Ending the HIV Epidemic: A Plan for the United States

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

OBJECTIVE

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

DESIGN

A systematic review.

METHODS

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

RESULTS

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

CONCLUSION

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

Understanding Opportunities for Prescribing Pre-exposure Prophylaxis at Two Academic Medical Centers in a High Priority Jurisdiction for Ending the HIV Epidemic

Pre-exposure prophylaxis (PrEP) is an effective yet underutilized tool for HIV prevention. We examined opportunities for prescribing PrEP at two large, urban, academic healthcare institutions. We analyzed electronic medical record data for 1/1/2015-12/31/2021 among patients ≥ 18 years of age, with ≥ 1 negative HIV test with indications for PrEP. Eligible encounters were six months after a sexually transmitted infection, or when injection drug use (IDU) was documented. We categorized encounter setting, including the emergency department (ED) and obstetrics and gynecology/women's health (OBGYN) department. We performed logistic mixed effects regression, reporting odds ratios and confidence intervals (OR, aOR, 95% CI). Overall, 9644 people contributed 53,031 encounters with 4653 PrEP prescriptions. The two institutions had different patient population demographics, with institution A having a higher proportion of women, patients aged 18-24, and non-Hispanic Blacks (NHB), and institution B having a higher proportion of men who have sex with men (MSM), non-Hispanic Whites (NHW), and Hispanic/Latinos. Adjusted models found lower odds of PrEP prescriptions for NHB (aOR 0.21 [0.15, 0.29]), Hispanic/Latino (aOR 0.53 [0.37, 0.76]), heterosexual women (aOR 0.10 [0.06, 0.17]), IDU (aOR 0.01 [0.001, 0.08]), and encounters at the ED or OBGYN (0.14 [0.06, 0.31]). Increased odds of PrEP prescription were seen among NHW (aOR 4.85 [3.45, 6.82]), MSM (aOR 24.87 [15.79, 39.15]), and patients at institution B (aOR 1.78 [1.25, 2.53]). Institution A contained people historically underrepresented in PrEP prescriptions, while institution B accounted for most PrEP prescriptions. Opportunities exist to improve equity in PrEP prescriptions among demographic groups and in hospital settings.

Assessing the efficiency and effectiveness of community-based voluntary counseling and testing for HIV in Turin: insights from the fast-track cities initiative - a cross-sectional study

BACKGROUND

This study evaluated the efficiency and effectiveness of Community-Based Voluntary Counseling and Testing (CBVCT) for HIV in Turin as part of the Fast-Track Cities initiative. It aimed to understand demographic characteristics and risk behaviors to identify factors associated with routine testing. The findings can help to better tailor interventions for reducing HIV transmission and improving public health outcomes.

METHODS

A cross-sectional design was employed, utilizing anonymous questionnaires administered throughout 2022. Participants were individuals attending rapid serological testing sessions for HIV organized by third-sector associations in Turin, Northern Italy. The sample comprised 795 participants who attended HIV testing sessions. Data were collected via paper-based questionnaires (n = 495), later digitized for analysis. Descriptive statistics, univariate, and logistic regression analyses were conducted to examine socio-demographic characteristics, risk behaviors, and testing outcomes. Cost-effectiveness was evaluated using a Markov model stratifying patients by CD4 + levels to assess QALYs and direct healthcare costs.

RESULTS

The study achieved a high HIV testing rate of 99.9%, with a positivity rate of 0.5%. All individuals with reactive tests were successfully linked to care. Syphilis testing had a lower uptake (76.7%) and identified a positivity rate of 0.7%. Significant demographic and behavioral differences were found: previously tested participants are more likely to be older (p < 0.001, OR = 1.15) than first-time testers, more likely to be MSM (Men who have Sex with Men) than MSF (Men who have Sex with Female) and FSM (Female who has Sex with Male) (p < 0.001, OR = 0.132; p < 0.001, OR = 0.183); and are more likely to have had a history of sexually transmitted infections (STIs)(p = 0.003, OR = 0.128). Immediate HIV diagnosis and access to antiviral therapy reduce healthcare costs by €3,841 per patient, with total savings of €23,808 due to lower treatment expenses before immunodeficiency onset.

CONCLUSIONS

CBVCT programs in Turin demonstrated high feasibility and effectiveness in engaging the target population and ensuring linkage to care. However, syphilis testing requires greater integration. The findings highlight the need for targeted interventions to address disparities in testing behaviors and reinforce the economic sustainability of early HIV diagnosis and treatment.

