criteria. Results included using logistic regression analysis and data from 2015 to 2017 in six studies and underpinnings with minority stress theory in four studies. Eight studies omitted race/ethnicity in subsamples and six grouped lesbians with adolescent gay/bisexual men. Seven studies examined substance use, six examined violence, and five examined mental health. Condom use and number of partners were the most studied HIV risk behavior outcomes in four studies, whereas intercourse in the last 3 months was an outcome in only one study. Protective factors were not present.

CONCLUSION

Limitations found the need to highlight better inclusion of race/ethnicity and sexual orientation. Adding contemporary survey items is also necessary, such as nonbinary sex and gender identity, access to HIV prevention (condoms, HIV testing, and preexposure prophylaxis), and experiences with stigma, to elucidate risk behaviors among populations disproportionately affected by HIV infections, including Blacks/African Americans and Hispanics/Latinos.

Initiation of HIV pre-exposure prophylaxis among youth in the United States, 2015-2018

Adolescents and young adults ("youth") account for one-fifth of new HIV diagnoses in the U.S. HIV pre-exposure prophylaxis (PrEP), which became FDA approved in adolescents in May 2018, is highly effective at preventing HIV infection though there are limited data for PrEP initiation in youth. We aimed to quantify PrEP initiation and identify factors associated with PrEP initiation among youth at risk for HIV. We conducted a retrospective cohort study of youth aged 13-26 years who had an indication for PrEP between 1 January 2015, and 31 December 2018. We used data on commercially insured US individuals from the IBM MarketScan Commercial Database. We compared factors among youth who did and did not receive PrEP. We developed a multivariable logistic regression model to identify the association of all study covariates with receipt of PrEP. Among potentially PrEP eligible youth, only 2171 (1.6%) received a PrEP prescription in the year following their PrEP eligible claim. In multivariable models, youth who received PrEP were more likely to be older (adjusted odd ratio [aOR] for 18-20 year olds = 5.11; 95% CI = 3.35-7.77; aOR for 21-26 year olds = 16.90; 95% CI = 11.0-24.7), male (aOR = 92.42; 95% CI = 68.24-125), have sexual activity with elevated risk (aOR = 7.47; 95% CI = 6.50-8.60), or be diagnosed with gonorrhea or syphilis than youth who did not receive PrEP. Our findings highlight an opportunity to improve HIV prevention early in the life course.

Rumination influences the relationship between trauma and depression over time among youth living with HIV

BACKGROUND

Traumatizing events often result in long-term mental health symptoms. Identifying the features of the post-trauma experiences that can impact mental health symptoms is key to designing effective interventions.

METHODS

Youth living with HIV (YLH),1 predominantly sexual and gender minorities (SGM;2 84 % gay, bisexual, transgender, queer, pansexual identities), 78 % Black and Latino, (N = 170) were recruited in New Orleans, LA and Los Angeles, CA from 13 youth-serving agencies. They were assessed for trauma, rumination and depression, with 78 % reassessed for depression at 4 and 74 % at 8 months later. Relationships between these variables were examined using a Bayesian approach to structural equation modeling.

RESULTS

At recruitment, 78 % of YLH reported at least one traumatic event, and 21 % met the cut-off score indicating depression on the PHQ-9. Ruminations were reported by 41 % of YLH. While associations between trauma and depression were modest (rmean = 0.19), ruminations were moderately associated with depressive symptoms over time (rmean = 0.34). Ruminations were only modestly associated with trauma (rmean = 0.19) but had a robust negative association (λSTD = -0.29) with the slope of depressive symptoms such that the more ruminations YLH experienced, the smaller the decline in depression over time. The associations between trauma and depression were more modest (λSTD ≤ 0.12). Limitations The main limitations of this study are the lack of a scale to measure trauma and the use of a single item measure of rumination.

CONCLUSION

Ruminations appear to be associated with traumatic events for a large subset of young people, suggesting that future interventions should consider including components addressing ruminations.

CLINICALTRIALS

gov registration NCT03109431.

Viral suppression and associated factors among children tested for HIV viral load at Amhara Public Health Institute, Dessie Branch, Ethiopia: a cross-sectional study

OBJECTIVE

This study aims to assess viral suppression and associated factors among children tested for HIV viral load at the Amhara Public Health Institute, Dessie Branch, Ethiopia.

