Understanding Stakeholders' Perspectives to Increase COVID-19 Vaccine and Booster Uptake Among Black Individuals With Rheumatic Conditions

OBJECTIVE

Disparities in COVID-19 vaccine and booster uptake persist. This study aimed to obtain perspectives from community and physician stakeholders on COVID-19 vaccine and booster hesitancy and strategies to promote vaccine uptake among Black individuals with rheumatic and musculoskeletal conditions.

METHODS

We invited community leaders and physicians in greater Boston and Chicago to participate in semi-structured interviews using a moderator guide developed a priori. Participants were queried about how to best address vaccine hesitancy, strategies to target high-risk populations, and factors to identify future community leaders. Interviews were audio recorded, transcribed verbatim, and analyzed thematically using Dedoose.

RESULTS

A total of 8 physicians and 12 community leaders participated in this study between November 2021 and October 2022. Qualitative analyses revealed misinformation/mixed messaging and mistrust, with subthemes including conspiracy theories, concerns regarding vaccine development and function, racism and historical injustices, and general mistrust of health care systems as the top cited reasons for COVID-19 vaccine hesitancy. Participants also shared demographic-specific differences, such as race, ethnicity, age, and gender that influenced the identified themes, with emphasis on COVID-19 vaccine access and apathy. Strategies for community-based vaccine-related information dissemination included personal storytelling with an iterative and empathetic approach, while recognizing the importance of protecting community leader well-being.

CONCLUSION

To increase vaccine uptake among Black individuals with rheumatic conditions, strategies should acknowledge and respond to racial/ethnic and socioeconomic injustices that engender vaccine hesitancy. Messaging should be compassionate, individually tailored, and recognize heterogeneity in experiences and opinions. Results from these analyses will inform a planned community-based intervention in Boston and Chicago.

Racial Disparities in Periprosthetic Joint Infections after Primary Total Joint Arthroplasty: A Retrospective Study

In the United States, racial disparities have been observed in complications following total joint arthroplasty (TJA), including readmissions and mortality. It is unclear whether such disparities also exist for periprosthetic joint infection (PJI). The clinical data registry of a large New England hospital system was used to identify patients who underwent TJA between January 2018 and December 2021. The comorbidities were evaluated using the Elixhauser Comorbidity Index (ECI). We used Poisson regression to assess the relationship between PJI and race by estimating cumulative incidence ratios (cIRs) and 95% confidence intervals (CIs). We adjusted for age and sex and examined whether ECI was a mediator using structural equation modeling. The final analytic dataset included 10,018 TJAs in 9681 individuals [mean age (SD) 69 (10)]. The majority (96.5%) of the TJAs were performed in non-Hispanic (NH) White individuals. The incidence of PJI was higher among NH Black individuals (3.1%) compared with NH White individuals (1.6%) [adjusted cIR = 2.12, 95%CI = 1.16-3.89; p = 0.015]. Comorbidities significantly mediated the association between race and PJI, accounting for 26% of the total effect of race on PJI incidence. Interventions that increase access to high-quality treatments for comorbidities before and after TJA may reduce racial disparities in PJI.

Need for open data on COVID-19 vaccine uptake among pregnant people in the Caribbean: a call to action

Pregnant people with coronavirus disease 2019 (COVID-19) have a higher risk of adverse maternal and fetal outcomes compared with pregnant people without COVID-19. In 2021, large increases in maternal mortality were reported in Jamaica, almost half of which were attributable to COVID-19. COVID-19 vaccination has been shown to reduce these risks, but low- and middle-income countries lack free, publicly available data, known as open data, on COVID-19 vaccine uptake for their pregnant populations. The objectives of this paper were to: review how high-income countries use open data to detect trends in COVID-19 vaccine uptake among pregnant people and develop vaccination distribution strategies; outline barriers to making open data available for maternal COVID-19 vaccination in the Caribbean; and propose a multipronged strategy that would increase the availability of open data on maternal COVID-19 vaccination in the Caribbean. A multipronged strategy to fill the data void would involve: (i) utilizing existing Caribbean maternal immunization data collection entities; (ii) adapting digital software tools to establish maternal electronic immunization registries; and (iii) collaborating with local partners skilled in data analytics. Making open data available for COVID-19 vaccine uptake among pregnant people in the Caribbean could offer substantial benefits, including the development of measurable maternal COVID-19 vaccination goals and the facilitation of vaccine decision-making discussions between providers and pregnant people.

Factors Associated With Coronavirus Disease 2019 Vaccine Uptake Among Pregnant Women and Nonpregnant Women of Reproductive Age in Jamaica

Background

Despite high rates of coronavirus disease 2019 (COVID-19)-related maternal mortality, Jamaica currently has little data on COVID-19 vaccine uptake among pregnant women.

Methods

We conducted a cross-sectional, web-based survey of 192 reproductive-aged women in Jamaica from February 1 to 8, 2022. Participants were recruited from a convenience sample of patients, providers, and staff at a teaching hospital. We assessed self-reported COVID-19 vaccination status and COVID-19-related medical mistrust (operationalized as vaccine confidence, government mistrust, and race-based mistrust). We used multivariable modified Poisson regression to test the association between vaccine uptake and pregnancy.

Results

Of 192 respondents, 72 (38%) were pregnant. Most (93%) were Black. Vaccine uptake was 35% in pregnant women versus 75% in nonpregnant women. Pregnant women were more likely to cite healthcare providers versus the government as trustworthy sources of COVID-19 vaccine information (65% vs 28%). Pregnancy, low vaccine confidence, and government mistrust were associated with a lower likelihood of COVID-19 vaccination (adjusted prevalence ratio [aPR] = 0.68 [95% confidence interval {CI}, .49-.95], aPR = 0.61 [95% CI, .40-.95], and aPR = 0.68 [95% CI, .52-.89], respectively). Race-based mistrust was not associated with COVID-19 vaccination in the final model.

