Ending the HIV Epidemic: A Plan for the United States

Leveraging CD4 Cell Count at Entry Into Care to Monitor Success of Human Immunodeficiency Virus Prevention, Treatment, and Public Health Programming in the Greater St Louis Area Between 2017 and 2020

CD4 cell count at entry into human immunodeficiency virus (HIV) care is a useful indicator of success of multiple steps in HIV public health programming. We demonstrate that CD4 cell count at care initiation was stable in St Louis between 2017 and 2019 but declined in 2020. Missouri efforts in the Ending the HIV Epidemic plan should focus on rapidly identifying individuals with undiagnosed HIV infection.

Factors Associated with Antiretroviral Therapy Adherence Among a Community-Based Sample of Sexual Minority Older Adults with HIV

Older sexual minorities (e.g., gay, bisexual) living with HIV are at risk for poor HIV outcomes due to their frequent experience with both psychosocial challenges and structural barriers to care. This study utilized a stochastic search variable selection (SVSS) approach to explore potential psychosocial and structural factors associated with HIV-related health outcomes among a community-based sample of older sexual minorities (N = 150) in South Florida, an U.S. HIV-epidemic epicenter. After SVSS, a forward entry regression approach suggested unstable housing, illicit substance use, current nicotine use, and depression were all associated with poorer ART adherence among older sexual minority adults living with HIV. No associations between potential correlates and biological measures of HIV disease severity were observed. Findings highlight a need to focus on multiple levels of intervention that target a combination of psychosocial and structural factors to improve HIV-care outcomes among older sexual minorities and achieve Ending the HIV Epidemic goals.

Provider Implicit Bias in Prescribing HIV Pre-exposure Prophylaxis (PrEP) to People Who Inject Drugs

BACKGROUND

Multiple HIV outbreaks among people who inject drugs (PWIDs) have occurred in the USA since 2015, highlighting the need for additional HIV prevention tools. Despite high levels of need, pre-exposure prophylaxis (PrEP) is drastically underutilized among PWIDs. Implicit bias toward PWID held by clinicians may impede PrEP scale-up among these underserved patients. This study examined how primary care providers' (PCPs) clinical decisions related to PrEP can be impacted by biases when the patient has a history of substance use.

METHODS

We conducted an online survey of PCPs (n = 208). The survey included the implicit association test (IAT) to assess unconscious attitudes toward PWIDs, direct questions regarding clinicians' explicit PWID attitudes, and an embedded experiment in which we systematically varied the risk behavior of a hypothetical patient and asked PCPs to make clinical judgments.

RESULTS

A minority (32%) of PCPs reported explicit PWID bias. The IAT indicated strong implicit PWID bias (meant IAT score = 0.59, p < .0001) among 88% of the sample. Only 9% of PCPs had no implicit or explicit PWID bias. PWID patients were judged as less likely to adhere to a PrEP regimen, less responsible, and less HIV safety conscious than heterosexual or gay male patients. Anticipated lack of adherence mediated PCPs' intent to prescribe PrEP to PWID.

CONCLUSIONS

PCPs' bias may contribute to PrEP being under-prescribed to PWID. Implicit and explicit PWID biases were common in our sample. This study illustrates the need to develop and test tailored interventions to decrease biases against PWID in primary care settings.

Prevalence, characteristics and challenges of late HIV diagnosis in Germany: an expert narrative review

PURPOSE

We aimed to review the landscape of late HIV diagnosis in Germany and discuss persisting and emerging barriers to earlier diagnosis alongside potential solutions.

METHODS

We searched PubMed for studies informing the prevalence, trends, and factors associated with late HIV diagnosis in Germany. Author opinions were considered alongside relevant data.

RESULTS

In Germany, older individuals, heterosexuals, and migrants living with HIV are more likely to be diagnosed late. The rate of late diagnosis in men who have sex with men (MSM), however, continues to decrease. Indicator conditions less often prompt HIV testing in women and non-MSM. During the COVID-19 pandemic, the absolute number of late diagnoses fell in Germany, but the overall proportion increased, probably reflecting lower HIV testing rates. The Ukraine war and subsequent influx of Ukrainians living with HIV may have substantially increased undiagnosed HIV cases in Germany. Improved indicator testing (based on unbiased assessments of patient risk) and universal testing could help reduce late diagnoses. In patients who receive a late HIV diagnosis, rapid treatment initiation with robust ART regimens, and management and prevention of opportunistic infections, are recommended owing to severely compromised immunity and increased risks of morbidity and mortality.

CONCLUSION

Joint efforts are needed to ensure that UNAIDS 95-95-95 2030 goals are met in Germany. These include greater political will, increased funding of education and testing campaigns (from government institutions and the pharmaceutical industry), continued education about HIV testing by HIV experts, and broad testing support for physicians not routinely involved in HIV care.

An Exploratory Study to Describe Transgender People with HIV Who Accessed Medicaid and Their Viral Suppression Over Time in New York City, 2013-2017

Purpose

Although HIV surveillance contains information on HIV outcomes among transgender persons with HIV (TPWH), it does not include other important data, for example, gender-affirming health care, which may influence viral suppression (VS). We describe TPWH accessing Medicaid and the association of gender-affirming surgery with VS.

Methods

Through matching Medicaid claims with HIV registry data, a cohort of previously identified TPWH in Medicaid was compared to cisgender women and men in terms of VS in 2013-2017 in New York City. Medicaid claims were used to identify TPWH who obtained gender-affirming surgery (e.g., chest, genital surgeries). We described the VS of those who had surgery and examined temporal trends in VS pre- and postsurgery and by surgery type.

Results

1730 TPWH were enrolled in Medicaid and in HIV care in 2013-2017. Overall for VS at last laboratory, TPWH in Medicaid had lower VS (76.0%) than cisgender women (80.4%) and men (83.3%). The exception was the 185 TPWH who obtained gender-affirming surgery (86.5%). Among 160 TPWH in Medicaid who obtained gender-affirming surgery and achieved VS, VS increased presurgery (66.3% 2 years prior, 76.9% 1 year prior) and remained high 1 year after (86.3%) and 2 years after (87.7%) (the last percentage is only among those who had surgery before 2017, N=81).

Conclusion

Gender-affirming surgery may be an important motivator to becoming virally suppressed and was associated with sustained high VS, which can lead to improved survival and quality of life. Medicaid and other insurers should consider improving access to gender-affirming surgery among TPWH.

RING Program: The CFAR Diversity, Equity, and Inclusion Pathway Initiative

BACKGROUND

Case Western Reserve University (CWRU)/University Hospitals Cleveland Medical Center in Cleveland, OH, and the University of Pittsburgh (Pitt) in Pittsburgh, PA, forged a strategic alliance to form the Rustbelt Center for AIDS Research. The Rustbelt Center for AIDS Research developed a National Institutes of Health-supported diversity, equity, and inclusion pathway initiative termed the "Rustbelt Investigators for the Next Generation (RING) Program" that provides research training experiences for Puerto Rican students that will help them pursue a biomedical research career in HIV.

SETTING

The RING Program provides 10-week research training experiences in different disciplines of HIV/AIDS for under-represented minority undergraduate and masters students from 4 campuses (Río Piedras, Mayagüez, Humacao, and Cayey) at the University of Puerto Rico. Mentors are drawn from both CWRU and Pitt.

RESULTS

The RING Program recently completed our first wave of recruitment. Recruitment sessions were either virtual or on site at the University of Puerto Rico campuses and included an overview presentation, a Q&A session, and in-person interviews. We interviewed 32 eligible applicants and accepted 10 into the program, of which 9 were female. Five students were matched with faculty at CWRU and 5 with faculty at Pitt.

CONCLUSIONS

The RING Program is a comprehensive program in laboratory and implementation science that aims to enhance under-represented Hispanic undergraduate and masters students' passion for pursuing a biomedical research career in HIV.

A qualitative assessment of barriers to healthcare and HIV prevention services among men who have sex with men in non-metropolitan areas of the south

HIV cases are increasing in the rural Southern United States, especially among men who have sex with men (MSM). To facilitate healthcare access and encourage HIV prevention for non-metropolitan MSM, it is essential to examine their barriers to care. This qualitative study conducted semi-structured interviews with 20 MSM living in non-metropolitan areas of the South. Analysis revealed that MSM experience multiple barriers accessing healthcare in non-metropolitan areas such as finding knowledgeable and affirming providers with desired characteristics and beliefs and communicating with providers about sexual health and HIV prevention. To aid in identification, many respondents expressed a desire for providers to publicly signal that they provide care for sexual and gender minority patients and are an inclusive clinical space. Overall, results suggest that MSM face unique healthcare-related challenges, beyond those typically experienced by the broader population in non-metropolitan areas, because of tailored identity-based needs. To better support MSM in non-metropolitan areas, especially in the South where increased experiences of stigma are found, providers should seek further training regarding sexual health communication and HIV prevention, indicate on websites and in offices that they support sexual and gender minority patients, and provide telehealth services to MSM living in more geographically isolated areas.