DESIGN

An institutional cross-sectional study was conducted. An observational checklist was used to collect the data. Data were entered into EpiData and analysed using SPSS (V.25). The data were analysed descriptively. Variables with p=0.25 from the bivariable analysis were entered into a multivariable logistic regression model, and significant variables (p=0.05) were retained in the multivariable model.

SETTING AND PARTICIPANTS

This cross-sectional study was conducted among 522 randomly selected children tested for HIV viral load at the Amhara Public Health Institute, Dessie Branch, Ethiopia. The study included children under the age of 15 years with complete records.

RESULTS

Viral suppression was 73% (95% CI: 60.41% to 77.63%). Treatment duration on antiretroviral therapy (adjusted OR (AOR)=0.207; 95% CI: 0.094 to 0.456) and regimen substitution (AOR=0.490; 95% CI: 0.306 to 0.784) were significantly associated with viral suppression rate.

CONCLUSIONS

In this study, the overall magnitude of viral suppression in Amhara Public Health Institute, Dessie Branch is low as compared with the WHO's 95% viral suppression target. Viral suppression was significantly associated with antiretroviral therapy duration and regimen substitution.

Application of Elastic Net Regression for Modeling COVID-19 Sociodemographic Risk Factors

Objectives

COVID-19 has been at the forefront of global concern since its emergence in December of 2019. Determining the social factors that drive case incidence is paramount to mitigating disease spread. We gathered data from the Social Vulnerability Index (SVI) along with Democratic voting percentage to attempt to understand which county-level sociodemographic metrics had a significant correlation with case rate for COVID-19.

Methods

We used elastic net regression due to issues with variable collinearity and model overfitting. Our modelling framework included using the ten Health and Human Services regions as submodels for the two time periods 22 March 2020 to 15 June 2021 (prior to the Delta time period) and 15 June 2021 to 1 November 2021 (the Delta time period).

Results

Statistically, elastic net improved prediction when compared to multiple regression, as almost every HHS model consistently had a lower root mean square error (RMSE) and satisfactory R2 coefficients. These analyses show that the percentage of minorities, disabled individuals, individuals living in group quarters, and individuals who voted Democratic correlated significantly with COVID-19 attack rate as determined by Variable Importance Plots (VIPs).

Conclusions

The percentage of minorities per county correlated positively with cases in the earlier time period and negatively in the later time period, which complements previous research. In contrast, higher percentages of disabled individuals per county correlated negatively in the earlier time period. Counties with an above average percentage of group quarters experienced a high attack rate early which then diminished in significance after the primary vaccine rollout. Higher Democratic voting consistently correlated negatively with cases, coinciding with previous findings regarding a partisan divide in COVID-19 cases at the county level. Our findings can assist policymakers in distributing resources to more vulnerable counties in future pandemics based on SVI.

Primary Care Provider HIV PrEP Knowledge, Attitudes, and Prescribing Habits: A Cross-Sectional Survey of Late Adopters in Rural and Suburban Practice

OBJECTIVE

Pre-exposure prophylaxis (PrEP) is a recommended strategy for HIV prevention, yet PrEP prescribing rates in primary care remain low. The aim of this study was to further describe the current knowledge, attitudes, and prescribing behaviors of HIV PrEP in primary care providers with a focus on the perceived barriers and facilitators to PrEP prescribing.

METHODS

Cross-sectional survey of primary care providers at rural and suburban practices in a large academic institution.

RESULTS

Survey response rate was 48.0% (n = 134). Most respondents (96.3%) reported little clinical experience in care of persons living with HIV. Respondents self-reported positive attitudes and high overall knowledge of PrEP with low prescribing rates and less comfort with lab testing. More respondents are asked about PrEP by patients (54%) than start conversations about PrEP with patients (39%). Family Physicians and providers 5 to 10 years from completion of training overall reported higher knowledge, attitudes and prescribing behaviors. Lack of PrEP education was identified as the greatest barrier and an electronic medical record order set as the greatest facilitator to prescribing PrEP.

CONCLUSIONS

With the goal to end the HIV epidemic, PrEP provision in nonurban primary care settings may be an important strategy for increased access to PrEP and reduced HIV transmission. This study, which includes a variety of providers that possess high knowledge, yet low experience prescribing PrEP, likely demonstrates the limitations of interventions which solely focus on provider education. System-based practice solutions, such as order sets, may be needed to target infrequent prescribers of PrEP.