Estimating the population need for preexposure prophylaxis for HIV in the United States

Preexposure prophylaxis (PrEP) is highly effective in preventing HIV infections and is recommended for people without HIV who are at ongoing risk of HIV acquisition. In 2019, the U.S. launched the "Ending the HIV Epidemic in the U.S." initiative, which aims to reduce by 90 % the number of annual new HIV infections. To monitor progress towards this goal, several national indicators have been established, one of which is PrEP coverage. Several ways to monitor PrEP use have been developed, each with its own advantages and disadvantages. We developed a method to estimate PrEP "need" in the U.S. that could be used as a denominator to estimate PrEP coverage. The "population need for PrEP" (PPN) is estimated based on the number of people needed to treat (NNT) with PrEP to prevent an additional HIV infection in subpopulations whose annual HIV incidence is ≥ 1 %. This is done in three steps: 1) calculating NNT for each transmission group using 1 % incidence threshold and clinical trial-and cohort-generated evidence of the degree of PrEP effectiveness in each transmission group, 2) estimating the proportion of new HIV infections in subpopulations with incidence at least 1 % from epidemiologic data, 3) multiplying estimates from steps 1 and 2 with the number of new HIV infections for each transmission group from Surveillance. The estimates for each transmission group are then added together, and the number of current PrEP users is finally added to this estimate to produce PPN. This method is relatively easy to calculate and can provide public health authorities at the national, state, or local level with pragmatic estimates of PrEP "need" among different demographic or transmission groups, which can help with planning, resource allocation, and monitoring progress.

Brief Report: Improving Perinatal HIV Care During the COVID-19 Pandemic: Implementing a Mobile Integrated Health Program to Close the Gap

BACKGROUND

Pregnant people with HIV (PWH) often experience loss to follow-up and viral nonsuppression after delivery, contributing to morbidity and HIV transmission. The COVID-19 pandemic disrupted health systems and exacerbated health disparities, including for PWH and their infants. To improve perinatal HIV outcomes, we implemented a perinatal care program in September 2020 that offered multidisciplinary home visits through a mobile integrated health (MIH) unit within a large, safety-net health care system in Atlanta, GA.

METHODS

We analyzed data collected from PWH who delivered 1 year before (August 31, 2019-August 31, 2020; pre-implementation) to 6 months after (September 1, 2020-February 28, 2021; post-implementation) MIH implementation to compare HIV clinical outcomes. We evaluated barriers, facilitators, and patient preferences through exit surveys with MIH program participants.

RESULTS

Overall, 32 (53%) delivered before and 28 (47%) PWH delivered after MIH implementation; most were non-Hispanic Black. Three-fourths who delivered post-MIH used MIH, mostly (62%) for postpartum obstetric visits. HIV visit attendance within 3 months and retention in care at 6 months of delivery were significantly higher post-implementation ( P = 0.04). Participants noted that the MIH program significantly improved appointment scheduling and access to health care services during the pandemic ( P < 0.05). Participants highly rated the preferability, convenience, safety, and use of the MIH program for future pregnancies.

CONCLUSIONS

Implementation of a perinatal MIH program for PWH and their infants led to significant improvement in engagement in HIV care after delivery. Our findings demonstrate that novel, interdisciplinary programming can fill critical gaps in care delivery, including during periods of health care disruption.

Minimal Reduction in HIV Transmission Needed for HIV Cluster Detection and Response to be Cost Saving

HIV cluster detection and response (CDR) provides a framework for identifying rapid HIV transmission and guiding implementation of proven HIV prevention and care strategies. Characterizing the relative benefits of CDR is important for guiding policy makers in resource allocation for HIV prevention. We sought to understand how many HIV infections would need to be averted by CDR activities to achieve various return-on-investment (ROI) thresholds. We conducted an ROI analysis of CDR in 2022, incorporating costs and benefits across US jurisdictions funded for HIV surveillance and prevention. Setting ROI thresholds between 1 and 5, we estimated the number of HIV infections that would need to be averted annually by CDR activities to reach ROI thresholds. A scenario was considered cost saving if the ROI > 1. Based on the number of people in national priority molecular clusters and estimated transmission in these clusters, we determined the percent reduction in transmission within these clusters that would be required to achieve the threshold number of HIV infections averted. The number of HIV infections needing to be averted annually ranged from 19 infections (ROI = 1) to 94 infections (ROI = 5). Among 657 HIV transmissions within national priority molecular clusters, the percent reduction in HIV transmission needed to meet ROI thresholds ranged from 2.9% (ROI = 1) to 14.3% (ROI = 5). In conclusion, CDR activities would need to avert a minimal number of HIV infections nationally to achieve cost savings.