Using Motivational Interviewing to Increase HIV PrEP Initiation and Adherence: a Scoping Review

Despite evidence that pre-exposure prophylaxis (PrEP) reduces HIV risk, initiation and adherence remain low among vulnerable communities. Motivational interviewing (MI) can improve HIV prevention behaviors. However, limited research identifies how MI impacts PrEP uptake and adherence. This scoping review examines essential components of MI-based interventions that aimed to improve PrEP use, including the number and duration of sessions, counselor characteristics, and interview content. We searched four databases, PubMed, CINAHL Plus, Embase, and Web of Science, and reviewed 379 articles. Studies were considered if they (a) were published between 2012 and 2023, (b) used MI independently or part of a multi-component intervention strategy, and (c) focused on improving PrEP initiation or adherence. Seven articles met inclusion criteria. Regarding intervention components, the number of MI sessions varied and duration ranged between 15 and 60 min. MI counselors varied in credentialing and demographic characteristics. MI content included PrEP education, identifying initiation and adherence barriers, and strategizing ways to overcome barriers. MI is an important component of interventions that aim to improve PrEP initiation and adherence. However, the variability and limited details across studies hinder our ability to assess MI efficacy on PrEP initiation and adherence or replicate these approaches in future interventions.

Progress in Pathological and Therapeutic Research of HIV-Related Neuropathic Pain

HIV-related neuropathic pain (HRNP) is a neurodegeneration that gradually develops during the long-term course of acquired immune deficiency syndrome (AIDS) and manifests as abnormal sock/sleeve-like symmetrical pain and nociceptive hyperalgesia in the extremities, which seriously reduces patient quality of life. To date, the pathogenesis of HRNP is not completely clear. There is a lack of effective clinical treatment for HRNP and it is becoming a challenge and hot spot for medical research. In this study, we conducted a systematic review of the progress of HRNP research in recent years including (1) the etiology, classification and clinical symptoms of HRNP, (2) the establishment of HRNP pathological models, (3) the pathological mechanisms underlying HRNP from three aspects: molecules, signaling pathways and cells, (4) the therapeutic strategies for HRNP, and (5) the limitations of recent HRNP research and the future research directions and prospects of HRNP. This detailed review provides new and systematic insight into the pathological mechanism of HRNP, which establishes a theoretical basis for the future exploitation of novel target drugs. HIV infection, antiretroviral therapy and opioid abuse contribute to the etiology of HRNP with symmetrical pain in both hands and feet, allodynia and hyperalgesia. The pathogenesis involves changes in cytokine expression, activation of signaling pathways and neuronal cell states. The therapy for HRNP should be patient-centered, integrating pharmacologic and nonpharmacologic treatments into multimodal intervention.

An Exploratory Study of the PrEP Modality Preferences Among a Convenience Sample of Parents of Sexual and Gender Minority Adolescents

PURPOSE

Parents' attitudes toward contraceptive delivery methods have been shown to impact their adolescents' use of contraceptive methods. However, little is known about the HIV pre-exposure prophylaxis (PrEP) delivery method attitudes of parents of sexual and gender minority (SGM) adolescents assigned male at birth (AMAB). This exploratory, mixed-method formative study examined the PrEP delivery method preferences among a convenience sample of 33 parents of SGM adolescents AMAB who live in Texas.

METHODS

Participants completed an online survey, where they selected their preferred PrEP method for their SGM adolescent AMAB to use: PrEP as a daily oral pill, a bimonthly injectable, or a yearly implant. Parents answered an open-ended question about their reasons for choosing their preferred method. We analyzed data through descriptive statistics and inductive content analysis.

RESULTS

Findings from this convenience sample suggest that there is not one PrEP delivery method that parents of SGM adolescents AMAB prefer: one third of parents (33.3%) selected PrEP as a daily oral pill, 45.5% selected PrEP as a bimonthly injectable, and 21.2% selected PrEP as an annual implant. Parents cited multiple reasons for selecting a delivery method over another, with the most prevalent reasons being adherence (57.6%), access or cost (21.2%), and generic convenience or ease (21.2%).

DISCUSSION

Findings from this formative exploratory study sets the stage for future research and intervention development in increasing parental knowledge, preferences, and preference motivations for PrEP delivery methods.

"If I have to drive 100 miles, I'll drive 100 miles to get it": a qualitative exploration of HIV care travel behavior

ABSTRACTAlabama depends heavily on Ryan White HIV/AIDS Program (RWHAP) funding, yet patient enrollment at one large, RWHAP-funded, academically-affiliated HIV clinic in Alabama has steadily increased each year, with approximately 20% bypassing more proximal RWHAP clinics. To understand reasons why patients travel long distances and bypass closer clinics to receive care, we conducted eight focus groups over Zoom, each containing between 2-3 participants (n = 18) and applied thematic analysis to code the data. Primary themes included: (1) Reasons for Traveling Long Distances to Receive HIV Medical Care, (2) Experiences with HIV Medical Care during the COVID-19 Pandemic, and (3) Travel Challenges. Some participants were attracted by the clinic's one-stop-shop model, while others eschewed local clinics to avoid status disclosure. An overarching travel challenge was lack of transportation, yet most participants favored in-person appointments over telehealth despite driving long distances. Future research should explore patient attitudes towards telehealth in greater depth.

Spatial accessibility of pre-exposure prophylaxis (PrEP): different measure choices and the implications for detecting shortage areas and examining its association with social determinants of health

PURPOSE

We examine how various pre-exposure prophylaxis (PrEP) accessibility measures impact the detection of PrEP shortage areas and the relation of shortage areas to social determinants of health (SDOH).

METHODS

Using ZIP Code Tabulation Areas (ZCTAs) in New York City as a case study, we compared 25 measures of spatial PrEP accessibility across four categories, including density, proximity, two-step floating catchment area (2SFCA), and Gaussian 2SFCA (G2SFCA). Bayesian spatial regression models were used to examine how PrEP accessibility is associated with SDOH.

RESULTS

Using density to measure PrEP accessibility for small areas such as ZCTAs poses challenges to statistical modeling because the measured accessibility values are highly skewed with excess zeros, leading to the necessity of using complex models such as the two-part mixture model. When G2SFCA measures are used, which account for distance decay effects and the competition from the PrEP demand side, findings on PrEP shortage area detection and the association between PrEP accessibility and SDOH were more consistent and less sensitive to spatial scales (i.e., varying from 10- to 30-minute driving).

CONCLUSIONS

This research adds to the nascent research on PrEP accessibility measurement and sheds light on selecting an appropriate measure to assess spatial disparities in PrEP accessibility and its associations with SDOH.

Racial/ethnic disparities in estimated undiagnosed HIV infection among adolescents and adults in the United States, 2017-2021

In 2021, there were an estimated 153 500 persons aged at least 13 years with undiagnosed HIV infection. Estimated rates among Black/African American, Hispanic/Latino, and White persons were used to assess disparity trends from 2017 to 2021. Rates decreased across two absolute and relative disparity measures. Despite these declines, Black and Hispanic persons had rates 8.3 and 4.2 times the rate of White persons in 2021. Increased testing and innovative efforts are needed to address HIV-related disparities.

Use of Tenofovir Alafenamide Fumarate for HIV Pre-Exposure Prophylaxis and Incidence of Hypertension and Initiation of Statins

Importance

Pre-exposure prophylaxis (PrEP) is an important tool for preventing HIV infection. However, PrEP's impact on cardiometabolic health is understudied.

Objective

To examine the risk of incident hypertension and statin initiation among adult (age ≥18 years) health plan members starting PrEP with tenofovir alafenamide fumarate (TAF) compared with propensity score-matched adults taking tenofovir disoproxil fumarate (TDF).

Design, Setting, and Participants

This retrospective cohort study used electronic health records (EHRs) from Kaiser Permanente Southern California. Adult members starting PrEP in Kaiser Permanente Southern California between October 2019 and May 2022 were included. Propensity score matching with multiple imputation (50 matched data sets) was conducted to generate 1 TAF:4 TDF matched data sets with balanced baseline covariates.