Principles for Ending Human Immunodeficiency Virus as an Epidemic in the United States: A Policy Paper of the Infectious Diseases Society of America and the HIV Medical Association

While we have the tools to achieve this goal, the persistent barriers to healthcare services experienced by too many individuals will need to be addressed to make significant progress and improve the health and quality of life of all people with human immunodeficiency virus (HIV). The necessary structural changes require actions by federal, state, and local policymakers and range from ensuring universal access to healthcare services to optimizing care delivery to ensuring a robust and diverse infectious diseases and HIV workforce. In this article, we outlines 10 key principles for policy reforms that, if advanced, would make ending the HIV epidemic in the United States possible and could have much more far-reaching effects in improving the health of our nation.

An overview of programmatic indicators to monitor the roll-out of HIV preexposure prophylaxis

Preexposure prophylaxis (PrEP) is increasingly implemented in national HIV prevention programmes through routine care. Monitoring will be vital to understand whether programmes succeed in engaging people into using PrEP appropriately, and in reducing the HIV epidemic. Yet, it is currently unclear which indicators are most suited to monitor PrEP programmes' performance. We therefore aimed to identify and map indicators that are currently used or suggested for monitoring PrEP programmes. We conducted a scoping review based on the framework by Arksey and O'Malley. We combined a systematic search in the peer-reviewed literature with hand-searching grey literature documents describing indicators and strategies that are used or suggested for PrEP monitoring. Only literature published after 2012 was included. No geographical restrictions were set. We charted data on indicator definitions, data sources used, reported experiences with monitoring and any relevant contextual factors. Ultimately, 35 peer-reviewed and 14 grey literature records were included. We identified indicators related to preuptake stages of PrEP, uptake and coverage, and programme impact. The indicators most commonly suggested for national-level monitoring were the number of new and current PrEP users, the number of HIV seroconversions among PrEP users and some variably defined indicators related to continuation and discontinuation of PrEP. Despite its perceived high relevance, studies reported several challenges to routinely monitor the population in need of PrEP and track prevention-effective PrEP use. In conclusion, a variety of indicators is currently used or suggested for monitoring PrEP programmes. Implementing proxy measures that track different aspects of PrEP use over time, and making synergies with research more explicit, could be used as strategies to obtain more granular insights into trends revealed by routine monitoring.

Usability and Utility of Human Immunodeficiency Virus Pre-exposure Prophylaxis Clinical Decision Support to Increase Knowledge and Pre-exposure Prophylaxis Initiations among Pediatric Providers

OBJECTIVES

 An effective clinical decision support system (CDSS) may address the current provider training barrier to offering preexposure prophylaxis (PrEP) to youth at risk for human immunodeficiency virus (HIV) infection. This study evaluated change in provider knowledge and the likelihood to initiate PrEP after exposure to a PrEP CDSS. A secondary objective explored perceived provider utility of the CDSS and suggestions for improving CDSS effectiveness.

METHODS

 This was a prospective study using survey responses from a convenience sample of pediatric providers who launched the interruptive PrEP CDSS when ordering an HIV test. McNemar's test evaluated change in provider PrEP knowledge and likelihood to initiate PrEP. Qualitative responses on CDSS utility and suggested improvements were analyzed using framework analysis and were connected to quantitative analysis elements using the merge approach.

RESULTS

 Of the 73 invited providers, 43 had available outcome data and were included in the analysis. Prior to using the CDSS, 86% of participants had never been prescribed PrEP. Compared to before CDSS exposure, there were significant increases in the proportion of providers who were knowledgeable about PrEP (p = 0.0001), likely to prescribe PrEP (p < 0.0001) and likely to refer their patient for PrEP (p < 0.0001). Suggestions for improving the CDSS included alternative "triggers" for the CDSS earlier in visit workflows, having a noninterruptive CDSS, additional provider educational materials, access to patient-facing PrEP materials, and additional CDSS support for adolescent confidentiality and navigating financial implications of PrEP.

CONCLUSION

 Our findings suggest that an interruptive PrEP CDSS attached to HIV test orders can be an effective tool to increase knowledge and likelihood to initiate PrEP among pediatric providers. Continual improvement of the PrEP CDSS based on provider feedback is required to optimize usability, effectiveness, and adoption. A highly usable PrEP CDSS may be a powerful tool to close the gap in youth PrEP access and uptake.