Conclusions

Pregnancy, low vaccine confidence, and government mistrust were associated with a lower likelihood of COVID-19 vaccination among reproductive-aged women in Jamaica. Future studies should evaluate the efficacy of strategies proven to improve maternal vaccination coverage, including standing "opt-out" vaccination orders and collaborative provider and patient-led educational videos tailored for pregnant individuals. Strategies that decouple vaccine messaging from government agencies also warrant evaluation.

Acceptability of COVID-19 vaccines among Black immigrants living in the United States

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This study examined acceptability of the COVID-19 vaccines among Black immigrants in the U.S.

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Our results highlight that COVID-19 vaccine hesitancy is high among Black immigrants in the U.S.

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Culturally-relevant interventions are needed to ensure optimal vaccination rates in this group.

Background

Coronavirus disease 2019 (COVID-19) has disproportionately affected the Black community in the United States (U.S.). The emergency authorization of three COVID-19 vaccines in the U.S.—issued between December 2020 and February 2021—will significantly reduce hospitalizations and deaths due to COVID-19. To date, no published study on COVID-19 vaccine acceptability among Black individuals in the U.S. has examined the unique experiences of Black immigrants.

Methods

Between January and February 2021, we conducted an online quantitative survey of first and second generation Black immigrants across the U.S. (n = 388). We fit bivariate and multivariable multinomial logistic regression models to examine acceptability of the COVID-19 vaccines.

Results

Overall, 57% of participants reported that they would get the COVID-19 vaccine immediately if it was available to them or had already received at least one dose of the vaccine, 37% would delay getting the vaccine, and 6% indicated that they would never get the vaccine. Compared to participants who reported that they would get the COVID-19 vaccine immediately/had already received at least one dose, participants who indicated that they would never get the vaccine were more likely to have an associate’s degree or lower [adjusted odds ratio (aOR) 9.25; 95% confidence interval (CI): 2.34 to 36.6] and a bachelor’s degree (aOR 3.79; 95% CI: 1.14 to 12.6) compared to having a master’s degree or higher. Additionally, compared to participants who reported that they would get the COVID-19 vaccine immediately/had already received at least one dose, participants who indicated that they would delay getting the COVID-19 vaccine were more likely to: identify as female (aOR 2.62; 95% CI: 1.45 to 4.72), identify as heterosexual (aOR 4.33; 95% CI: 1.46 to 12.9), report having been employed in healthcare operations and care delivery in the previous 6 months (aOR 2.08; 95% CI: 1.02 to 4.25), and history of a laboratory-confirmed COVID-19 diagnosis (aOR 2.44; 95% CI: 1.15 to 5.19).

Conclusion

Our results suggest that COVID-19 vaccine hesitancy may be high among Black immigrants in the U.S. We found that lower educational attainment, being female, and employment in healthcare setting were associated with vaccine refusal and delay. Culturally-relevant interventions are needed to ensure optimal vaccination rates among this vulnerable population.

Lifting Universal Masking in Schools - Covid-19 Incidence among Students and Staff

BACKGROUND

In February 2022, Massachusetts rescinded a statewide universal masking policy in public schools, and many Massachusetts school districts lifted masking requirements during the subsequent weeks. In the greater Boston area, only two school districts - the Boston and neighboring Chelsea districts - sustained masking requirements through June 2022. The staggered lifting of masking requirements provided an opportunity to examine the effect of universal masking policies on the incidence of coronavirus disease 2019 (Covid-19) in schools.

METHODS

We used a difference-in-differences analysis for staggered policy implementation to compare the incidence of Covid-19 among students and staff in school districts in the greater Boston area that lifted masking requirements with the incidence in districts that sustained masking requirements during the 2021-2022 school year. Characteristics of the school districts were also compared.

RESULTS

Before the statewide masking policy was rescinded, trends in the incidence of Covid-19 were similar across school districts. During the 15 weeks after the statewide masking policy was rescinded, the lifting of masking requirements was associated with an additional 44.9 cases per 1000 students and staff (95% confidence interval, 32.6 to 57.1), which corresponded to an estimated 11,901 cases and to 29.4% of the cases in all districts during that time. Districts that chose to sustain masking requirements longer tended to have school buildings that were older and in worse condition and to have more students per classroom than districts that chose to lift masking requirements earlier. In addition, these districts had higher percentages of low-income students, students with disabilities, and students who were English-language learners, as well as higher percentages of Black and Latinx students and staff. Our results support universal masking as an important strategy for reducing Covid-19 incidence in schools and loss of in-person school days. As such, we believe that universal masking may be especially useful for mitigating effects of structural racism in schools, including potential deepening of educational inequities.

CONCLUSIONS

Among school districts in the greater Boston area, the lifting of masking requirements was associated with an additional 44.9 Covid-19 cases per 1000 students and staff during the 15 weeks after the statewide masking policy was rescinded.

Association of culturally competent care with influenza vaccination coverage in the United States

BACKGROUND

Cultural minority groups in the United States have lower vaccination rates or worse influenza-related outcomes. Culturally competent care, which aims to engage the social, cultural, and linguistic needs of all patients, may address some of these disparities.

OBJECTIVE

We investigate how self-reported measures of culturally competent care is associated with influenza vaccination rates in the United States.