Exposures

PrEP initiation with either TAF or TDF during the study period.

Main Outcomes and Measures

Incident hypertension and statin initiation within 2 years of PrEP initiation were ascertained through blood pressure and outpatient pharmacy records, respectively. Risk differences and odds ratios (ORs) were estimated using logistic regression and g-computation.

Results

A total of 6824 eligible individuals were identified (mean [SD] age, 33.9 [10.3] years; 6618 [97%] male). This pool was used to generate 2 cohorts without baseline hypertension or statin use for matching (hypertension: n = 5523; statin: n = 6149) In both cohorts, those starting PrEP with TAF were older and were more likely to be non-Hispanic White compared with those starting with TDF. In matched analysis adjusting for baseline covariates, TAF use was associated with elevated risk of incident hypertension (TAF: n = 371; risk difference, 0.81 [95% CI, 0.12-1.50]; OR, 1.64 [95% CI, 1.05-2.56]). TAF use was also associated with elevated risk of statin initiation (TAF: n = 382; risk difference, 0.85 [95% CI, 0.37-1.33]; OR, 2.33 [95% CI, 1.41-3.85]). Subgroup analyses restricted to individuals 40 years and older at PrEP initiation showed similar results with larger risk difference in statin initiation (risk difference, 4.24 [95% CI, 1.82-6.26]; OR, 3.05 [95% CI, 1.64-5.67]).

Conclusions and Relevance

In this study of people taking PrEP, TAF use was found to be associated with higher incident hypertension and statin initiation compared with TDF use, especially in those 40 years or older. Continued monitoring of blood pressure and lipids for TAF users is warranted.

Health Information on Pre-Exposure Prophylaxis From Search Engines and Twitter: Readability Analysis

BACKGROUND

Pre-exposure prophylaxis (PrEP) is proven to prevent HIV infection. However, PrEP uptake to date has been limited and inequitable. Analyzing the readability of existing PrEP-related information is important to understand the potential impact of available PrEP information on PrEP uptake and identify opportunities to improve PrEP-related education and communication.

OBJECTIVE

We examined the readability of web-based PrEP information identified using search engines and on Twitter. We investigated the readability of web-based PrEP documents, stratified by how the PrEP document was obtained on the web, information source, document format and communication method, PrEP modality, and intended audience.

METHODS

Web-based PrEP information in English was systematically identified using search engines and the Twitter API. We manually verified and categorized results and described the method used to obtain information, information source, document format and communication method, PrEP modality, and intended audience. Documents were converted to plain text for the analysis and readability of the collected documents was assessed using 4 readability indices. We conducted pairwise comparisons of readability based on how the PrEP document was obtained on the web, information source, document format, communication method, PrEP modality, and intended audience, then adjusted for multiple comparisons.

RESULTS

A total of 463 documents were identified. Overall, the readability of web-based PrEP information was at a higher level (10.2-grade reading level) than what is recommended for health information provided to the general public (ninth-grade reading level, as suggested by the Department of Health and Human Services). Brochures (n=33, 7% of all identified resources) were the only type of PrEP materials that achieved the target of ninth-grade reading level.

CONCLUSIONS

Web-based PrEP information is often written at a complex level for potential and current PrEP users to understand. This may hinder PrEP uptake for some people who would benefit from it. The readability of PrEP-related information found on the web should be improved to align more closely with health communication guidelines for reading level to improve access to this important health information, facilitate informed decisions by those with a need for PrEP, and realize national prevention goals for PrEP uptake and reducing new HIV infections in the United States.

Measuring time in buprenorphine treatment stages among people with HIV and opioid use disorder by retention definition and its association with cocaine and hazardous alcohol use

BACKGROUND

We use a novel, longitudinal approach to describe average time spent in opioid use disorder (OUD) cascade of care stages for people with HIV (PWH) and with OUD, incorporating four definitions of treatment retention. Using this approach, we describe the impact of cocaine or hazardous alcohol use on time spent retained on buprenorphine.

METHODS

We followed PWH with OUD enrolled in the Johns Hopkins HIV Clinical Cohort from their first buprenorphine treatment episode between 2013 and 2020. We estimated 4-year restricted mean time spent on buprenorphine below buprenorphine retention threshold, on buprenorphine above retention threshold, off buprenorphine and in HIV care, loss to follow-up, and death. Retention definitions were based on retention threshold (180 vs 90 days) and allowable treatment gap (7 vs 30 days). Differences in 2-year restricted mean time spent retained on buprenorphine were estimated for patients with and without cocaine or hazardous alcohol use.

RESULTS

The study sample (N = 179) was 63% male, 82% non-Hispanic Black, and mean age was 53 (SD 8) years. Patients spent on average 13.9 months (95% CI 11.4, 16.4) on buprenorphine over 4 years. There were differences in time spent retained on buprenorphine based on the retention definition, ranging from 6.5 months (95% CI 4.6, 8.5) to 9.6 months (95% CI 7.4, 11.8). Patients with cocaine use spent fewer months retained on buprenorphine. There were no differences for patients with hazardous alcohol use.

CONCLUSIONS

PWH with OUD spend relatively little time receiving buprenorphine in their HIV primary care clinic. Concurrent cocaine use at buprenorphine initiation negatively impact time on buprenorphine.

Recommendations on data sharing in HIV drug resistance research

 • Human immunodeficiency virus (HIV) drug resistance has implications for antiretroviral treatment strategies and for containing the HIV pandemic because the development of HIV drug resistance leads to the requirement for antiretroviral drugs that may be less effective, less well-tolerated, and more expensive than those used in first-line regimens.  • HIV drug resistance studies are designed to determine which HIV mutations are selected by antiretroviral drugs and, in turn, how these mutations affect antiretroviral drug susceptibility and response to future antiretroviral treatment regimens.  • Such studies collectively form a vital knowledge base essential for monitoring global HIV drug resistance trends, interpreting HIV genotypic tests, and updating HIV treatment guidelines.  • Although HIV drug resistance data are collected in many studies, such data are often not publicly shared, prompting the need to recommend best practices to encourage and standardize HIV drug resistance data sharing.  • In contrast to other viruses, sharing HIV sequences from phylogenetic studies of transmission dynamics requires additional precautions as HIV transmission is criminalized in many countries and regions.  • Our recommendations are designed to ensure that the data that contribute to HIV drug resistance knowledge will be available without undue hardship to those publishing HIV drug resistance studies and without risk to people living with HIV.

Barriers and facilitators to PrEP use and HIV testing for subgroups of Latino sexual minority men

Pre-exposure prophylaxis (PrEP) and HIV testing inadequately reach Latino sexual minority men (LSMM), fueling HIV disparities. This study identified determinants of LSMM's PrEP use and HIV testing and examined differences across subgroups (i.e., age and immigration history). First, we identified the most to least endorsed barriers and facilitators of PrEP use and HIV testing among LSMM (1) over vs. under 40 years old, and (2) across immigration histories (U.S. born, recent immigrant, established immigrant). Next, we examined differences in barrier/facilitator ratings across these age and immigration status groups. Key overall determinants were cost, knowledge, and perceived benefit/need. However, there was variation in determinants across age groups (i.e., cost, affordability, navigation support, and normalization) and immigration statuses (i.e., language, immigration concerns, and HIV knowledge). There were also differences across service types; mistrust and concerns was a barrier related to PrEP but not HIV testing. We found unique and common multilevel factors across prevention services and subgroups. Language, cost, and clinic/system issues are key barriers in accessing HIV prevention that should be considered when developing implementation strategies to enhance the reach of these services to LSMM.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Strategies of Managing Repeated Measures: Using Synthetic Random Forest to Predict HIV Viral Suppression Status Among Hospitalized Persons with HIV

The HIV/AIDS epidemic remains a major public health concern since the 1980s; untreated HIV infection has numerous consequences on quality of life. To optimize patients' health outcomes and to reduce HIV transmission, this study focused on vulnerable populations of people living with HIV (PLWH) and compared different predictive strategies for viral suppression using longitudinal or repeated measures. The four methods of predicting viral suppression are (1) including the repeated measures of each feature as predictors, (2) utilizing only the initial (baseline) value of the feature as predictor, (3) using the last observed value as the predictors and (4) using a growth curve estimated from the features to create individual-specific prediction of growth curves as features. This study suggested the individual-specific prediction of the growth curve performed the best in terms of lowest error rate on an independent set of test data.

