The Continuum of HIV Care in Rural Communities in the United States and Canada: What Is Known and Future Research Directions

The role of socio-demographic determinants in the geo-spatial distribution of newly diagnosed HIV infections in small areas of Catalonia (Spain)

BACKGROUND

Spatial visualization of HIV surveillance data could improve the planning of programs to address the HIV epidemic. The objectives of the study were to describe the characteristics and the spatial distribution of newly diagnosed HIV infection in Catalonia and to identify factors associated with HIV infection rates.

METHODS

Surveillance data from the national registry were presented in the form of descriptive and ring maps and used to study the spatial distribution of new HIV diagnoses in Catalonia (2012-2016) and associated risk factors at the small area level (ABS, acronym for "basic health area" in Catalan). Incident cases were modeled using the following as predictors: type of municipality, prevalence of young men and migrant groups, GBMSM activity indicators, and other variables at the aggregated level.

RESULTS

New HIV diagnoses are heterogeneously distributed across Catalonia. The predictors that proved to be significantly associated with a higher rate of new HIV diagnoses were ABS located in the city of Barcelona (IRR, 2.520; P < 0.001), a higher proportion of men aged 15-44 years (IRR, 1.193; P = 0.003), a higher proportion of GBMSM (IRR, 1.230; P = 0.030), a higher proportion of men from Western Europe (IRR, 1.281; P = 0.003), a higher proportion of men from Latin America (IRR, 1.260; P = 0.003), and a higher number of gay locations (IRR, 2.665; P < 0.001). No association was observed between the HIV diagnosis rate and economic deprivation.

CONCLUSIONS

Ring maps revealed substantial spatial associations for the rate of new HIV diagnoses. New HIV diagnoses are concentrated in ABS located in urban areas. Our results show that, in the case of HIV infection, the socioeconomic deprivation index on which the Catalan government bases its budget allocation policies among the ABS should not be the only criterion used.

Influence of the definition of rurality on geographic differences in HIV outcomes in British Columbia: a retrospective cohort analysis

BACKGROUND

Improving rural health is often identified as a priority area for research and policy in Canada. We examined how findings on HIV outcomes (virologic suppression) can vary depending on the definition of rurality used.

METHODS

We performed retrospective cohort analyses using the Comparative Outcomes and Service Utilization Trends study population-based cohort of adults (age ≥ 19 yr) living with HIV in British Columbia between Apr. 1, 2012, and Mar. 31, 2013. We performed univariate logistic regression analyses using the following geographic variables to predict HIV virologic suppression: rurality defined by forward sortation area, by Statistical Area Classification and by health authority. We mapped suppression using geographic information systems.

RESULTS

Virologic suppression was observed in 5605 (65.2%) of 8598 participants. In univariate analysis, rurality defined by Statistical Area Classification (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.65-0.82), but not by forward sortation area, was associated with lower odds of suppression. When we examined suppression by health authority, Northern Health had the lowest odds of suppression (OR 0.46, 95% CI 0.36-0.58 compared to Vancouver Coastal Health). Geographic information systems mapping showed poorer suppression in northern areas.

INTERPRETATION

Health outcome findings can vary depending on the definition of the geographic variable. When including geographic variables, researchers should carefully consider variable definitions and whether other classification systems, such as north-south, are more appropriate than rurality for their analysis.

Opioid Use Disorders in People Living with HIV/AIDS: A Review of Implications for Patient Outcomes, Drug Interactions, and Neurocognitive Disorders

The opioid epidemic has had a significant, negative impact in the United States, and people living with HIV/AIDS (PLWHA) represent a vulnerable sub-population that is at risk for negative sequela from prolonged opioid use or opioid use disorder (OUD). PLWHA are known to suffer from HIV-related pain and are commonly treated with opioids, leading to subsequent addictive disorders. PLWHA and OUD are at an increased risk for attrition in the HIV care continuum, including suboptimal HIV laboratory testing, delayed entry into HIV care, and initiation or adherence to antiretroviral therapy. Barriers to OUD treatment, such as medication-assisted therapy, are also apparent for PLWHA with OUD, particularly those living in rural areas. Additionally, PLWHA and OUD are at a high risk for serious drug–drug interactions through antiretroviral-opioid metabolic pathway-related inhibition/induction, or via the human ether-a-go-go-related gene potassium ion channel pathways. HIV-associated neurocognitive disorders can also be potentiated by the off-target inflammatory effects of opioid use. PLWHA and OUD might require more intensive, individualized protocols to sustain treatment for the underlying opioid addiction, as well as to provide proactive social support to aid in improving patient outcomes. Advancements in the understanding and management of PLWHA and OUD are needed to improve patient care. This review describes the effects of prescription and non-prescription opioid use in PLWHA.