METHODS

The National Health Interview Survey (NHIS) 2017 was queried for respondents asked a set of questions which assessed respondents' access to culturally competent care in the past year. The outcome of interest was self-reported receipt of the annual influenza vaccine. Sample-weighted multivariable logistic regressions estimated the adjusted odds ratios and 95 % confidence intervals (95 %CI) of influenza vaccination with response to the cultural competency survey questions as the dependent variable of interest. Subsequent marginal modeling predicted the adjusted vaccination rates among cultural minorities (racial/ethnic minorities, LGBTQ + adults, foreign-born individuals, and non-English speakers) and respondents with high-risk comorbidities for worse influenza outcomes. Models were adjusted for other known determinants of vaccination coverage.

RESULTS

20,303 sample adults were included in the analyses. There were significantly higher odds of influenza vaccination among respondents who were "always" or "most of the time" treated with respect by their providers (aOR 1.53, 95 %CI [1.23-1.90], P < 0.001), given easy-to-understand information (aOR 1.37, 95 %CI [1.19-1.58], P < 0.001), asked about their opinions or beliefs about their care (aOR 1.29, 95 %CI [1.19-1.39], P < 0.001), and seen by providers who shared or understood their culture (aOR 1.15 95 %CI [1.01-1.30], P = 0.03), compared to their counterparts who responded with "some" or "none of the time" to the same survey questions. Higher adjusted influenza vaccination rates were seen among multiple racial/ethnic groups, LGBTQ + adults, foreign-born individuals, non-English speakers, and individuals with high-risk comorbidities who reported positive responses to the cultural competency survey questions.

CONCLUSIONS

We demonstrate a positive association between self-reported frequency of access to culturally competent care and receipt of the annual influenza vaccine. These findings support future efforts to evaluate vaccination outcomes among patients who receive components of culturally competent care, such as linguistically appropriate services, race-concordant healthcare workforce, and community engagement.

Correlates of Homonegativity Towards Men Who Have Sex With Men Among Black Individuals in the United States

This study aims to identify the factors that are associated with homonegativity toward men who have sex with men (MSM) within Black communities since the expansion of LGBTQ rights. A survey was completed in 2016 by a nationally representative sample of 868 Black respondents, 18-50 years old, via e-mail. Demographics, perception of same-gender sexual behaviors, religiosity, experienced racism, and contact with the carceral system (CS) were assessed. 61.6% of respondents endorsed at least one homonegative belief. Being male, residing in the South, attending religious services, receiving homonegative faith messaging, and having contact with the CS were significantly associated with homonegativity toward MSM while experiencing racism, older age, and residing in a non-metropolitan area were not. Education efforts on LGBTQ identities in Black communities should engage faith communities, extend to metropolitan and non-metropolitan areas of the South, and include younger and older adults. Programs that decrease the arrest of Black individuals may also help reduce homonegativity toward MSM.

A qualitative study of COVID-19 vaccine intentions and mistrust in Black Americans: Recommendations for vaccine dissemination and uptake

BACKGROUND

COVID-19 vaccination rates among Black Americans have been lower than White Americans and are disproportionate to their population size and COVID-19 impact. This study examined reasons for low vaccination intentions and preferred strategies to promote COVID-19 vaccination.

METHODS

Between November 2020 and March 2021, we conducted semi-structured interviews with 24 participants who expressed low vaccination intentions in a RAND American Life Panel survey; we also interviewed five stakeholders who represent organizations or subgroups in Black communities that have been highly affected by COVID-19.

RESULTS

Many interviewees discussed the "wait-and-see" approach, citing that more time and evidence for vaccine side effects and efficacy are needed. Perceived barriers to COVID-19 vaccination included structural barriers to access (e.g., transportation, technology) and medical mistrust (e.g., towards the vaccines themselves, the government, healthcare providers and healthcare systems, and pharmaceutical companies) stemming from historical and contemporary systematic racism against Black communities. Interviewees also discussed strategies to promote COVID-19 vaccines, including acknowledging systemic racism as the root cause for mistrust, preferred messaging content (e.g., transparent messages about side effects), modes, and access points (e.g., a variety of medical and non-medical sites), and trusted information sources (e.g., trusted leaders, Black doctors and researchers).

CONCLUSIONS

These insights can inform ways to improve initial and booster vaccination uptake as the COVID-19 pandemic progresses.

COVID-19 Vaccine Intentions and Mistrust in a National Sample of Black Americans

BACKGROUND

National data indicate low intentions for COVID-19 vaccination among a substantial minority of Black Americans, and disproportionately lower vaccination rates among Black Americans than White Americans.

METHODS

A total of 207 of the 318 Black participants (65%) in the RAND American Life Panel, a nationally representative internet panel, were surveyed about COVID-19 vaccine intentions in November-December 2020. Participants' census tracts were geocoded using the Centers for Disease Control and Prevention's Social Vulnerability Index.

RESULTS

Overall, 35% agreed or strongly agreed that they would not get a COVID-19 vaccine, 40% agreed or strongly agreed that they would get vaccinated, and 25% reported "don't know." Significant multivariable predictors of not wanting to get vaccinated included high mistrust of the vaccine itself (e.g., concerns about harm and side effects), OR (95% CI) = 2.2 (1.2-3.9), p = .007, and weak subjective norms for vaccination in one's close social network, OR (95% CI) = 0.6 (0.4-0.7), p < .001. Residence in an area of higher socioeconomic vulnerability was a marginally significant predictor, OR (95% CI) = 3.1 (0.9-11.0), p = .08.