Proposing the observational-implementation hybrid approach: designing observational research for rapid translation

We propose the observational-implementation hybrid approach-the incorporation of implementation science methods and measures into observational studies to collect information that would allow researchers to anticipate, estimate, or infer the effects of interventions and implementation strategies. Essentially, we propose that researchers collect implementation data early in the research pipeline, in situations where they might not typically be thinking about implementation science. We describe three broad contextual scenarios through which the observational-implementation hybrid approach would most productively be applied. The first application is for observational cohorts that individually enroll participants-either for existing (to which implementation concepts could be added) or for newly planned studies. The second application is with routinely collected program data, at either the individual or aggregate levels. The third application is to the collection of data from study participants enrolled in an observational cohort study who are also involved in interventions linked to that study (e.g., collecting data about their experiences with those interventions). Examples of relevant implementation data that could be collected as part of observational studies include factors relevant to transportability, participant preferences, and participant/provider perspectives regarding interventions and implementation strategies. The observational-implementation hybrid model provides a practical approach to make the research pipeline more efficient and to decrease the time from observational research to health impact. If this approach is widely adopted, observational and implementation science studies will become more integrated; this will likely lead to new collaborations, will encourage the expansion of epidemiological training, and, we hope, will push both epidemiologists and implementation scientists to increase the public health impact of their work.

Alcohol use and the longitudinal HIV care continuum for people with HIV who enrolled in care between 2011 and 2019

PURPOSE

We described the impact of alcohol use on longitudinal engagement in HIV care including loss to follow-up, durability of viral suppression, and death.

METHODS

We followed a cohort of 1781 people with HIV from enrolled in care at one of seven US clinics, 2011-2019 through 102 months. We used a multistate, time-varying Markov process and restricted mean time to summarize engagement in HIV care over follow-up according to baseline self-reported alcohol use (none, moderate, or unhealthy).

RESULTS

Our sample (86% male, 54% White) had median age of 35 years. Over 102 months, people with no, moderate, and unhealthy alcohol use averaged 62.3, 61.1, and 59.5 months virally suppressed, respectively. People who reported unhealthy or moderate alcohol use spent 5.1 (95% confidence intervals (CI): 0.8, 9.3) and 7.6 (95%CI: 3.1, 11.7) more months lost to care than nondrinkers. Compared to no use, unhealthy alcohol use was associated with 3.4 (95%CI: -5.6, -1.6) fewer months in care, not virally suppressed. There were no statistically significant differences after adjustment for demographic and clinical characteristics.

CONCLUSIONS

Moderate or unhealthy drinking at enrollment in HIV care was associated with poor retention in care. Alcohol use was not associated with time spent virally suppressed.

Condomless Sex Among HIV-affected AYA in an Era of Undetectable = Untransmittable and Pre-exposure Prophylaxis

Given poor adherence to treatment and prevention techniques, condomless sex jeopardizes adolescents and young adults (AYA) with perinatally-acquired HIV-infection (PHIV) or perinatal HIV-exposure who are uninfected (PHEU). We examined condomless sex and its association with PHIV-status, psychiatric disorder, and sociodemographics. Data come from a US-based study of primarily Black and Latinx AYAPHIV and AYAPHEU (N = 340). Linear regression models examined condomless sex longitudinally by PHIV-status, psychiatric trajectories, and sociodemographics. Rates of viremia (AYAPHIV) and PrEP use (AYAPHEU) were assessed. 56% of participants reported recent condomless sex, with higher prevalence among: AYAPHEU vs. AYAPHIV (24% vs. 19%, p = 0.017); Latinx vs. non-Latinx AYA (25% vs. 17%, p = 0.014); and AYA with increasing psychiatric comorbidity (44%) and consistent anxiety (23%) vs. low-level disorder (17%; p < 0.05). AYAPHIV had high rates of unsuppressed viral load and AYAPHEU limited PrEP use. Preventing condomless sex is challenging within AYAPHIV and AYAPHEU. Developing accessible combination HIV/mental health interventions is much-needed.

Effects of mode of transportation on PrEP persistence among urban men who have sex with men

Little is known about the effect of travel-related factors, such as mode of transportation, on retention in PrEP care, or PrEP persistence. We used data from the 2020 American Men's Internet Survey and conducted multilevel logistic regression to estimate the association between mode of transportation used for healthcare access and PrEP persistence among urban gay, bisexual, and other men who have sex with men (MSM) in the U.S. MSM using public transportation were less likely to report PrEP persistence (aOR: 0.51; 95% CI: 0.28-0.95) than MSM using private transportation. There were no significant associations between PrEP persistence and using active transportation (aOR: 0.67; 95% CI: 0.35-1.29) or multimodal transportation (aOR: 0.85; 95% CI: 0.51-1.43) compared to using private transportation. Transportation-related interventions and policies are needed to address structural barriers to accessing PrEP services and to improve PrEP persistence in urban areas.

Understanding why racial/ethnic inequities along the HIV care continuum persist in the United States: a qualitative exploration of systemic barriers from the perspectives of African American/Black and Latino persons living with HIV

BACKGROUND

Racial/ethnic inequities along the HIV care continuum persist in the United States despite substantial federal investment. Numerous studies highlight individual and social-level impediments in HIV, but fewer foreground systemic barriers. The present qualitative study sought to uncover and describe systemic barriers to the HIV care continuum from the perspectives of African American/Black and Latino persons living with HIV (PLWH) with unsuppressed HIV viral load, including how barriers operated and their effects.

METHODS

Participants were African American/Black and Latino PLWH with unsuppressed HIV viral load (N = 41). They were purposively sampled for maximum variability on key indices from a larger study. They engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed. Data were analyzed using directed content analysis.

RESULTS

Participants were 49 years old, on average (SD = 9), 76% were assigned male sex at birth, 83% were African American/Black and 17% Latino, 34% were sexual minorities (i.e., non-heterosexual), and 22% were transgender/gender-nonbinary. All had indications of chronic poverty. Participants had been diagnosed with HIV 19 years prior to the study, on average (SD = 9). The majority (76%) had taken HIV medication in the six weeks before enrollment, but at levels insufficient to reach HIV viral suppression. Findings underscored a primary theme describing chronic poverty as a fundamental cause of poor engagement. Related subthemes were: negative aspects of congregate versus private housing settings (e.g., triggering substance use and social isolation); generally positive experiences with health care providers, although structural and cultural competency appeared insufficient and managing health care systems was difficult; pharmacies illegally purchased HIV medication from PLWH; and COVID-19 exacerbated barriers. Participants described mitigation strategies and evidenced resilience.

CONCLUSIONS

To reduce racial/ethnic inequities and end the HIV epidemic, it is necessary to understand African American/Black and Latino PLWH's perspectives on the systemic impediments they experience throughout the HIV care continuum. This study uncovers and describes a number of salient barriers and how they operate, including unexpected findings regarding drug diversion and negative aspects of congregate housing. There is growing awareness that systemic racism is a core determinant of systemic barriers to HIV care continuum engagement. Findings are interpreted in this context.

Delivery of the HIV Service and Telemedicine Through Effective Patient-Reported Outcomes (+STEP) Intervention to Increase Screening and Treatment of Mental Health and Substance Use Disorders for People Living With HIV in Alabama: Protocol for an Effectiveness-Implementation Study

BACKGROUND

The syndemic of mental health (MH) and substance use disorders (SUDs) is common among persons living with HIV and jeopardizes HIV treatment adherence, engagement in care, and viral load suppression. Electronic patient-reported outcomes (ePROs), completed through tablet or computer, and telemedicine are evidence- and technology-based interventions that have been used to successfully increase screening and treatment, respectively, a model that holds promise for persons living with HIV. To date, there is limited guidance on implementing ePROs and telemedicine into HIV clinical practice even though it is well known that these evidence-based tools improve diagnosis and access to care.

OBJECTIVE

To address this, we aim to conduct a multicomponent intervention for persons living with HIV, including the delivery of HIV services and telemedicine through effective ePROs (+STEP), to increase screening and treatment of MH and SUD in Ryan White HIV/AIDS Program (RWHAP)-funded clinics in Alabama.

METHODS

Through this intervention, we will conduct a readiness, acceptability, and accessibility assessment and implement +STEP to improve the diagnosis and treatment of MH and SUD at RWHAP clinics in Alabama. To describe implementation strategies that address barriers to the uptake of +STEP in RWHAP clinics, we will conduct qualitative interviews in years 1 (early implementation), 2 (scale up), and 4 (maintenance) with patients and key staff to evaluate barriers, facilitators, and implementation strategies. Our Results will enable us to modify strategies to enhance +STEP penetration over time and inform the implementation blueprint, which we will develop for both RWHAP clinics in Alabama and future sites. We will assess the impact of implementing +STEP on diagnoses, referrals, and health care use related to MH, SUD, and HIV by comparing clinical outcomes from patients receiving these interventions (ePROs and telemedicine) with historical controls.