Magnitude of non-adherence to antiretroviral therapy and associated factors among adult people living with HIV/AIDS in Benishangul-Gumuz Regional State, Ethiopia

Introduction

Following global efforts to increase antiretroviral therapy (ART) access and coverage, Ethiopia has made significant achievement with a 6.3% annual decline in the HIV/AIDS incidence rate between 1990 and 2016. Such success depends not only on access to ART but also on attaining optimum treatment adherence. Emerging studies in Ethiopia has shown the increasing prevalence of poor adherence and lack of the desired viral suppression, but the extent and factors associated with non-adherence to ART are not well known, especially in the current study setup. In this study, we examined the magnitude and factors associated with treatment and non-adherence to ART among people living with HIV in Benishangul-Gumuz Regional State, northwest Ethiopia.

Methods

An institutional facility based cross-sectional descriptive study was carried out among adult people living with HIV/AIDS from mid-December 2016 to February 2017 with only 98.9% response rate. Sociodemographic factors (age, gender, marital status and residential area), economic factors (educational status, income, asset possession, employment status, dietary diversity, nutritional status and food security), and clinical characteristics (CD4 count, duration on ART and history of opportunistic infections) were explanatory variables. ART non-adherence was measured using a visual analogue scale (VAS). We used binary logistic regression and subsequent multivariate logistic regression analysis to determine the factors associated with ART non-adherence.

Result

Overall, 39.7% of the participants were found non-adherent to ART. Strong association was found between non-adherence to ART and young age below 25 years (AOR: 4.30, 95% CI [1.39-3.35]; p = 0.011), urban residential area (AOR: 2.78, CI [1.23-7.09], p = 0.043), lack of employment (AOR: 1.75, 95% CI [1.05-2.91], p = 0.032), food insecurity (AOR: 2.67, 95% CI [7.59-8.97]; p < 0.0001), malnutrition (AOR: 1.55, 95% CI [1.94-2.56]; p = 0.027) and opportunistic infections (AOR: 1.81, 95% CI [1.11-2.97]; p = 0.018).

Conclusion

The prevalence of non-adherence to ART in this study was high. Sociodemographic and economic factors such as young age of below 25 years, urban residential area, lack of employment, food insecurity, malnutrition and opportunistic infections were among the factors associated with non-adherence to ART.

Facilitators and Barriers of Pre-exposure Prophylaxis (PrEP) Uptake Among Rural Men who have Sex with Men Living in the Midwestern U.S

Facilitators and barriers of Pre-exposure Prophylaxis (PrEP) uptake have been established in prior studies; however, most of these studies comprise samples of MSM from metropolitan cities and hypothetical PrEP use. There is a dearth of literature on the uptake factors among rural U.S. MSM who are prescribed PrEP. Thirty-four rural Midwestern MSM who currently take PrEP participated in semi-structured telephone interviews about their barriers and facilitators to their PrEP use. Interviews were analyzed using an inductive thematic analysis approach. There were four barriers: (1) lack of rural dissemination of PrEP information, (2) concern about side and adverse effects of using PrEP, (3) cost of PrEP uptake and engagement, and (4) lack of access to PrEP care and PrEP care quality. Individual and social facilitators that participants utilized to overcome these barriers are discussed. Findings elevate the importance of multilevel interventions that address PrEP adoption from a patient, provider, and healthcare system perspective.

Deconstructing Syndemics: The Many Layers of Clustering Multi-Comorbidities in People Living with HIV