CONCLUSIONS

High mistrust around COVID-19 vaccines may lower vaccine confidence. Social network members' attitudes can be influential in encouraging vaccination. Public health communications could use transparent and clear messaging on safety and efficacy, and acknowledge historical and ongoing discrimination and racism as understandable reasons for low confidence in COVID-19 vaccines. Future research is needed to consider vaccine access challenges in tandem with mistrust as contributing to low vaccination rates across health conditions.

Toward Greater Pre-exposure Prophylaxis Equity: Increasing Provision and Uptake for Black and Hispanic/Latino Individuals in the U.S

Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition and is a critical tool in the Ending the HIV Epidemic in the U.S. initiative. However, major racial and ethnic disparities across the pre-exposure prophylaxis continuum, secondary to structural inequities and systemic racism, threaten progress. Many barriers, operating at the individual, network, healthcare, and structural levels, impede PrEP access and uptake within Black and Hispanic/Latino communities. This review provides an overview of those barriers and the innovative and collaborative solutions that health departments, healthcare organizations, and community partners have implemented to increase PrEP provision and uptake among disproportionately affected communities. Promising strategies at the individual and network levels focus on increasing patient support throughout the PrEP continuum, positioning and training community members to expand knowledge of and interest in PrEP, and leveraging mobile technologies to support PrEP uptake. Healthcare-level solutions include expanding the venues and types of healthcare professionals that can provide PrEP, and structural- and policy-level options focus on financial assistance programs and health insurance expansion. Key research gaps include demonstrating that pilot studies and interventions remain effective at scale and across varied contexts. Although the last 2 decades have provided effective tools to end the HIV epidemic, realizing this vision for the U.S. will require addressing persistent and pervasive HIV-related disparities in Black and Hispanic/Latino communities. Federal, state, and local partners should expand efforts to address longstanding health and structural inequities and partner with disproportionately affected communities to rapidly expand PrEP scale-up.

Disparities in SARS-CoV-2 Vaccination-to-Infection Risk During the COVID-19 Pandemic in Massachusetts

This cohort study examines the alignment of vaccination and SARS-CoV-2 risk in Massachusetts by creating and applying a vaccination-to-infection risk ratio.

The transient effect of a peer support intervention to improve adherence among adolescents and young adults failing antiretroviral therapy in Harare, Zimbabwe: a randomized control trial

Background

Adolescents and young adults living with HIV in sub Saharan Africa are at high risk of poor adherence to antiretroviral therapy (ART) and virologic failure (VF).

Methods

We conducted a randomized control trial among adolescents and young adults on ART with VF to assess the effectiveness of a community-based peer support intervention aimed at improving VF. Viral load (VL) levels were obtained at 12, 24 and 36 weeks. A subset of the participants had baseline HIV drug resistance (HIVDR) genotyped using Sanger sequencing.

Results

The participants’ median (interquartile range (IQR)) age was 18.1 (IQR: 15.1–20.0) years and half (50.5%, n = 107) were male. At week 24, the proportion of subjects with a detectable viremia was significantly lower in the intervention arm than in the standard of care (SOC) arm (76.0% (n = 79) vs. 89.0% (n = 96), p = 0.013). At Week 36, there remained a difference in the proportion of subjects with a detectable VL between the intervention arm (68.3%, n = 71) and SOC arm (79.6%, n = 86), which was trending towards statistical significance (p = 0.059). There was no difference in the probability of having a detectable VL over time between the intervention and SOC groups (adjusted odds ratio: 1.14, p = 0.439). Baseline HIVDR was observed in 44.0% of the participants in the intervention and 56.0% in the SOC group (p = 0.146).

Conclusion

A transient effect of the peer support intervention in improving VF was observed among adolescents and young people failing ART.

Trial registration: This study is registered with www.clinicaltrials.gov under the reference number: NCT02833441

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-021-00356-w.

Neighborhood Social Cohesion and Inequalities in COVID-19 Diagnosis Rates by Area-Level Black/African American Racial Composition

Geographic inequalities in COVID-19 diagnosis are now well documented. However, we do not sufficiently know whether inequalities are related to social characteristics of communities, such as collective engagement. We tested whether neighborhood social cohesion is associated with inequalities in COVID-19 diagnosis rate and the extent the association varies across neighborhood racial composition. We calculated COVID-19 diagnosis rates in Philadelphia, PA, per 10,000 general population across 46 ZIP codes, as of April 2020. Social cohesion measures were from the Southeastern Pennsylvania Household Health Survey, 2018. We estimated Poisson regressions to quantify associations between social cohesion and COVID-19 diagnosis rate, testing a multiplicative interaction with Black racial composition in the neighborhood, which we operationalize via a binary indicator of ZIP codes above vs. below the city-wide average (41%) Black population. Two social cohesion indicators were significantly associated with COVID-19 diagnosis. Associations varied across Black neighborhood racial composition (p <0.05 for the interaction test). In ZIP codes with ≥41% of Black people, higher collective engagement was associated with an 18% higher COVID-19 diagnosis rate (IRR=1.18, 95%CI=1.11, 1.26). In contrast, areas with <41% of Black people, higher engagement was associated with a 26% lower diagnosis rate (IRR=0.74, 95%CI=0.67, 0.82). Neighborhood social cohesion is associated with both higher and lower COVID-19 diagnosis rates, and the extent of associations varies across Black neighborhood racial composition. We recommend some strategies for reducing inequalities based on the segmentation model within the social cohesion and public health intervention framework.

Hidden in Plain Sight: Identifying Women Living in the United States Who Could Benefit From HIV Preexposure Prophylaxis

HIV preexposure prophylaxis (PrEP) with oral tenofovir/emtricitabine is an effective means of decreasing human immunodeficiency virus (HIV) acquisition among women. However, few women are prescribed and are taking PrEP. This article offers perspectives on barriers to use and strategies to increase uptake among women.