RESULTS

The first study site began implementation in April 2022. A total of 2 additional sites have initiated ePROs. Final results are expected in 2026. The results of this study will provide a foundation for future research expanding access to ePROs for improved diagnosis linked to telemedicine access to accelerate patients along the continuum of care from MH and SUD diagnosis to treatment.

CONCLUSIONS

Achieving the end of the HIV epidemic in the United States necessitates programs that accelerate movement across the MH and SUD care continuum from diagnosis to treatment for persons living with HIV. Scaling these services represents a path toward improved treatment outcomes with both individual health and population-level prevention benefits of sustained HIV viral suppression in the era of undetectable=untransmittable (U=U). This study will address this evidence gap through the evaluation of the implementation of +STEP to establish the necessary systems and processes to screen, identify, and better treat substance use and MH for people living with HIV.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40470.

A Qualitative Study of the Benefits and Utility of Brief Motivational Interviewing to Reduce Sexually Transmitted Infections among Men Who Have Sex with Men

Several studies have demonstrated the effectiveness of motivational interviewing (MI) in reducing sexual risk behaviors. However, limited information is available on the acceptability of brief MI among men who have sex with men (MSM) in poor resource settings like sub-Saharan Africa. The objective of this study was to assess the views of MSM about the benefits and utility of brief MI (bMI) in changing their risky behavior. A qualitative study among men who have sex with men (MSM) who were enrolled in a longitudinal observational study between December 2021 and May 2023. The setting was in Tshwane North and participants were scheduled for baseline, 6-month, and 12-month visits. All participants received 20 min one-on-one face-to-face brief motivational interview (bMI) sessions during their follow-up visits. At month 12, an exit interview was conducted with consenting conveniently sampled participants (n = 23) who had completed all scheduled visits and received three bMI sessions. The findings indicated that the most recalled conversation was related to multiple sexual partners, having sex under the influence of alcohol, and MSM learned more about sexually transmitted diseases. Many expressed being comfortable with the sessions because the counselor was respectful and non-judgmental. Most found the bMI sessions to have a positive impact on changing and reducing risky sexual behaviors, particularly it reportedly increased their use of condoms and reduced the number of multiple partners. MSM found the bMI to be useful and acceptable in reducing sexual risk behaviors among MSM.

HIV Prevention Services for Hispanic/Latino Persons in THRIVE, 2015-2020

INTRODUCTION

Hispanic/Latino men who have sex with men (MSM) and transgender women (TGW) are disproportionately affected by HIV in the U.S. This study evaluated HIV prevention services and outcomes among Hispanic/Latino MSM and TGW in the Targeted Highly Effective Interventions to Reduce the HIV Epidemic (THRIVE) demonstration project and consider lessons learned.

METHODS

The authors described the THRIVE demonstration project services provided to Hispanic/Latino MSM and TGW in 7 U.S. jurisdictions from 2015 to 2020. HIV prevention service outcomes were compared between 1 site with (2,147 total participants) and 6 sites without (1,129 total participants) Hispanic/Latino-oriented pre-exposure prophylaxis clinical services, and Poisson regression was used to estimate the adjusted RR between sites and pre-exposure prophylaxis outcomes. Analyses were conducted from 2021 to 2022.

RESULTS

The THRIVE demonstration project served 2,898 and 378 Hispanic/Latino MSM and TGW, respectively, with 2,519 MSM (87%) and 320 TGW (85%) receiving ≥1 HIV screening test. Among 2,002 MSM and 178 TGW eligible for pre-exposure prophylaxis, 1,011 (50%) MSM and 98 (55%) TGW received pre-exposure prophylaxis prescriptions, respectively. MSM and TGW were each 2.0 times more likely to be linked to pre-exposure prophylaxis (95% CI=1.4, 2.9 and 95% CI=1.2, 3.6, respectively) and 1.6 and 2.1 times more likely to be prescribed pre-exposure prophylaxis (95% CI=1.1, 2.2 and 95% CI=1.1, 4.1), respectively, at the site providing Hispanic/Latino-oriented pre-exposure prophylaxis clinical services than at other sites and adjusted for age group.

CONCLUSIONS

The THRIVE demonstration project delivered comprehensive HIV prevention services to Hispanic/Latino MSM and TGW. Hispanic/Latino-oriented clinical settings may improve HIV prevention service delivery to persons in Hispanic/Latino communities.

Prediction of Sex and the Potential Use of On-Demand PrEP Among Young Men Who Have Sex With Men in the United States

BACKGROUND

On-demand dosing of preexposure prophylaxis (PrEP) requires accurate prediction of sex; however, prediction abilities among young men who have sex with men (YMSM) have not been characterized.

SETTING

A nationally recruited prospective cohort of YMSM ages 16-24 years.

METHODS

We followed 120 YMSM for 8 weeks using digital daily surveys (DDSs) to measure engagement in and prediction of anal sex over 24 hours, along with condom use and other encounter-level circumstances. Our main outcome, an "unpredicted spontaneous encounter," was defined as an anal sex encounter that occurred without sufficient prior knowledge to (hypothetically) enable protective on-demand PrEP use according to dosing guidelines. We operationalized this outcome as an anal sex encounter for which a participant indicated: (1) on the prior day's DDS that there was a low likelihood of sex occurring in the subsequent 24 hours (unpredicted) and (2) on the current day's DDS that he knew ≤2 hours in advance that the encounter would occur (spontaneous).

RESULTS

Approximately one-third of all anal sex encounters during the study period were unpredicted and spontaneous and would not have been protected (hypothetically) by on-demand dosing. More than two-thirds of participants experienced such an encounter and almost three-quarters of all acts were condomless.

CONCLUSIONS

On-demand PrEP to prevent HIV acquisition may be challenging for many YMSM. Clinical and public health approaches that account for patients' predictive abilities alongside their dosing preferences may help to optimize selection of and adherence to PrEP dosing strategies.

Assessing the reliability of the CD4 depletion model in the presence of Ending the HIV Epidemic initiatives

BACKGROUND

Accurate estimates of HIV incidence are necessary to monitor progress towards Ending the HIV Epidemic (EHE) initiative targets (90% decline by 2030). U.S. incidence estimates are derived from a CD4 depletion model (CD4 model). We performed simulation-based analyses to investigate the ability of this model to estimate HIV incidence when implementing EHE interventions that have the potential to shorten the duration between HIV infection and diagnosis (diagnosis delay).

METHODS

Our simulation study evaluates the impact of three parameters on the accuracy of incidence estimates derived from the CD4 model: rate of HIV incidence decline, length of diagnosis delay, and sensitivity of using CD4 + cell counts to identify new infections (recency error). We model HIV incidence and diagnoses after the implementation of a theoretical prevention intervention and compare HIV incidence estimates derived from the CD4 model to simulated incidence.

RESULTS

Theoretical interventions that shortened the diagnosis delay (10-50%) result in overestimation of HIV incidence by the CD4 model (10-92%) in the first year and by more than 10% for the first 6 years after implementation of the intervention. Changes in the rate of HIV incidence decline and the presence of recency error had minimal impact on the accuracy of incidence estimates derived from the CD4 model.

CONCLUSION

In the setting of EHE interventions to identify persons with HIV earlier during infection, the CD4 model overestimates HIV incidence. Alternative methods to estimate incidence based on objective measures of incidence are needed to assess and monitor EHE interventions.

Engaging Latino sexual minority men in PrEP and behavioral health care: multilevel barriers, facilitators, and potential implementation strategies

Latino sexual minority men (LSMM) are affected by HIV and behavioral health disparities. Evidence-based HIV-prevention and behavioral health (BH) services are not sufficiently scaled up to LSMM. The current study identified multilevel barriers and facilitators to LSMM's use of HIV-prevention and BH services. LSMM (N = 290) in South Florida, a US HIV epicenter, completed a battery of measures potentially associated with pre-exposure prophylaxis (PrEP) and BH treatment use. Stochastic search variable selection (SSVS) followed by multiple linear regression analyses identified variables associated with engagement in PrEP and BH treatment. Multilevel determinants of PrEP and BH treatment engagement were identified, with most identified determinants being at the relational level (e.g., stigma, discrimination based on income and immigration status, personal recommendation for treatment). Individual (e.g., knowledge, self-efficacy) and structural (e.g., financial stress) determinants were also identified. Accordingly, modifiable leverage points to enhance the reach of PrEP and BH treatment to LSMM include educating and enhancing the perceived relevance of services, de-stigmatizing and normalizing via peer examples, bolstering self-efficacy, and building trust.