The HIV epidemic has dramatically changed over the past 30 years; there are now fewer newly infected people (especially children), fewer AIDS-related deaths, and more people with HIV (PWH) receiving treatment. However, the HIV epidemic is far from over. Despite the tremendous advances in anti-retroviral therapies (ART) and the implementation of ART regimens, HIV incidence (number of new infections over a defined period of time) and prevalence (the burden of HIV infection) in certain regions of the world and socio-economic groups are still on the rise. HIV continues to disproportionally affect highly marginalized populations that constitute higher-risk and stigmatized groups, underserved and/or neglected populations. In addition, it is not uncommon for PWH to suffer enhanced debilitating conditions resulting from the synergistic interactions of both communicable diseases (CDs) and non-communicable diseases (NCDs). While research utilizing only a comorbidities framework has advanced our understanding of the biological settings of the co-occurring conditions from a molecular and mechanistic view, harmful interactions between comorbidities are often overlooked, particularly under adverse socio-economical and behavioral circumstances, likely prompting disease clustering in PWH. Synergistic epidemics (syndemics) research aims to capture these understudied interactions: the mainly non-biological aspects that are central to interpret disease clustering in the comorbidities/multi-morbidities only framework. Connecting population-level clustering of social and health problems through syndemic interventions has proved to be a critical knowledge gap that will need to be addressed in order to improve prevention and care strategies and bring us a step closer to ending the HIV epidemic.

Assessing Gaps in Comprehensive HIV Care Across Settings of Care for Women Living with HIV in Canada

Background: Women living with HIV in Canada experience barriers to comprehensive HIV care. We sought to describe care gaps across a typology of care. Methods: We analyzed baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). A typology of care was characterized by primary HIV physician and care setting. Quality-of-care indicators included the following: Pap test, Pap test discussions, reproductive goal discussions, breast cancer screening, antiretroviral therapy (ART) use, adherence, HIV viral load, and viral load discussions. We defined comprehensive care with three indicators: Pap test, viral load, and either reproductive goal discussions over last 3 years or breast cancer screening, as indicated. Multivariable logistic regression analyses measured associations between care types and quality-of-care indicators. Results: Among women living with HIV accessing HIV care, 56.4% (657/1,164) experienced at least one gap in comprehensive care, most commonly reproductive goal discussions. Women accessed care from three types of care: (1) physicians (specialist and family physicians) in HIV clinics (71.6%); (2) specialists in non-HIV clinics (17.6%); and (3) family physicians in non-HIV clinics (10.8%), with 55.5%, 63.9%, and 50.8% gaps in comprehensive care, respectively. Type 3 care had double the odds of not being on ART: adjusted odds ratio (AOR 2.09, 95% confidence interval [CI] 1.16-3.75), while Type 2 care had higher odds of not having discussed the importance of Pap tests (AOR 1.48, 95% CI 1.00-2.21). Discussion: Women continue to experience gaps in care, across types of care, indicating the need to evaluate and strengthen women-centered models of care.

A systematic review of the geospatial barriers to antiretroviral initiation, adherence and viral suppression among people living with HIV

Background With the emergence of antiretroviral therapy (ART), Treatment as Prevention (TasP) has become the cornerstone of both HIV clinical care and HIV prevention. However, despite the efficacy of treatment-based programs and policies, structural barriers to ART initiation, adherence and viral suppression have the potential to reduce TasP effectiveness. These barriers have been studied using Geographic Information Systems (GIS). While previous reviews have examined the use of GIS for HIV testing - an essential antecedent to clinical care - to date, no reviews have summarised the research with respect to other ART-related outcomes.

METHODS

Therefore, the present review leveraged the PubMed database to identify studies that leveraged GIS to examine the barriers to ART initiation, adherence and viral suppression, with the overall goal of understanding how GIS has been used (and might continue to be used) to better study TasP outcomes. Joanna Briggs Institute criteria were used for the critical appraisal of included studies.

RESULTS

In total, 33 relevant studies were identified, excluding those not utilising explicit GIS methodology or not examining TasP-related outcomes.

CONCLUSIONS

Findings highlight geospatial variation in ART success and inequitable distribution of HIV care in racially segregated, economically disadvantaged, and, by some accounts, increasingly rural areas - particularly in the United States. Furthermore, this review highlights the utility and current limitations of using GIS to monitor health outcomes related to ART and the need for careful planning of resources with respect to the geospatial movement and location of people living with HIV (PLWH).

Cohort profile: the STOP HIV/AIDS Program Evaluation (SHAPE) study in British Columbia, Canada

PURPOSE

The Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) Program Evaluation (SHAPE) study is a longitudinal cohort developed to monitor the progress of an HIV testing and treatment expansion programme across the province of British Columbia (BC). The study considers how sociostructural determinants such as gender, age, sexual identity, geography, income and ethnicity influence engagement in HIV care.