HIV Risk-Related Behaviors and Willingness to Use Pre-Exposure Prophylaxis Among Black Americans with an Arrest History

OBJECTIVE

Black individuals in the USA are arrested and incarcerated at a significantly higher rate than White individuals, and incarceration is associated with increased HIV vulnerability. Pre-exposure prophylaxis (PrEP) reduces the risk for HIV transmission, but little is known about the relationship between HIV risk behavior and willingness to use PrEP among Black individuals with an arrest history.

METHOD

A total of 868 individuals completed a nationally representative survey and provided baseline data on sexual risk. Participants were grouped as those with a history of arrest (N = 226) and those with no history of arrest (N=619) based on self-reported arrest history. Our study examined HIV risk behaviors associated with willingness to use PrEP between those with arrest history and those without arrest history.

RESULTS

Participants with an arrest history were more likely to have a lifetime history of anal sex (p<0.0001) and sexually transmitted diseases (p=0.0007). A history of multiple sexual partners in the past 3 months was associated with PrEP willingness in individuals with an arrest history [aPR 2.61 (1.77, 3.85), p<0.0001], adjusting for other covariates in the model.

CONCLUSIONS

Differences in risk behavior and willingness to use PrEP exist by arrest history. Understanding these risk behaviors are necessary to increase access to PrEP. PrEP uptake and adherence interventions, when recommended and made available for individuals at substantive risk of HIV infection at the time of arrest and during incarceration, are essential to reducing the spread of HIV in correctional facilities and in communities to which they return.

COVID-19 Related Medical Mistrust, Health Impacts, and Potential Vaccine Hesitancy Among Black Americans Living With HIV

BACKGROUND

Medical mistrust, a result of systemic racism, is prevalent among Black Americans and may play a role in COVID-19 inequities. In a convenience sample of HIV-positive Black Americans, we examined associations of COVID-19-related medical mistrust with COVID-19 vaccine and COVID-19 treatment hesitancy and negative impacts of COVID-19 on antiretroviral therapy (ART) adherence.

METHODS

Participants were 101 HIV-positive Black Americans (age: M = 50.3 years; SD = 11.5; 86% cisgender men; 77% sexual minority) enrolled in a randomized controlled trial of a community-based ART adherence intervention in Los Angeles County, CA. From May to July 2020, participants completed telephone interviews on negative COVID-19 impacts, general COVID-19 mistrust (eg, about the government withholding information), COVID-19 vaccine and treatment hesitancy, and trust in COVID-19 information sources. Adherence was monitored electronically with the Medication Event Monitoring System.

RESULTS

Nearly all participants (97%) endorsed at least one general COVID-19 mistrust belief, and more than half endorsed at least one COVID-19 vaccine or treatment hesitancy belief. Social service and health care providers were the most trusted sources. Greater COVID-19 mistrust was related to greater vaccine and treatment hesitancy [b (SE) = 0.85 (0.14), P < 0.0001 and b (SE) = 0.88 (0.14), P < 0.0001, respectively]. Participants experiencing more negative COVID-19 impacts showed lower ART adherence, assessed among a subset of 49 participants [b (SE) = -5.19 (2.08), P = 0.02].

DISCUSSION

To prevent widening health inequities, health care providers should engage with communities to tailor strategies to overcome mistrust and deliver evidence-based information, to encourage COVID-19 vaccine and treatment uptake.

Disparities in SARS-CoV-2 Testing in Massachusetts During the COVID-19 Pandemic

This cohort study examines disparities in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing during the coronavirus disease 2019 (COVID-19) pandemic in Massachusetts.

HIV-Related Mistrust (or HIV Conspiracy Theories) and Willingness to Use PrEP Among Black Women in the United States

Uptake of pre-exposure prophylaxis (PrEP) among Black women living in the US is suboptimal. We sought to determine the association between HIV-related medical mistrust (or belief in HIV conspiracy theories) and willingness to use PrEP among Black women. We analyzed data from the 2016 National Survey on HIV in the Black Community (NSHBC), a nationally representative cross-sectional survey. Among NSHBC participants, 522 were women and 347 (69.0%) reported HIV risk factors. Only 14.1% were aware that PrEP exists; 30.8% reported willingness to use PrEP. HIV-related medical mistrust was reported by 60.4% of women. In multivariable analysis, controlling for income, education, marital status and health care engagement, belief in conspiracy theories was significantly associated with higher willingness to use PrEP. The HIV-Related Medical Mistrust Scale item: "there is a cure for HIV, but the government is withholding it from the poor" was independently associated with higher PrEP willingness. This finding speaks to the need for an improved understanding of the role of HIV-related medical mistrust among Black women to improve uptake of biomedical HIV prevention.

Sexual Orientation Identity, Race/Ethnicity, and Lifetime HIV Testing in a National Probability Sample of U.S. Women and Men: An Intersectional Approach