Implementation and Evaluation of a Collaborative, Pharmacy-Based Hepatitis C and HIV Screening Program

INTRODUCTION

Pharmacy-based HIV and hepatitis C virus (HCV) screening services developed in conjunction with state and local health departments can improve public health through increased access to testing and a linkage-to-care strategy. The objective of this study was to evaluate the impact of implementing HIV and HCV screening in community pharmacies.

METHODS

This prospective, multicenter implementation project was conducted from July 2015 through August 2018. Sixty-one pharmacies participated in 3 US regions. We assessed the effectiveness of point-of-care testing, counseling, and disease education for populations at increased risk for HIV and HCV infection through screening programs offered in community pharmacies. Pharmacy customers were offered screening with point-of-care HIV and/or HCV tests. Reactive test results were reported to state or local health departments for disease surveillance.

RESULTS

A total of 1,164 patients were screened for HIV, HCV, or both at the 61 participating pharmacies; the average number of patients screened per pharmacy was 19. Pharmacists conducted 1,479 HIV or HCV tests among the 1,164 patients. Five of 612 (0.8%) HIV tests yielded a reactive result, and 181 of 867 (20.9%) of HCV tests yielded a reactive result.

CONCLUSION

Patients at increased risk of HIV or HCV can benefit from screening for infection at community pharmacies. Ease of accessibility to testing coupled with a strategy for linkage to care designed for the local community can improve patient care and improve the course of treatment for HIV and HCV.

Sexual Mixing by HIV Status and Pre-exposure Prophylaxis Use Among Men Who Have Sex With Men: Addressing Information Bias

BACKGROUND

Population-level estimates of sexual network mixing for parameterizing prediction models of pre-exposure prophylaxis (PrEP) effectiveness are needed to inform prevention of HIV transmission among men who have sex with men (MSM). Estimates obtained by egocentric sampling are vulnerable to information bias due to incomplete respondent knowledge.

METHODS

We estimated patterns of serosorting and PrEP sorting among MSM in the United States using data from a 2017-2019 egocentric sexual network study. Respondents served as proxies to report the HIV status and PrEP use of recent sexual partners. We contrasted results from a complete-case analysis (unknown HIV and PrEP excluded) versus a bias analysis with respondent-reported data stochastically reclassified to simulate unobserved self-reported data from sexual partners.

RESULTS

We found strong evidence of preferential partnering across analytical approaches. The bias analysis showed concordance between sexual partners of HIV diagnosis and PrEP use statuses for MSM with diagnosed HIV (39%; 95% simulation interval: 31, 46), MSM who used PrEP (32%; 21, 37), and MSM who did not use PrEP (83%; 79, 87). The fraction of partners with diagnosed HIV was higher among MSM who used PrEP (11%; 9, 14) compared with MSM who did not use PrEP (4%; 3, 5). Comparatively, across all strata of respondents, the complete-case analysis overestimated the fractions of partners with diagnosed HIV or PrEP use.

CONCLUSIONS

We found evidence consistent with HIV and PrEP sorting among MSM, which may decrease the population-level effectiveness of PrEP. Bias analyses can improve mixing estimates for parameterization of transmission models.

Hair levels of steroid, endocannabinoid, and the ratio biomarkers predict viral suppression among people living with HIV/AIDS in China

BACKGROUND

Predicting viral suppression early is crucial to improving treatment outcomes among people living with HIV/AIDS (PLWH) in clinics. Viral suppression is affected by stress, making stress indicators a potential predictive factor. Most of previous studies used the self-report questionnaire as stress indicators, but there were great drawbacks due to its subjective. In contrast, end products of neuroendocrine systems such as hypothalamic-pituitaryadrenal (HPA) and hypothalamic-pituitary-gonadal (HPG) axes and endogenous cannabinoid system (ECS) that involved in regulating stress as objective stress indicators are urgently needed to predict viral suppression. Therefore, this study aimed to investigate whether neuroendocrine indictors can strongly predict viral suppression among PLWH in China.