PARTICIPANTS

Between January 2016 and September 2018, 644 BC residents who were at least 19 years old and diagnosed with HIV were enrolled in the study and completed a baseline survey. Participants will complete two additional follow-up surveys (18 months apart) about their HIV care experiences, with clinical follow-up ongoing.

FINDINGS TO DATE

Analyses on baseline data have found high levels of HIV care engagement and treatment success among SHAPE participants, with 95% of participants receiving antiretroviral therapy and 90% having achieved viral suppression. However, persistent disparities in HIV treatment outcomes related to age, injection drug use and housing stability have been identified and require further attention when delivering services to marginalised groups.

FUTURE PLANS

Our research will examine how engagement in HIV care evolves over time, continuing to identify barriers and facilitators for promoting equitable access to treatment and care among people living with HIV. A qualitative research project, currently in the formative phase, will compliment quantitative analyses by taking a strengths-based approach to exploring experiences of engagement and re-engagement in HIV treatment among individuals who have experienced delayed treatment initiation or treatment interruptions.

The Health Resources and Services Administration's Ryan White HIV/AIDS Program in rural areas of the United States: Geographic distribution, provider characteristics, and clinical outcomes

Background

People living with HIV (PLWH) residing in rural areas experience substantial barriers to HIV care, which may contribute to poor HIV health outcomes, including retention in HIV care and viral suppression. The Health Resources and Services Administration’s Ryan White HIV/AIDS Program (HRSA RWHAP) is an important source of HIV medical care and support services in rural areas. The purpose of this analysis was to (1) assess the reach of the RWHAP in rural areas of the United States, (2) compare the characteristics and funded services of RWHAP provider organizations in rural and non-rural areas, and (3) compare the characteristics and clinical outcomes of RWHAP clients accessing medical care and support services in rural and non-rural areas.

Methods and findings

Data for this analysis were abstracted from the 2017 RWHAP Services Report (RSR), the primary source of annual, client-level RWHAP data. Organizations funded to deliver RWHAP any service (“RWHAP providers”) were categorized as rural or non-rural according to the HRSA FORHP’s definition of modified Rural-Urban Commuting Area (RUCA) codes. RWHAP clients were categorized based on their patterns of RWHAP service use as “visited only rural providers,” “visited only non-rural providers,” or “visited rural and non-rural providers.” In 2017, among the 2,113 providers funded by the RWHAP, 6.2% (n = 132) were located in HRSA-designated rural areas. Rural providers were funded to deliver a greater number of service categories per site than non-rural providers (44.7% funded for ≥5 services vs. 34.1% funded for ≥5 services, respectively). Providers in rural areas served fewer clients than providers in non-rural areas; 47.3% of RWHAP providers in rural areas served 1–99 clients, while 29.6% of non-rural providers served 1–99 clients. Retention in care and viral suppression outcomes did not differ on the basis of whether a client accessed services from rural or non-rural providers.

Conclusions

RWHAP providers are a crucial component of HIV care delivery in the rural United States despite evidence of significant barriers to engagement in care for rural PLWH, RWHAP clients who visited rural providers were just as likely to be retained in care and reach viral suppression as their counterparts who visited non-rural providers. The RWHAP, especially in partnership with Rural Health Clinics and federally funded Health Centers, has the infrastructure and expertise necessary to address the HIV epidemic in rural America.

Assessing Differences in CDC-Funded HIV Testing by Urbanicity, United States, 2016

HIV prevention efforts have contributed to a decline in annual HIV infections in the United States. However, progress has been uneven and certain groups and geographic areas continue to be disproportionately affected. Subsequent to implementation of CDC's high-impact HIV prevention approach to reducing new infections, we analyzed national-level CDC-funded HIV test data from 2016 to describe the population being reached in three urbanicity settings (metropolitan: ≥ 1,000,000 population; urban: 50,000-999,999; rural: < 50,000). Over 70% of CDC-funded HIV tests and almost 80% of persons newly diagnosed with HIV as a result of CDC-funded testing occurred in metropolitan areas. Nonetheless, CDC-funded testing efforts are reaching urban and rural areas, especially in the South, providing opportunities to identify persons unaware of their HIV status and link those with newly diagnosed HIV to medical care and prevention services. While CDC-funded testing efforts have continued to focus on population subgroups and geographic areas at greatest risk, efforts should also continue in rural areas and among groups in need with a low national burden.