Purpose: We examined differences in lifetime human immunodeficiency virus (HIV) testing in relation to both sexual orientation identity and race/ethnicity among U.S. women and men. Methods: We used 2013-2017 National Health Interview Survey data and multivariable logistic regression to assess the distribution of lifetime HIV testing across and within sexual orientation identity and racial/ethnic groups of U.S. women (n = 60,867) and men (n = 52,201) aged 18-64 years. Results: Among women, Black lesbian (74.1%) and bisexual (74.0%) women had the highest prevalence whereas Asian lesbian women (32.5%) had the lowest prevalence of lifetime HIV testing. Among men, the prevalence of lifetime HIV testing was the highest among Latino gay men (92.6%) and the lowest among Asian heterosexual men (32.0%). In most cases, Black women and Black and Latino men had significantly higher adjusted odds whereas Asian women and men had lower adjusted odds of lifetime HIV testing compared with their White counterparts within sexual orientation identity groups. In many instances, bisexual women and gay men had significantly higher adjusted odds of lifetime HIV testing relative to their heterosexual counterparts within racial/ethnic groups. Compared with White heterosexual individuals, most sexual orientation identity and racial/ethnic subgroups had significantly higher adjusted odds whereas Asian heterosexual, bisexual, and lesbian women and Asian heterosexual and bisexual men may have lower adjusted odds of lifetime HIV testing. Conclusion: Culturally relevant, linguistically appropriate, and structurally competent programs and practices are needed to facilitate lifetime HIV testing among diverse sexual orientation identity and racial/ethnic subgroups of women and men, including multiply marginalized subgroups that are undertested or disproportionately affected by HIV/AIDS.

Neighborhood Crime and Sexual Transmission Risk Behavior among Black Men Living with HIV

Here, we examined the association of exposure to neighborhood crime with sexual risk-taking behavior among Black men living with HIV. HIV-positive Black men on antiretroviral therapy in California completed an audio computer-assisted self-interview. Crime risk per census block group was derived from the Federal Bureau of Investigation's Uniform Crime Report. Among 193 men, the mean (SD) number of sexual partners among those who were sexually active was 2.7 (3.3). 49% reported condomless sex, and 23% reported sex with an HIV-negative or unknown-serostatus partner. In multivariate analysis, illicit drug use ([IRR=1.86; 95%CI: 1.20-2.89] p=.006), depressive symptoms ([IRR=1.59; 95%CI: 1.03-2.44] p=.03), an undetectable viral load ([IRR=1.91; 95%CI: 1.22-3.00] p=.005), and neighborhood total crime risk ([IRR=1.02; 95%CI: 1.01-1.04] p=.007) remained significant. Among Black men living with HIV, exposure to neighborhood crime is associated with having multiple sexual partners whose HIV status was negative or unknown.

Spatial Access and Willingness to Use Pre-Exposure Prophylaxis Among Black/African American Individuals in the United States: Cross-Sectional Survey

Background

Uptake of pre-exposure prophylaxis (PrEP) among black individuals in the United States is low and may be associated with the limited availability of clinics where PrEP is prescribed.

Objective

We aimed to determine the association between spatial access to clinics where PrEP is prescribed and willingness to use PrEP.

Methods

We identified locations of clinics where PrEP is prescribed from AIDSVu.org and calculated the density of PrEP clinics per 10,000 residents according to the ZIP code. Individual-level data were obtained from the 2016 National Survey on HIV in the Black Community. We used multilevel modelling to estimate the association between willingness to use PrEP and clinic density among participants with individual-level (HIV risk, age, gender, education, income, insurance, doctor visit, census region, urban/rural residence) and ZIP code–level (%poverty, %unemployed, %uninsured, %black population, and density of health care facilities) variables.

Results

All participants identified as black/African American. Of the 787 participants, 45% were men and 23% were found to be at high risk based on the self-reported behavioral characteristics. The mean age of the participants was 34 years (SD 9), 54% of participants resided in the South, and 26% were willing to use PrEP. More than one-third (38%) of the sample had to drive more than 1 hour to access a PrEP provider. Participants living in areas with higher PrEP clinic density were significantly more willing to use PrEP (one SD higher density of PrEP clinics per 10,000 population was associated with 16% higher willingness [adjusted prevalence ratio=1.16, 95% CI: 1.03-1.31]).

Conclusions

Willingness to use PrEP was associated with spatial availability of clinics where providers prescribe PrEP in this nationally representative sample of black African Americans.

HIV-Related Medical Mistrust, HIV Testing, and HIV Risk in the National Survey on HIV in the Black Community

Black Americans are greatly affected by HIV disparities and exhibit high levels of medical mistrust, including HIV conspiracy beliefs, a form of mistrust around HIV's origin and treatment. A 2002-2003 national survey of Black Americans found that 48% believed that "HIV is a manmade virus." However, the extent to which such beliefs remain widespread is unknown. Moreover, HIV conspiracy beliefs have been associated with greater HIV risk, but have also been associated with a higher testing likelihood-and no research to date has attempted to explain these seemingly contradictory findings. We obtained updated data on prevalence and correlates of HIV conspiracy beliefs from the US National Survey on HIV in the Black Community, a nationally representative e-mail survey of 868 Black individuals aged 18-50 years (February-April 2016). Substantial percentages agreed that HIV is man-made (31%) and that the government is withholding a cure for HIV (40%). HIV conspiracy beliefs and HIV risk were both significantly associated with a higher HIV testing likelihood. The association between HIV conspiracy beliefs and HIV testing was significantly mediated by individual-level HIV risk (73% of total effect), but not by area-level socioeconomic position (an ecological determinant of higher HIV prevalence). Mistrust remains high among Black Americans, but the association of mistrust with prevention behaviors is complex. People who do not trust the public health system may also be at greater risk-and thus, more likely to get tested, potentially due to greater access to community-based testing venues that engage higher risk populations.

Faith leaders' messaging is essential to enhance HIV prevention among black Americans: results from the 2016 National Survey on HIV in the black community (NSHBC)

Background

To investigate whether religious service attendance and faith leaders’ messages about HIV and same-sex relationships are associated with acceptance of HIV prevention strategies.