METHODS

This cross-sectional study recruited 1198 PLWH on antiretroviral therapy (ART) in Guangxi, China. The concentrations of steroids (i.e., cortisol, cortisone, dehydroepiandrosterone, testosterone and progesterone) and endocannabinoids (i.e., N-arachidonoyl-ethanolamine and 1-arachidonyl glycerol) in hair were quantitated using the LC-APCI+-MS/MS method. To screen biomarkers that were used to predict viral suppression, association between hair biomarkers and viral suppression was examined by Mann-Whitney U test and partial correlation analyses. Receiver operating characteristic (ROC) curves and binary logistic regression based on the optimal classification threshold determined with ROC curves were used to estimate the prediction effects of the screened biomarkers on viral suppression (HIV-1 RNA < 200 copies/mL).

RESULTS

Hair levels of dehydroepiandrosterone (DHEA), and N-arachidonoyl-ethanolamine (AEA), and the cortisol to DHEA ratio exhibited significant intergroup differences (ps < 0.05) and were correlated with HIV viral load (ps < 0.05). Hair DHEA concentrations strongly predicted viral suppression, showing good classification performance (area under the ROC curve = 0.651, p < 0.01) and strong predictive utility (adjusted odd ratio = 2.324, 95 % confidence interval = 1.211-4.899, p < 0.05) with an optimal threshold of 10.5 pg/mg. A hair AEA concentration of 2.4 pg/mg was the optimal threshold for predicting viral suppression based on good classification performance (area under the ROC curve = 0.598, p < 0.05) and predictive power (adjusted odd ratio = 2.124, 95 % confidence interval = 1.045-4.244, p < 0.05). In hair levels of cortisol to DHEA, viral suppression was observed to be highly predictive, with a threshold of 10.5 pg/mg being optimal for classification (area under the ROC curve = 0.624, p < 0.05) and prediction (adjusted odd ratio = 0.421, 95 % confidence interval = 0.201-0.785, p < 0.05).

CONCLUSION

Hair levels of DHEA, and AEA and the cortisol to DHEA ratio were screened and verified to have significant predictive power with optimal thresholds for predicting viral suppression in a large-scale cohort. The data may provide new insights into predictors of successful virological outcomes and inform public health intervention and clinical practice to assist PLWH in achieving and sustaining viral suppression.

Individual and structural-level Correlates of Pre-exposure Prophylaxis (PrEP) lifetime and current use in a nationwide sample of young sexual and gender minorities

The objective of this analysis was to describe individual and structural-level factors associated with pre-exposure prophylaxis (PrEP) use among a sample of sexual and gender minorities (SGM) at risk for HIV recruited using limited interaction strategies. SGM (N = 3330), ages 15-34, without HIV enrolled in a nationwide limited interaction cohort study from 2017 to 2020. A baseline cross-sectional single-survey design examined individual and structural-level correlates of PrEP lifetime use and current use using logistic regression. PrEP lifetime use and current use were reported by 31.2% and 23.9%, respectively, of SGM with PrEP data (n = 3077). PrEP use outcomes (lifetime or current use) in cisgender MSM were associated with being over age 18, Black or other race, Hispanic/Latina/x/o ethnicity, being gay, being out to one's healthcare provider, having health insurance, being a college graduate, and having a greater number of PrEP peers. PrEP use outcomes (lifetime use or current use) in transgender/non-binary participants were associated with being over age 24, being Latinx, being transgender vs. non-binary, being assigned male at birth, being out to their healthcare provider, living in the western or northeastern United States, and having more peers on PrEP. More work is needed to address lower PrEP uptake in SGM under 18 and those whose sex risk may be more dynamic (e.g., non-binary, pansexual/queer, and bisexual SGM) and such strategies should consider utilizing peers to provide information and ameliorate structural barriers.

Linkage to HIV Medical Care and Social Determinants of Health Among Adults With Diagnosed HIV Infection in 41 States and the District of Columbia, 2017

OBJECTIVES

To reduce the number of new HIV infections and improve HIV health care outcomes, the social conditions in which people live and work should be assessed. The objective of this study was to describe linkage to HIV medical care by selected demographic characteristics and social determinants of health (SDH) among US adults with HIV at the county level.