Exploring the Pre-exposure Prophylaxis (PrEP) Health Care Experiences Among Men Who Have Sex With Men (MSM) Who Live in Rural Areas of the Midwest

Most pre-exposure prophylaxis (PrEP) research samples men who have sex with men (MSM) who live in metropolitan cities. There is a limited understanding of the PrEP experiences among rural MSM. Thirty-four semi-structured interviews were conducted to explore the PrEP health care experiences among 34 rural Midwestern MSM. Of the 34 participants, 23 obtained PrEP from their non-primary care provider (PCP). Three themes were present: (1) PrEP is unavailable in rural areas, (2) PrEP is inaccessible in rural areas due to PCPs being unwilling to prescribe PrEP, and (3) PrEP services are unamicable in rural areas due to stigmatizing attitudes and behaviors of PCPs. It is important to address PrEP care continuum factors in all settings; however, these factors are often exacerbated in rural areas due to social determinants. Without further research and programming, organizational and social determinants may contribute to lower rates of PrEP outcomes in rural areas.

HIV Outbreak Control With Effective Access to Care and Harm Reduction in North Carolina, 2017-2018

Objectives. To assess and control a potential outbreak of HIV among people who inject drugs in Western North Carolina.Methods. Disease intervention specialists offered testing for hepatitis B and hepatitis C, harm reduction materials, and linkage to care to 7 linked people recently diagnosed with HIV who also injected drugs. Contacts were offered the same services and HIV testing. HIV genotype analysis was used to characterize HIV spread. We assessed testing and care outcomes by using state surveillance information.Results. Disease intervention specialists contacted 6 of 7 linked group members and received information on 177 contacts; among 96 prioritized contacts, 42 of 96 (44%) were exposed to or diagnosed with hepatitis C, 4 of 96 (4%) had hepatitis B, and 14 of 96 (15%) had HIV (2 newly diagnosed during the investigation). HIV genotype analysis suggested recent transmission to linked group members and 1 contact. Eleven of 14 with HIV were virally suppressed following the outbreak response.Conclusions. North Carolina identified and rapidly responded to an HIV outbreak among people reporting injecting drugs. Effective HIV care, the availability of syringe exchange services, and the rapid response likely contributed to controlling this outbreak.

Understanding African American youth and adult perspectives on sex education in rural North Carolina

African American youth in the US rural South are at elevated risk for poor sexual health outcomes, including sexually transmitted infections and teen pregnancy. Historically, the southeastern USA has lagged behind in providing comprehensive sexuality-based education in secondary school, which may contribute to poor reproductive and sexual health outcomes. This study aims to understand the perspectives of African American youth and adults on comprehensive sexuality-based education in rural North Carolina. Twenty-four individuals (12 youth and 12 adults) participated in both semi-structured interviews and small discussion groups. Data were analysed and coded using inductive and deductive approaches to thematic analysis. Results indicated that comprehensive sexuality-based education was highly desirable; however, current efforts were viewed as insufficient. While both young people and adults agreed that abstinence was the most desirable path for youth, participants also acknowledged young people's autonomy in engaging in sexual activity and suggested that comprehensive sexuality-based education was needed to protect against unintended consequences. The findings of this study have practical implications for addressing challenges associated with providing sexuality-based education to African American youth in rural communities and offers suggestions regarding directions for future research.

Implementation of an Immediate HIV Treatment Initiation Program in a Public/Academic Medical Center in the U.S. South: The Miami Test and Treat Rapid Response Program

Test and Rapid Response Treatment (TRRT) linkage programs have demonstrated improved HIV suppression rates. This paper describes the design and implementation of the Miami TRRT initiative and its clinical impact. Assisted by a dedicated care navigator, patients receiving a reactive HIV rapid test at the Florida Department of Health STD Clinic were offered same-day HIV care at the University of Miami/Jackson Memorial Medical Center Adult HIV Outpatient Clinic. Patient retention and labs were tracked for 12 months. Of the 2337 individuals tested, 46 had a reactive HIV test; 41 (89%) consented to participate. For the 36 patients in continued care for a year, 33 (91.7%) achieved virological suppression (< 200 copies/mL) within 70 days of their reactive HIV rapid test; at 12 months, 35 (97.2%) remained suppressed, and mean CD4 T cell counts increased from 452 ± 266 to 597 ± 322 cells/mm³. The Miami TRRT initiative demonstrated that immediate linkage to care is feasible and improves retention and suppression in a public/academic medical center in the U.S. South.