Methods

Multivariable Poisson regression assessed whether attending religious services, faith leaders’ messages about HIV and same-sex relationships, and supportiveness of those messages were associated with HIV testing, as well as knowledge of and willingness to use pre-exposure prophylaxis (PrEP) among 868 Black Americans [45% men; M (SD) = 34 (9) years-old] in the 2016 National Survey on HIV in the Black Community, USA.

Results

Participants who reported attending services monthly and/or hearing faith leaders’ messages that were supportive of same-sex relationships had a significantly higher likelihood of willingness to use PrEP (adjusted Rate Ratio[ARR] = 1.76; 95% confidence interval [CI] = 1.09, 2.48) and aRR = 2.19; 95% CI = 1.35, 3.55, respectively), independent of HIV risk. Homophobia was significantly associated with higher likelihood of being aware of PrEP and testing for HIV testing in the past 12 months.

Conclusions

Faith leaders’ messaging can influence Black Americans’ perceptions and uptake of HIV prevention strategies. Faith institutions and faith leaders should be involved in designing and disseminating HIV prevention strategies.

Facilitators and Barriers to Pre-Exposure Prophylaxis (PrEP) Use Among Black Individuals in the United States: Results from the National Survey on HIV in the Black Community (NSHBC)

This study explores willingness to use PrEP among Black individuals in the US. From February to April 2016, an online survey was administered to a nationally representative sample of Black individuals. 855 individuals who were HIV negative by self-report participated [mean age: 33.6 (SD 9.2); 45.5% male]. Among all respondents, 14.5% were aware of, and 26.0% would be willing to use PrEP. Among high-risk individuals (N = 327), 19.8% knew about and 35.1% would be willing to use PrEP. The most common reason for lack of willingness among high-risk individuals was low self-perceived risk (65.1%). In multivariate analysis, individuals reporting single marital status [OR 1.8 (1.2, 2.5), p = 0.002], depressive symptoms [OR 1.6 (1.2, 2.2), p = 0.0054], arrest history [OR 1.7(1.2, 2.4), p = 0.0003], PrEP knowledge [OR 1.5 (1.0, 2.3), p = 0.0247] and belief in HIV conspiracies [OR 1.3 (1.1, 1.5), p = 0.0075] were more willing to use PrEP. Participants who saw a health care provider less frequently were less willing to use PrEP [OR 0.5 (0.4, 0.8), p = 0.0044]. Among a nationally representative sample of Black individuals, few high risk individuals were willing to use PrEP. Interventions to increase risk awareness, PrEP knowledge and access to care are necessary to improve PrEP uptake.

African born women living with HIV in the United States: unmet needs and opportunities for intervention

Africa born (immigrant) women comprise a disproportionate number of Black women living with HIV in the United States. Though they are at risk for mental health disorders, including psychological distress and depression, little is known about their experience with these important predictors of quality of life, retention in care and adherence to antiretroviral therapy. In this qualitative study, we used constructivist grounded theory to explore the psychosocial and mental health challenges of African born women living with HIV in Boston and New York City. We conducted one-on-one semi-structured interviews with 45 women. Major themes contributing to psychological distress and depressive symptoms included (1) pre-immigration HIV-related stigma; (2) persistent HIV-related stigma post-immigration, (3) undocumented immigration status, (4) economic insecurity, and (5) intimate partner violence (IPV). Many participants described ongoing depressive symptoms or histories of depressive episodes. Yet, most had not been formally diagnosed or treated for depression. Prayer, consultation with faith leadership, and support groups were described most frequently as useful interventions. Future research should explore these thematic areas among a larger, more representative sample of African born women living with HIV to determine differences by country of origin across thematic areas. These data would be useful to inform development of innovative and culturally appropriate interventions.

Mass incarceration and the impact of prison release on HIV diagnoses in the US South

Background

The purpose of this study was to determine the impact of prison release on HIV incidence in the southern region of the United States, the region with the highest rates of both incarceration and new HIV diagnoses nationwide.

Methods

5-year HIV diagnoses rates were calculated at the ZIP code level for nine cities and metropolitan statistical areas in the US South (ZIP codes, N = 600). Multilevel regression models were constructed and adjusted rate ratios (ARRs) were estimated for overall, male and female HIV diagnoses rates.

Results

Across the nine cities, in multilevel, multivariate analysis, controlling for income inequality (GINI coefficient), percent living in poverty and percent Non-Hispanic Black population, the ZIP code level overall HIV diagnosis rate was significantly associated with prison release [ARR 1.004 (95%CI 1.0007, 1.006), p<0.01]. A 10-person increase in prison release rate would result in a 4% increase in overall 5-year HIV diagnosis rate—approximately 9.4 additional cases per 100,000 population. In gender-stratified models, prison release rate was significantly associated with the ZIP code level HIV diagnosis rate for males [ARR 1.004 (95%CI 1.0004, 1.007), p<0.01], but not for females.

Conclusions

In the southern region of the US, prison release is significantly associated with HIV incidence. HIV prevention interventions should promote timely linkage to ongoing treatment for released inmates living with HIV.