Implementation Facilitators and Barriers for Primary Care Providers Prescribing Daily Oral PrEP to Adolescents in the United States

Primary care providers (PCPs) are critical in prescribing human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) to adolescents at risk of HIV. More research is needed to identify facilitators and barriers PCPs encounter in prescribing PrEP to eligible adolescents post-Food and Drug Administration (FDA) approval. This online cross-sectional survey examined the PrEP implementation facilitators and barriers among a national sample of PCPs in the United States. PCPs (n = 502) specializing in family medicine or pediatrics were recruited from a Qualtrics panel from July 15 to August 9, 2022. We analyzed the collected data using content analysis and applied the Expert Recommendations for Implementing Change (ERIC) to codebook creation and data analysis. We conducted a Fisher's exact chi-square test of independence to compare facilitator and barrier prevalence differences between participants who had and had not prescribed PrEP to an adolescent patient. Results demonstrate that (1) distributing prescriber-focused educational materials, (2) involving parents, (3) changing liability laws, (4) enhancing adolescent PrEP uptake and adherence, (5) changing clinical resources, and (6) using mass/social media to change community norms might be strategies that influence PCPs prescribing PrEP to eligible adolescent patients. Results from this study could facilitate the planning of hybrid implementation-effectiveness trials designed to determine the acceptability, feasibility, and effectiveness of implementation strategies in improving the practices of PCPs prescribing PrEP to at-risk adolescents.

Projected Benefits of Long-Acting Antiretroviral Therapy in Nonsuppressed People With Human Immunodeficiency Virus Experiencing Adherence Barriers

Background

In a demonstration project, long-acting, injectable cabotegravir-rilpivirine (CAB-RPV) achieved viral suppression in a high proportion of people with HIV (PWH) who were virologically nonsuppressed with adherence barriers. We projected the long-term impact of CAB-RPV for nonsuppressed PWH experiencing adherence barriers.

Methods

Using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) model, we compared 3 strategies: (1) standard of care oral integrase inhibitor-based ART (INSTI); (2) INSTI-based ART with supportive social services ("wraparound services" [WS]) (INSTI/WS); and (3) CAB-RPV with WS (CAB-RPV/WS). Model outcomes included viral suppression (%) and engagement in care (%) at 3 years, and life expectancy (life-years [LYs]). Base case cohort characteristics included mean age of 47y (standard deviation [SD], 10y), 90% male at birth, and baseline mean CD4 count 150/µL (SD, 75/µL). Viral suppression at 3 months was 13% (INSTI), 28% (INSTI/WS), and 60% (CAB-RPV/WS). Mean loss to follow-up was 28/100 person-years (PY) (SD, 2/100 PY) without WS and 16/100 PY (SD, 1/100 PY) with WS.

Results

Projected viral suppression at 3 years would vary widely: 16% (INSTI), 38% (INSTI/WS), and 44% (CAB-RPV/WS). Life expectancy would be 7.4 LY (INSTI), 9.0 LY (INSTI/WS), and 9.4 LY (CAB-RPV/WS). Projected benefits over oral ART would be greater for PWH initiating CAB-RPV/WS at lower CD4 counts. Across plausible key parameter ranges, CAB-RPV/WS would improve viral suppression and life expectancy compared with oral INSTI strategies.

Conclusions

These model-based results support that long-acting injectable CAB-RPV with extensive support services for nonsuppressed PWH experiencing adherence barriers is likely to increase viral suppression and improve survival. A prospective study to provide further evidence is needed.

Client preferences for HIV Care Coordination Program features in New York City: latent class analysis of a discrete choice experiment

INTRODUCTION

The PROMISE study, launched in 2018, evaluates the implementation of revisions to the HIV Care Coordination Program (CCP) designed to minimize persistent disparities in HIV outcomes among high-need persons living with HIV in New York City. We conducted a discrete choice experiment (DCE) assessing the preferences of CCP clients to inform improvements to the program's design.

METHODS

Clients chose between two hypothetical CCP options that varied across four program attributes: help with antiretroviral therapy (ART) adherence (directly observed therapy [DOT] vs. remind via phone/text vs. adherence assessment), help with primary care appointments (remind and accompany vs. remind and transport vs. remind only), help with issues other than primary care (coverage and benefits vs. housing and food vs. mental health vs. specialty medical care) and visit location (meet at home vs. via phone/video vs. program visit 30 or 60 minutes away). The latent class analysis identified different preference patterns. A choice simulation was performed to model client preferences for hypothetical CCPs as a whole.

RESULTS

One hundred and eighty-one CCP clients from six sites implementing the revised CCP completed the DCE January 2020-March 2021. Most clients had stable housing (68.5%), reported no problem substance use in the last 3 months (72.4%) and achieved viral suppression (78.5) with only 26.5% receiving DOT within a CCP. 77.3% of responses were obtained before the COVID-19 pandemic. Preferences clustered into three groups. Visit location and ART adherence support were the most important attributes. Group 1 (40%) endorsed telehealth for visit location; telehealth for ART adherence support; and help with securing housing/food; Group 2 (37%) endorsed telehealth for visit location; telehealth for ART adherence support; and staff reminding/arranging appointment transportation; Group 3 (23%) endorsed staff meeting clients at program location and staff working with clients for medication adherence. In the choice simulation, Basic and Medium hypothetical CCPs were endorsed more than Intensive CCPs.

CONCLUSIONS

This DCE revealed a strong preference for telehealth and a relatively low preference for intensive services, such as DOT and home visits; preferences were heterogeneous. The findings support differentiated care and remote service delivery options in the NYC CCP, and can inform improvements to CCP design.

Qualitative Examination of the Impact of the COVID-19 Pandemic on Access and Adherence to Pre-exposure Prophylaxis (PrEP) Among Sexual and Gender Minorities

During the COVID-19 pandemic, pre-exposure prophylaxis (PrEP) access and adherence decreased nationwide. This study examined pandemic-related disruptions to PrEP access and adherence among clients of a health center (Center) in Los Angeles, California. Clients (n = 25) and Center personnel (n = 11) completed qualitative interviews from March to July 2021. Although the Center provided options for remote PrEP care (i.e., telehealth, STI self-testing kits, and prescription delivery), clients experienced difficulty navigating services or lacked equipment for telehealth. More than half (n = 13) of clients discontinued PrEP during COVID-19 due to decreased sexual partners, relocation, or insurance status changes. Among those who continued PrEP, the majority reported no change in adherence, while a minority reported worsening adherence due to distractions/forgetting, prescription refill issues, lack of insurance coverage, and fear of completing in-person visits. Findings highlight the challenges of navigating PrEP services during COVID-19 and suggest PrEP services enhancement to adapt to crisis events.

Utilizing Community Based Participatory Research Methods in Black/African American and Hispanic/Latinx Communities in the US: The CDC Minority HIV Research Initiative (MARI-Round 4)

The Centers for Disease Control and Prevention Minority HIV Research Initiative (MARI) funded 8 investigators in 2016 to develop HIV prevention and treatment interventions in highly affected communities. We describe MARI studies who used community-based participatory research methods to inform the development of interventions in Black/African American and Hispanic/Latinx communities focused on sexual minority men (SMM) or heterosexual populations. Each study implemented best practice strategies for engaging with communities, informing recruitment strategies, navigating through the impacts of COVID-19, and disseminating findings. Best practice strategies common to all MARI studies included establishing community advisory boards, engaging community members in all stages of HIV research, and integrating technology to sustain interventions during the COVID-19 pandemic. Implementing community-informed approaches is crucial to intervention uptake and long-term sustainability in communities of color. MARI investigators' research studies provide a framework for developing effective programs tailored to reducing HIV-related racial/ethnic disparities.

Perspectives From Community-Based HIV Service Organization Leaders on Priorities in Serving Sexual and Gender Minority Populations

Sexual and gender minority (SGM) populations experience discrimination and care-related barriers when seeking appropriate sexual health services. Using rapid assessment procedures we conducted site visits with 11 community-based HIV service agencies to identify priorities, assets, and needs related to serving SGM clients and assessed the alignment of these services with the city's local Ending the HIV Epidemic plan. We identified and mapped themes across agencies into the Consolidated Framework for Implementation Research domains of inner and outer settings: client-facing materials; priorities in serving SGM communities; SGM policies and protocols; collecting sexual orientation and gender identity data; training and education; and funding and scope of programs. Rapid assessment procedures can accelerate the collection and interpretation of data to help public health institutions and community partners make timely adaptations when implementing comprehensive and culturally humble sexual health services for SGM communities.