Facilitators and Barriers: Clients' Perspective on the Virginia AIDS Drug Assistance Program's Affordable Care Act Implementation

Many AIDS drug assistance programs (ADAPs) purchased Affordable Care Act (ACA) qualified health plans (QHPs) for low-income people living with HIV. To date, little has been written about this from the client perspective. The study's objective was to gain information about the experience of Virginia ADAP-funded QHP enrollment and the impact of this change. English-speaking clients who were eligible for ADAP-funded QHPs were recruited at three HIV clinics in Virginia. The goal was to enroll ≥5% of those who were eligible for ADAP-funded QHPs in two Virginia Department of Health planning districts. Participants were surveyed about demographic characteristics, and semi-structured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (n = 53) met our recruitment goal. Two-thirds gained their ACA knowledge at HIV clinics from case managers and social workers. Many barriers to enrollment were identified, including internet access/literacy. Almost 9 out of 10 participants had concerns about privacy, which centered on QHP's mandated use of mail-order pharmacies. Except for medication concerns, most participants had positive perceptions of the impact of QHP enrollment on their health care. HIV clinic case managers and social workers are often the primary source of knowledge for patients about insurance options and their assistance is crucial for QHP enrollment. Our findings indicate that reducing identified barriers and addressing privacy concerns by allowing people to opt out of mail order pharmacies may encourage QHP enrollment.

Experiences of Stigma by Gay and Bisexual Men in Rural Oklahoma

Purpose: The unique experiences of men who have sex with men (MSM) residing in culturally conservative rural areas are not well represented in the scientific literature. The human immunodeficiency virus (HIV) epidemic in the United States has shifted toward rural areas where populations are dispersed and health care resources are limited. Methods: We recruited 40 sexual minority men, ages 22-66, residing in rural Oklahoma for in-depth, qualitative sexual health interviews that sought to understand how cultural and social environments impacted health behaviors. Findings: Participants described a stigmatizing social environment and less access to quality, sexual minority medical care within rural communities and perceived these as substantial barriers to enhancing health. Structural issues, including lack of sexual minority-affirming policies, institutional practices, and hostile cultural norms, were noted. Conclusions: Results indicate the need to develop greater awareness of stigma as an etiologic factor that contributes to the health of rural sexual minority populations, specifically when it relates to provision of culturally appropriate care.

Suboptimal geographic accessibility to comprehensive HIV care in the US: regional and urban-rural differences

Achieving US state and municipal benchmarks to end the HIV epidemic and promote health equity requires access to comprehensive HIV care. However, this care may not be geographically accessible for all people living with HIV (PLHIV). We estimated county-level drive time and suboptimal geographic accessibility to HIV care across the contiguous US, assessing regional and urban-rural differences. We integrated publicly available data from four federal databases to identify and geocode sites providing comprehensive HIV care in 2015, defined as the co-located provision of core HIV medical care and support services. Leveraging street network, US Census and HIV surveillance data (2014), we used geographic analysis to estimate the fastest one-way drive time between the population-weighted county centroid and the nearest site providing HIV care for counties reporting at least five diagnosed HIV cases. We summarized HIV care sites, county-level drive time, population-weighted drive time and suboptimal geographic accessibility to HIV care, by US region and county rurality (2013). Geographic accessibility to HIV care was suboptimal if drive time was >30 min, a common threshold for primary care accessibility in the general US population. Tests of statistical significance were not performed, since the analysis is population-based. We identified 671 HIV care sites across the US, with 95% in urban counties. Nationwide, the median county-level drive time to HIV care is 69 min (interquartile range (IQR) 66 min). The median county-level drive time to HIV care for rural counties (90 min, IQR 61) is over twice that of urban counties (40 min, IQR 48), with the greatest urban-rural differences in the West. Nationally, population-weighted drive time, an approximation of individual-level drive time, is over five times longer in rural counties than in urban counties. Geographic access to HIV care is suboptimal for over 170,000 people diagnosed with HIV (19%), with over half of these individuals from the South and disproportionately the rural South. Nationally, approximately 80,000 (9%) drive over an hour to receive HIV care. Suboptimal geographic accessibility to HIV care is an important structural barrier in the US, particularly for rural residents living with HIV in the South and West. Targeted policies and interventions to address this challenge should become a priority.

Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs

As direct-acting antiviral (DAA) therapy costs fall and eligibility criteria are relaxed, people who inject drugs (PWID) will increasingly become eligible for HCV treatment. Yet eligibility does not necessarily equate to access. Amidst efforts to expand treatment uptake in this population, we seek to synthesise and clarify the conceptual underpinnings of access to health care for PWID, with a view to informing research and practice. Integrating dominant frameworks of health service utilisation, care seeking processes, and ecological perspectives on health promotion, we present a comprehensive theoretical framework to understand, investigate and intervene upon barriers and facilitators to HCV care for PWID. Built upon the concept of Candidacy, the framework describes access to care as a continually negotiated product of the alignment between individuals, health professionals, and health systems. Individuals must identify themselves as candidates for services and then work to stake this claim; health professionals serve as gatekeepers, adjudicating asserted candidacies within the context of localised operating conditions; and repeated interactions build experiential knowledge and patient-practitioner relationships, influencing identification and assertion of candidacy over time. These processes occur within a complex social ecology of interdependent individual, service, system, and policy factors, on which other established theories provide guidance. There is a pressing need for a deliberate and nuanced theory of health care access to complement efforts to document the HCV 'cascade of care' among PWID. We offer this framework as an organising device for observational research, intervention, and implementation science to expand access to HCV care in this vulnerable population. Using practical examples from the HCV literature, we demonstrate its utility for specifying research questions and intervention targets across multiple levels of influence; describing and testing plausible effect mechanisms; and identifying potential threats to validity or barriers to research translation.

The Effects of Socio-demographic Characteristics on Indonesian Women's Knowledge of HIV/AIDS: A Cross-sectional Study

Objectives

The purpose of this study was to characterize Indonesian women’s knowledge of HIV/AIDS and to investigate the effects of socio-demographic characteristics thereupon with the goal of supporting the prevention and early detection of HIV/AIDS.

Methods

This cross-sectional study was conducted using secondary data from the standard Indonesian Demographic and Health Survey (IDHS) in 2012. A total of 34 984 subjects ranged in age from 15 years to 49 years. Data were analyzed using the chi-square test and logistic regression to identify the effects of socio-demographic characteristics on Indonesian women’s knowledge of HIV/AIDS.

Results

All socio-demographic characteristics except marital status were related to knowledge of HIV/AIDS among Indonesian women in the univariate analysis (p<0.05). Multivariate analysis revealed that only age group, education level, location of residence, and wealth index were related to Indonesian women’s knowledge of HIV/AIDS (p<0.05).

Conclusions

Indonesian women’s insufficient knowledge related to HIV/AIDS shows that the provision of accurate and comprehensive information related to HIV/AIDS are components of prevention and control interventions that should be improved. With greater knowledge, women are expected to be more likely to determine their own and their partners’ human immunodeficiency virus status and to take appropriate preventive steps.

Prevalence and correlates of HIV testing and HIV-positive status in the US: Results from the National Epidemiological Survey on Alcohol and Related Conditions III (NESARC-III)

We used the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III), a nationally representative sample of US adults (n = 34,653), to estimate the prevalence and correlates of HIV testing and HIV status. The diagnostic interview used was the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-5 Version. We found that in 2012-2013, the prevalence of a history of HIV testing was 53.0% among females and 47.0% among males. Among individuals tested, the prevalence of HIV was 1.06%, resulting in a known estimated prevalence of 0.54% in the full sample. In adjusted results, being non-white, aged 30-44, having college, being non-heterosexual, having history of unprotected sex or history of childhood sexual abuse and lower mental health-related quality of life increased the odds of having been tested, whereas being foreign-born, 45 years or older, family income ≥$20,000, being unemployed or a student, living in a rural setting and older age at first sex lowered those odds. Among those tested, being 30-64, being non-heterosexual, having history of unprotected sex or having a sexually transmitted disease in the last year was associated with greater odds of being HIV+. Having some college decreased those odds. In the adjusted results all psychiatric disorders were associated with increased rates of HIV testing, but only a lifetime history of drug use disorder and antisocial personality disorders were associated with HIV status among those tested. Despite CDC recommendations, only about half of US adults have ever been tested for HIV, interfering with efforts to eradicate HIV infection.