HIV Testing Among Black and Hispanic Immigrants in the United States

Late presentation is common among black and Hispanic US immigrants living with HIV. Little is known about HIV testing in this population because data are aggregated into racial and ethnic categories without regard to nativity. This study was undertaken to determine HIV testing patterns in these populations. We used data from the National Health Interview Survey (2007-2010), a nationally representative source of HIV testing data disaggregated by nativity. The sample consisted of 10,397 immigrants (83.9% Hispanic white, 13.1% non-Hispanic black, and 3.0% Hispanic black). The majority of participants were from the Caribbean, Central America, and Mexico (81.5%). Hispanic white immigrants were least likely to have undergone testing compared with non-Hispanic and Hispanic black immigrants (46.7% vs. 70.5% and 65.8%). Among immigrants with known risk factors or prior STDs, 59.2% and 74.8% reported previous HIV testing. Immigrants who had not recently talked to a healthcare provider were less likely to report testing: Hispanic white (AOR 0.65, 95% CI 0.58-0.72), non-Hispanic black (AOR 0.64, 95% CI 0.48-0.85), and Hispanic black (AOR 0.26, 95% CI 0.14-0.48). Only 17.2% of all immigrants intended to undergo HIV testing in the 12 months following participation in the survey. Among all three racial and ethnic groups, immigrants who reported a history of prior STDs were more likely to intend to test for HIV in the future. Many black and Hispanic immigrants to the United States have not undergone HIV testing. Interventions to increase access to HIV testing and awareness of transmission risk should be developed.

Community Cultural Norms, Stigma and Disclosure to Sexual Partners among Women Living with HIV in Thailand, Brazil and Zambia (HPTN 063)

BACKGROUND

Serostatus disclosure may facilitate decreased HIV transmission between serodiscordant partners by raising risk awareness and heightening the need for prevention. For women living with HIV (WLWH), the decision to disclose may be influenced by culturally determined, community-level stigma and norms. Understanding the impact of community HIV stigma and gender norms on disclosure among WLWH in different countries may inform intervention development.

METHODS

HPTN063 was a longitudinal, observational study of sexually active HIV-infected individuals, including heterosexual women, in care in Zambia, Thailand and Brazil. At baseline, a questionnaire measuring community HIV stigma and gender norms, anticipated stigma, demographic, partner/relationship characteristics, and intimate partner violence was administered. Longitudinal HIV disclosure to sexual partners was determined via audio-computer assisted self-interview (ACASI) at the baseline and quarterly during the one year following up. Logistic regression was conducted to identify the predictors of disclosure.

RESULTS

Almost half (45%) of women living with HIV acknowledged perceived community HIV stigma (the belief that in their community HIV infection among women is associated with sex work and multiple sexual partners). Many women (42.9%) also acknowledged perceived community gender norms (the belief that traditional gender norms such as submissiveness to husbands/male sexual partners is necessary and that social status is lost if one does not procreate). HIV disclosure to current sex partners was reported by 67% of women. In multivariate analysis, among all women, those who were older [OR 0.16, 95%CI(0.06,0.48)], reported symptoms of severe depression [OR 0.53, 95%CI(0.31, 0.90)], endorsed anticipated stigma [OR 0.30, 95%CI(0.18, 0.50)], and were unmarried [OR 0.43, 95%CI(0.26,0.71)] were less likely to disclose to current partners. In an analysis stratified by marital status and cohabitation, unmarried [OR 0.41, 95%CI(0.20,0.82)] and non-cohabiting women [OR 0.31, 95%CI(0.13,0.73)] who perceived community HIV stigma were less likely to disclose to their sex partners.

CONCLUSIONS

Perceived community level HIV stigma, along with individual level factors such as anticipated stigma, depressive symptoms, and older age, predict non-disclosure of HIV status to sexual partners among WLWH in diverse geographic settings. Interventions to promote disclosure among women in serodiscordant relationships should incorporate community-level interventions to reduce stigma and promote gender equality.

The major genetic determinants of HIV-1 control affect HLA class I peptide presentation

Infectious and inflammatory diseases have repeatedly shown strong genetic associations within the major histocompatibility complex (MHC); however, the basis for these associations remains elusive. To define host genetic effects on the outcome of a chronic viral infection, we performed genome-wide association analysis in a multiethnic cohort of HIV-1 controllers and progressors, and we analyzed the effects of individual amino acids within the classical human leukocyte antigen (HLA) proteins. We identified >300 genome-wide significant single-nucleotide polymorphisms (SNPs) within the MHC and none elsewhere. Specific amino acids in the HLA-B peptide binding groove, as well as an independent HLA-C effect, explain the SNP associations and reconcile both protective and risk HLA alleles. These results implicate the nature of the HLA-viral peptide interaction as the major factor modulating durable control of HIV infection.

Predictors of mortality in patients initiating antiretroviral therapy in Durban, South Africa

OBJECTIVE

To identify predictors of mortality in patients initiating antiretroviral therapy (ART) in Durban, South Africa.

DESIGN

We conducted a retrospective cohort study analyzing data on patients who presented to McCord Hospital, Durban, and started ART between 1 January 1999 and 29 February 2004. We performed univariate and multivariate analysis and constructed Kaplan-Meier curves to assess predictors.

RESULTS

Three hundred and nine patients were included. Forty-nine (16%) had died by the conclusion of the study. In univariate analysis, the strongest predictors of mortality were a CD4 cell count<50/microl (hazard ratio (HR) 3.70, 95% confidence interval (CI) 1.96-7.14), a haemoglobin concentration<or=8 g/dl (HR 1.23, 95% CI 1.08-1.40), a history of oral candidiasis (HR 3.17, 95% CI 1.70-5.87) and a history of cryptococcal meningitis (HR 2.76, 95% CI 1.80-19.2). A CD4 cell count<50/microl (HR 3.08, 95% CI 1.54-5.88) and a history of oral candidiasis (HR 2.58, 95% CI 1.37-4.88) remained significant in multivariate analysis. A history of tuberculosis was not a significant predictor of mortality.

CONCLUSIONS

Simple clinical and laboratory data independently predict mortality and allow for risk stratification in patients initiating ART in South Africa. Interventions enabling patients to be identified before they develop these clinical markers and earlier initiation of ART will help to ensure maximum benefits of therapy.