Preference for daily oral pills over long-acting antiretroviral therapy options among people with HIV

OBJECTIVE

To examine the characteristics of people with HIV (PWH) who prefer remaining on daily oral antiretroviral therapy (ART), rather than switching to long-acting ART (LA-ART).

DESIGN

Building upon a discrete choice experiment (DCE), we examined characteristics of individuals who always selected their current daily oral tablet regimen over either of two hypothetical LA-ART options presented in a series of 17 choice tasks.

METHODS

We used LASSO to select sociodemographic, HIV-related, and other health-related predictors of preferring current therapy over LA-ART, and logistic regression to measure the associations with those characteristics.

RESULTS

Among 700 PWH in Washington State and Atlanta, Georgia, 11% of participants ( n  = 74) chose their current daily treatment over LA-ART in all DCE choice tasks. We found that people with lower educational attainment, good adherence, more aversion to injections, and who participated from Atlanta to be more likely to prefer their current daily regimen over LA-ART.

CONCLUSIONS

Gaps in ART uptake and adherence remain, and emerging LA-ART treatments show promise to address these challenges and help a larger portion of PWH to achieve viral suppression, but preferences for these new treatments are understudied. Our results show that certain drawbacks of LA-ART may help to maintain demand for daily oral tablets, especially for PWH with certain characteristics. Some of these characteristics (lower educational attainment and Atlanta participation) were also associated with a lack of viral suppression. Future research should focus on overcoming barriers that impact preferences for LA-ART among those patients who could benefit most from this innovation.

State-level clustering in PrEP implementation factors among family planning clinics in the Southern United States

Background

Availability of PrEP-providing clinics is low in the Southern U.S., a region at the center of the U.S. HIV epidemic with significant HIV disparities among minoritized populations, but little is known about state-level differences in PrEP implementation in the region. We explored state-level clustering of organizational constructs relevant to PrEP implementation in family planning (FP) clinics in the Southern U.S.

Methods

We surveyed providers and administrators of FP clinics not providing PrEP in 18 Southern states (Feb-Jun 2018, N = 414 respondents from 224 clinics) on these constructs: readiness to implement PrEP, PrEP knowledge/attitudes, implementation climate, leadership engagement, and available resources. We analyzed each construct using linear mixed models. A principal component analysis identified six principal components, which were inputted into a K-means clustering analysis to examine state-level clustering.

Results

Three clusters (C1-3) were identified with five, three, and four states, respectively. Canonical variable 1 separated C1 and C2 from C3 and was primarily driven by PrEP readiness, HIV-specific implementation climate, PrEP-specific leadership engagement, PrEP attitudes, PrEP knowledge, and general resource availability. Canonical variable 2 distinguished C2 from C1 and was primarily driven by PrEP-specific resource availability, PrEP attitudes, and general implementation climate. All C3 states had expanded Medicaid, compared to 1 C1 state (none in C2).

Conclusion

Constructs relevant for PrEP implementation exhibited state-level clustering, suggesting that tailored strategies could be used by clustered states to improve PrEP provision in FP clinics. Medicaid expansion was a common feature of states within C3, which could explain the similarity of their implementation constructs. The role of Medicaid expansion and state-level policies on PrEP implementation warrants further exploration.

Using molecular network analysis to understand current HIV-1 transmission characteristics in an inland area of Yunnan, China

HIV-1 molecular surveillance provides a new approach to explore transmission risks and targeted interventions. From January to June 2021, 663 newly reported HIV-1 cases were recruited in Zhaotong City, Yunnan Province, China. The distribution characteristics of HIV-1 subtypes and HIV-1 molecular network were analysed. Of 542 successfully subtyped samples, 12 HIV-1 strains were identified. The main strains were CRF08_BC (47.0%, 255/542), CRF01_AE (17.0%, 92/542), CRF07_BC (17.0%, 92/542), URFs (8.7%, 47/542), and CRF85_BC (6.5%, 35/542). CRF08_BC was commonly detected among Zhaotong natives, illiterates, and non-farmers and was mostly detected in Zhaoyang County. CRF01_AE was frequently detected among married and homosexual individuals and mostly detected in Weixin and Zhenxiong counties. Among the 516 pol sequences, 187 (36.2%) were clustered. Zhaotong natives, individuals aged ≥60 years, and illiterate individuals were more likely to be found in the network. Assortativity analysis showed that individuals were more likely to be genetically associated when stratified by age, education level, occupation, and reporting area. The genetic diversity of HIV-1 reflects the complexity of local HIV epidemics. Molecular network analyses revealed the subpopulations to focus on and the characteristics of the risk networks. The results will help optimise local prevention and control strategies.

Racial, gender, and psychosocial disparities in viral suppression trends among people receiving coordinated HIV care in Los Angeles County

OBJECTIVE

To longitudinally evaluate differences in HIV viral suppression (<200 copies/ml) by intersections of race/ethnicity, gender, and psychosocial issues in people with HIV in the Los Angeles County Medical Care Coordination Program.

DESIGN

We analyzed 74 649 viral load measurements over 10 184 people with HIV enrolled in the Medical Care Coordination Program between January 1, 2013 and March 1, 2020.Methods: We fit Bayesian logistic hierarchical random effects models to test interactions between gender, race/ethnicity, and a psychosocial acuity score on viral suppression over time from 1 year prior to program enrollment to 24 months after enrollment.

RESULTS

The probability of viral suppression declined prior to enrollment, then increased and stabilized by 6 months after enrollment. Black/African American patients with low and moderate psychosocial acuity scores did not achieve the same increase in percentage of viral suppression as those in other racial/ethnic groups. Transgender women with high psychosocial acuity scores took longer (about 1 year) to achieve the same percentage of viral suppression as clients of other gender identities.

CONCLUSIONS

Some racial/ethnic and gender disparities in viral suppression persisted after enrollment in the Los Angeles County Medical Care Coordination Program while accounting for psychosocial acuity score, which may be explained by factors not assessed in the program.

Factors Associated With Rapid Linkage to HIV Medical Care Among Persons Newly Diagnosed With HIV Infection in the United States, 2019 to 2020

BACKGROUND

Rapid linkage to HIV medical care, ideally within 7 days of a person's diagnosis with HIV infection, is a vital strategy of the Ending the HIV Epidemic initiative in the United States. We analyzed HIV testing data to evaluate the prevalence of and factors associated with rapid linkage to HIV medical care.

METHODS

We used HIV testing data reported by Centers for Disease Control and Prevention-funded 60 state and local health departments and 29 community-based organizations from 2019 to 2020. Variables analyzed include rapid linkage to HIV medical care (within 7 days of diagnosis), demographic/population characteristics, geographic region, test site type, and test year. Multivariable Poisson regression analysis was conducted to evaluate the characteristics associated with rapid linkage to HIV medical care.

RESULTS

A total of 3,678,070 HIV tests were conducted, and 11,337 persons were newly diagnosed with HIV infection. Only 4710 persons (41.5%) received rapid linkage to HIV medical care, which was more likely among men who have sex with men or persons who were diagnosed in Phase I Ending the HIV Epidemic jurisdictions and less likely among persons diagnosed in sexually transmitted disease clinics or the South region.

CONCLUSIONS

Less than one-half of persons newly diagnosed with HIV infection in Centers for Disease Control and Prevention-funded HIV testing programs were linked to HIV medical care within 7 days of diagnosis. Rapid linkage to care varied significantly by population characteristics and setting. Identifying and removing potential individual, social, or structural barriers to rapid linkage to care can help improve HIV-related health equity and contribute to the national goal of ending the HIV epidemic.

The impact of COVID-19 on the HIV continuum of care: challenges, innovations, and opportunities

INTRODUCTION

In February 2019, the United States (US) launched the Ending the HIV Epidemic (EHE) initiative with emphasis on improving the various steps of the Human Immunodeficiency Virus (HIV) prevention and care continuum. However, in March 2020, the Coronavirus Disease 2019 (COVID-19) pandemic was declared, curtailing efforts to end the epidemic in the US.

AREAS COVERED

To describe the impact of the pandemic on EHE in the US, the authors performed a comprehensive literature review focusing on outcomes at each step of the HIV care continuum. Simultaneously, they identified examples of pandemic-era innovations that may help EHE.