METHODS

We used National HIV Surveillance System data from 42 US jurisdictions and data from the American Community Survey to describe differences in linkage to HIV medical care among adults aged ≥18 with HIV infection diagnosed in 2017. We categorized SDH variables into higher or lower levels of poverty (where <13% or ≥13% of the population lived below the federal poverty level), education (where <13% or ≥13% of the population had

RESULTS

Of 33 204 adults with HIV infection diagnosed in 2017, 78.4% were linked to HIV medical care ≤1 month after diagnosis. Overall, rates of linkage to care were significantly lower among men and women living in counties with higher versus lower poverty (PR = 0.96; 95% CI, 0.94-0.97), with lower versus higher health insurance coverage (PR = 0.93; 95% CI, 0.92-0.94), and with lower versus higher education levels (PR = 0.97; 95% CI, 0.96-0.98).

CONCLUSIONS

Increasing health insurance coverage and addressing economic and educational disparities would likely lead to better HIV care outcomes in these areas.

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Key Words

• HIV health care outcomes
• health disparity
• human immunodeficiency virus
• linkage to HIV medical care
• social determinants of health

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MESH Headings

• Adult
• District of Columbia
• Female
• HIV Infections/diagnosis
• HIV Infections/epidemiology
• HIV Infections/therapy
• Humans
• Insurance, Health
• Male
• Poverty
• Social Determinants of Health
• United States/epidemiology

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Affiliation(s)

Myrline Gillot Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
Zanetta Gant Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Xiaohong Hu Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
Anna Satcher Johnson Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA

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Barriers and facilitators to scaling up Healthy Choices, a motivational interviewing intervention for youth living with HIV

Background

This study included Community Health Workers and their supervisors from HIV clinical care teams who participated in the Healthy Choices intervention program. Healthy Choices is a Motivational Interviewing-based intervention aimed at improving medication adherence and reducing alcohol use for adolescents and emerging adults ages 16—24 living with HIV. In this study, the intervention was “scaled up” for delivery by local HIV care providers in real-world clinic settings.

Methods

Providers (N = 21) completed semi-structured interviews (N = 29) about their experiences with intervention scale-up. Rigorous thematic analyses were conducted within discussions of barriers and facilitators of intervention implementation.

Results

Three dominant thematic areas emerged from the data: (1) perceptions of the Healthy Choices intervention, (2) engaging high risk YLH in in-person behavior interventions, and (3) perspectives on implementation of the intervention using local staff. Results offer insights into implementation of MI-based interventions for adolescents and emerging adults in clinic settings using local clinical staff instead of dedicated research staff.

Conclusions

Overall, scaled-up intervention programs for youth are challenged to maintain scientific rigor, provide rigorous training and supports, and offer an attractive and engaging program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08453-w.

A Demedicalized Model to Provide PrEP in a Sexual Health Clinic

BACKGROUND

Sexual health clinics (SHCs) serve large numbers of patients who might benefit from preexposure prophylaxis (PrEP). Integrating longitudinal PrEP care into SHCs can overburden clinics. We implemented an SHC PrEP program that task shifted most PrEP operations to nonmedical staff, disease intervention specialists (DIS).

METHODS

We conducted a retrospective cohort analysis of PrEP patients in an SHC in Seattle, WA, from 2014 to 2020 to assess the number of patients served and factors associated with PrEP discontinuation. Clinicians provide same-day PrEP prescriptions, whereas DIS coordinate the program, act as navigators, and provide most follow-up care.

RESULTS

Between 2014 and 2019, 1387 patients attended an initial PrEP visit, 93% of whom were men who have sex with men. The number of patients initiating PrEP per quarter year increased from 20 to 81. The number of PrEP starts doubled when the clinic shifted from PrEP initiation at scheduled visits to initiation integrated into routine walk-in visits. The percentage of visits performed by DIS increased from 3% in 2014 to 45% in 2019. Median duration on PrEP use was 11 months. PrEP discontinuation was associated with non-Hispanic black race/ethnicity [hazard ratio (HR) 1.34, 95% confidence interval (CI) 1.02 to 1.76], age <20 years (HR 2.17, 95% CI: 1.26 to 3.75), age between 20 and 29 years (HR 1.55, 95% CI: 1.06 to 2.28), and methamphetamine use (HR 1.98, 95% CI: 1.57 to 2.49). The clinic had 750 patients on PrEP in the final quarter of 2019.

CONCLUSIONS

A demedicalized SHC PrEP model that task shifts most operations to DIS can provide PrEP at scale to high priority populations.