Community-Engaged Research as an Approach to Expedite Advances in HIV Prevention, Care, and Treatment: A Call to Action

Throughout the world, we continue to face profound challenges to reducing the impact of the HIV epidemic. Community-engaged research has emerged as an approach to increase our understanding of HIV and reduce health disparities, increase health equity, and promote community and population health. Our partnership has conducted more than 25 community-engaged research studies in the U.S. and Guatemala, and members have identified nine themes to facilitate community-engaged research and expedite advances in HIV prevention, care, and treatment. These themes include the inclusion of multisectoral partners, trust building and maintenance, the alignment of partner priorities, a can-do attitude, capacity and desire to move beyond service and conduct research, flexibility, power sharing, empowerment, an assets orientation, the shared and timely use of findings, and a stepwise approach. To reduce HIV disparities, community-engaged research is as critical now as ever, and we desperately need to reinvigorate our commitment to and support of it.

Challenges Facing a Rural Opioid Epidemic: Treatment and Prevention of HIV and Hepatitis C

PURPOSE OF REVIEW

This article reviews recent epidemiologic trends in HIV and hepatitis C virus (HCV) and strategies for treatment and prevention of these infections as they relate to the opioid epidemic.

RECENT FINDINGS

Among people who inject drugs (PWID) in the United States (US), HIV diagnoses are decreasing, while HCV is increasing. Care for HIV and HCV relies heavily on specialist infrastructure, which is lacking in rural areas. Antiretrovirals for HIV and direct-acting antivirals for HCV are effective among PWID, yet multiple barriers make it difficult for rural injectors to access these treatments. Similarly, access to syringe service programs, medication-assisted therapy for opioid addiction, and pre-exposure prophylaxis for HIV are all limited in rural areas. Previous research on HIV and HCV among PWID has focused on urban or international populations, yet the US opioid epidemic is moving away from metropolitan centers. Increasing rurality of opioid injection brings unique challenges in treatment and prevention. Research into the care of HIV, HCV, and opioid use disorder among rural populations is urgently needed.

Washington state satellite HIV clinic program: a model for delivering highly effective decentralized care in under-resourced communities

To improve access to high-quality HIV care in underserved regions of Western Washington (WA) State, we collaborated with the WA State Department of Health (DOH) and community partners to launch four satellite HIV clinics. Here, we describe this innovative clinical care model, present an estimate of costs, and evaluate patient care outcomes, including virologic suppression rates. To accomplish this, we assessed virologic suppression rates 12 months before and 12 months after the satellite clinics opened, comparing people living with HIV (PLWH) who enrolled in the satellite clinics versus all PLWH in the same regions who did not. We also determined virologic suppression rates in 2015 comparing satellite clinic versus non-satellite clinic patients and compared care quality indicators between the satellite clinics and the parent academic clinic. Results demonstrate that the change in virologic suppression rate 12 months before to 12 months after the satellite clinics opened was higher for patients who enrolled in the satellite clinics compared to all those in the same region who did not (18% versus 6%, p < 0.001). Virologic suppression in 2015 was significantly higher for satellite clinic than non-satellite clinic patients at three of four sites. Care quality indicators were met at a high level at the satellite clinics, comparable to the parent academic clinic. Overall, through community partnerships and WA DOH support, the satellite clinic program increased access to best practice HIV care and improved virologic suppression rates in difficult-to-reach areas. This model could be expanded to other regions with inadequate access to HIV practitioners, though financial support is necessary.

Accessibility and Uptake of Pre-Exposure Prophylaxis for HIV Prevention in the Veterans Health Administration

To increase access, the National PrEP Working Group is expanding outreach outside of primary care and among nonspecialists, ensuring uniformly high-quality care and targeting high-risk populations.

Barriers to Access and Adoption of Pre-Exposure Prophylaxis for the Prevention of HIV Among Men Who Have Sex With Men (MSM) in a Relatively Rural State

Biomedical intervention approaches, including antiretroviral pre-exposure prophylaxis (PrEP), have been demonstrated to reduce HIV incidence among several at-risk populations and to be cost effective. However, there is limited understanding of PrEP access and uptake among men who have sex with men (MSM) residing in relatively rural states. Twenty semistructured interviews were conducted (August-November 2016) to assess opinions of and perceived barriers to accessing and adopting PrEP among MSM residing in Oklahoma. Participants perceived substantial barriers to accessing PrEP including a stigmatizing environment and less access to quality, LGBT-sensitive medical care. Overall, geographic isolation limits access to health providers and resources that support sexual health for Oklahoma MSM. Addressing stigma situated across ecological levels in an effort to increase adoption of PrEP by MSM residing in rural states remains necessary. Without this, social determinants may continue to negatively influence PrEP adoption and sexual health outcomes.