EXPERT OPINION

Numerous studies demonstrated pandemic-related disruptions across the care continuum as well as the impact on preexisting barriers to care among People with HIV (PWH) at higher risk for poor outcomes. As the pandemic progressed, innovative approaches to delivering healthcare and providing essential services emerged, including widespread use of telemedicine, expansion of home-based care, self-collected sexually transmitted infection (STI) and HIV testing, and co-located testing for COVID-19 and HIV/STIs. While the COVID-19 pandemic initially hindered achieving EHE in the US, the ability to be agile, flexible, and creative led to innovation in HIV care delivery that may ultimately assist in meeting EHE goals as we transition into the post-pandemic era.

Intersectionality-informed analysis of durable viral suppression disparities in people with HIV

OBJECTIVE

The aim of this study was to examine drivers of durable viral suppression (DVS) disparities among people with HIV (PWH) using quantitative intersectional approaches.

DESIGN

A retrospective cohort analysis from electronic health records informed by intersectionality to better capture the concept of interlocking and interacting systems of oppression.

METHODS

We analyzed data of PWH seen at a LGBTQ federally qualified health center in Chicago (2012-2019) with at least three viral loads. We identified PWH who achieved DVS using latent trajectory analysis and examined disparities using three intersectional approaches: Adding interactions, latent class analysis (LCA), and qualitative comparative analysis (QCA). Findings were compared with main effects only regression.

RESULTS

Among 5967 PWH, 90% showed viral trajectories consistent with DVS. Main effects regression showed that substance use [odds ratio (OR) 0.56, 0.46-0.68] and socioeconomic status like being unhoused (OR: 0.39, 0.29-0.53), but not sexual orientation or gender identity (SOGI) were associated with DVS. Adding interactions, we found that race and ethnicity modified the association between insurance and DVS ( P for interaction <0.05). With LCA, we uncovered four social position categories influenced by SOGI with varying rates of DVS. For example, the transgender women-majority class had worse DVS rates versus the class of mostly nonpoor white cisgender gay men (82 vs. 95%). QCA showed that combinations, rather than single factors alone, were important for achieving DVS. Combinations vary with marginalized populations (e.g. black gay/lesbian transgender women) having distinct sufficient combinations compared with historically privileged groups (e.g. white cisgender gay men).

CONCLUSION

Social factors likely interact to produce DVS disparities. Intersectionality-informed analysis uncover nuance that can inform solutions.

Acceptability, Feasibility, and Appropriateness of Implementation of Long-acting Injectable Antiretrovirals: A National Survey of Ryan White Clinics in the United States

Background

The approval of long-acting injectable cabotegravir/rilpivirine (LAI CAB/RPV) heightened the urgency of ensuring effective implementation. Our study assesses readiness and barriers to implement LAI CAB/RPV across Ryan White-funded clinics in the United States.

Methods

We conducted a cross-sectional survey between December 2020 and January 2021 using validated 4-item measures: acceptability of intervention measure (AIM), intervention appropriateness measure (IAM), and feasibility of intervention measure (FIM). Associations between measures and clinic characteristics were evaluated via Spearman rank correlations. A 5-point Likert scale ranked potential barriers of implementation responses. Open-ended questions were analyzed through a thematic approach.

Results

Of 270 clinics, 44 (16%) completed the survey: 38% federally qualified health centers, 36% academic, 20% community-based organizations, 14% hospital outpatient, and 9% nonprofit. Means (SD; range) were as follows: AIM, 17.6 (2.4; 12-20); IAM, 17.6 (2.4; 13-20); and FIM, 16.8 (2.9; 7-20). Twenty percent were not at all ready to implement LAI CAB/RPV, and 52% were slightly or somewhat ready. There was a significant association between AIM and the proportion of Medicaid patients (AIM, rho = 0.312, P = .050). Community-based organizations scored the highest readiness measures (mean [SD]: AIM, 19.50 [1.41]; IAM, 19.25 [1.49]; FIM, 19.13 [1.36]) as compared with other clinics. Implementation barriers were cost and patients' nonadherence to visits.

Conclusions

There is variability of readiness yet high levels of perceived acceptability and appropriateness of implementing LAI CAB/RPV among Ryan White clinics, necessitating tailored interventions for successful implementation. A special focus on addressing the barriers of adherence and the cost of implementation is needed.

Implementing a Rapid Antiretroviral Therapy Program Using Starter Packs for Emergency Department Patients Diagnosed With HIV Infection

Background

Emergency departments (ED) have been identified as essential partners in the national plan to end the HIV epidemic. The initiation of rapid antiretroviral therapy (ART) may be an important strategy to minimize the treatment barriers faced by many ED patients diagnosed with HIV.

Methods

We describe the implementation and outcomes of a protocol to provide rapid ART by using starter packs for eligible ED patients testing HIV antigen/antibody (Ag/Ab) reactive. Eligible patients were not pregnant, were unlikely to have a false-positive Ag/Ab test result, were discharged home, were ART naive, had acceptable liver and renal function, lacked symptoms of an opportunistic infection, and were judged to be a good candidate.

Results

During the 1-year study period, 10 606 HIV tests were performed, and 106 patients were HIV Ag/Ab reactive and assessed for ED rapid ART eligibility. Thirty-one patients (29.2%) were eligible for ED rapid ART; 26 (24.5%) were offered it; and 25 accepted and were provided starter packs for an overall ED rapid ART treatment rate of 23.6%. Two patients receiving ED rapid ART were confirmed to be HIV negative. Patients provided ED rapid ART were more likely to follow up by 30 days (82.6% vs 50.0%, P = .01) than patients not provided ED rapid ART. The 6-month incidence of immune reconstitution inflammatory syndrome was 4.3% among the 23 patients who were HIV positive and receiving ED rapid ART.

Conclusions

The initiation of ED rapid ART for patients testing HIV Ag/Ab reactive is feasible, well accepted, and safe and may be an important facilitator of linkage to care.

Trends in U.S. HIV Peer Health Worker Training Strategies and Approaches: A Scoping Review of the Literature

ABSTRACT

Peer health workers (peers) are commonly engaged interventionists in the HIV care spectrum. The objective of this scoping review was to examine the range of evidence on training strategies and approaches for peer-led HIV behavioral interventions in the United States. Four electronic databases (Medline, CINAHL, EMBASE, and PsycINFO) were searched for peer-reviewed published literature (2010-2021) of peer-led HIV behavioral interventions directed to improving antiretroviral therapy adherence and/or retention in care. Eighteen studies met the inclusion criteria. Eleven studies referenced manualized training materials, and nine used role-play as part of their curricula. Peer training content and duration varied across studies, as well as evaluation of intervention fidelity, and peer competency. Findings highlight heterogeneity in peer training strategies and approaches. The expansion and sustainability of peer engagement in the HIV care continuum will require greater consensus among members of the research community on best practices for training.

Adults Aged ≥50 Years Reached by the Centers for Disease Control and Prevention's HIV Testing Programs in the United States and US Dependent Areas, 2019

OBJECTIVES

Older adults represent nearly half of people living with HIV in the United States. The objective of this analysis was to describe HIV testing, demographic characteristics, and risks of adults aged ≥50 years (older adults) reached in 2019 by HIV testing programs funded by the Centers for Disease Control and Prevention (CDC).

METHODS

We collected data from 101 CDC-funded community-based organizations and 61 health departments. All funding recipients submitted deidentified program service data for 2019 through a secure online CDC-supported system. We used multivariable robust Poisson regression to assess the association between demographic and risk characteristics and the proportion of tests that resulted in a new diagnosis. We also assessed the proportion of people who received a positive test result, were linked to HIV medical care, and were interviewed for partner services.

RESULTS

During 2019, among 2 452 507 CDC-funded HIV tests provided in the United States, 412 164 (16.8%) were provided to older adults. Among the 1059 (0.26% positivity) older adults with newly diagnosed HIV infection for whom we had data, 582 (68.4%) were linked to HIV medical care within 30 days of diagnosis and 494 (72.1%) were interviewed for partner services. Among the 2858 older adults with previously diagnosed HIV infection, 1321 (46.2%) reported not being in HIV medical care at the time of the test; of those with linkage data, 425 (49.9%) were linked to HIV medical care within 30 days of testing HIV positive.

CONCLUSIONS

More rapid disease progression and higher morbidity and mortality rates among older adults suggest that services are needed to ensure early diagnosis, rapid linkage, and interview for partner services.