Brief Report: Behavioral Readiness for Daily Oral PrEP in a Diverse Sample of Gay, Bisexual, and Other Men Who Have Sex With Men Who Have Not Been Offered PrEP by a Provider

BACKGROUND

Daily oral pre-exposure prophylaxis (PrEP) use among gay, bisexual, and other men who have sex with men (GBMSM) remains suboptimal. Assessing behavioral readiness for PrEP use among GBMSM who can benefit and offering PrEP may increase uptake among GBMSM. We measured 4-item readiness for taking PrEP among GBMSM who have not been offered PrEP by a provider.

METHODS

GBMSM in Atlanta, Chicago, and Raleigh-Durham reporting recent condomless anal sex were assessed for "readiness" to discuss PrEP with a provider, test for HIV, take a daily pill, attend provider appointments, and a 4-component composite score for PrEP readiness. χ 2 tests and multivariable logistic regression were applied to examine factors associated with readiness to use PrEP.

RESULTS

Study sample (n = 187) was 51% Black/African American, 15% Hispanic/Latino, 30% identified as bisexual or straight or other, and 29% had no health insurance. In total, 55% said they were ready to discuss PrEP with a provider, 88% were ready to get an HIV test, 45% were ready to take a daily pill, 48% were ready to attend appointments, and 37% reported overall PrEP readiness. Having no health insurance was associated with readiness for a daily pill [adjusted odds ratio (AOR) = 2.78, confidence interval (CI) = 1.34-5.78] and 4-item PrEP readiness (AOR = 2.34, CI = 1.13-4.85). Self-identification as gay (vs bisexual/straight) was associated with readiness to discuss PrEP (AOR = 2.14, CI = 1.05-4.36).

CONCLUSIONS

Only 37% of GBMSM with recent condomless anal sex were ready for PrEP based on the 4-item readiness. Readiness may differ based on sexual identity, insurance status, and other characteristics. Efforts are needed to increase readiness across behavioral components of PrEP use.

Development and Pilot Testing of an Addiction Clinic-Based Pre-Exposure Prophylaxis Uptake and Adherence Intervention for Women with Substance Use Disorders: Protocol for a Pilot Randomized Trial

BACKGROUND

Black and Hispanic women in the United States continue to bear disproportionate incidence of HIV related to sexual transmission and injection drug use. Specifically, women with substance use disorders (SUDs) are more likely to engage in vaginal or anal condomless sex associated with HIV transmission. Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention tool but is not widely used by racial or ethnic minority women. Effective interventions for engaging women with SUDs in HIV prevention interventions that are culturally appropriate and, therefore, more appealing to racial or ethnic minority women with SUDs are critically needed.

OBJECTIVE

This 3-phased study, including a pilot randomized controlled trial (RCT), will assess the initial efficacy, feasibility, and acceptability of an addiction clinic-based behavioral and PrEP services intervention to increase the uptake and adherence to PrEP among racial or ethnic minority women.

METHODS

A 3-phased mixed methods research design will involve formative qualitative methods using thematic analysis to design the intervention (phase 1), theatre testing to adapt and refine the intervention (phase 2), and RCT methods to pilot test the intervention for efficacy, feasibility, and acceptability (phase 3). The pilot RCT will enroll and randomize 60 women to either the standard SUD treatment program or SUD treatment integrated with PrEP services. The addiction clinic-based behavioral intervention will include 4 motivational counseling sessions guided by the Information-Motivation-Behavioral Skills Model to increase the uptake of PrEP. A mobile health app will be used to engage participants with the intention of motivating PrEP initiation and supporting adherence to PrEP. Following phase 3, generalized linear modeling will be used to model effects of the proportion of participants who fill their prescription and take at least 1 dose as a function of the intervention group.

RESULTS

Findings from individual qualitative interviews informed the development of the addiction clinic-based behavioral intervention. Study recruitment for the randomized pilot (phase 3) launched in May 2024. Additional statistical analyses will be performed upon completion of the study.

CONCLUSIONS

This addiction clinic-based behavioral intervention aims to increase PrEP uptake and adherence among racial or ethnic minority women who engage in sexual and substance use behaviors associated with increased susceptibility to HIV transmission. The addiction clinic-based behavioral intervention has the potential to reduce HIV-related disparities among Black and Hispanic women with SUDs. Findings from this study will provide a foundation for future HIV prevention interventions for racial or ethnic minority women with SUDs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06158607; https://clinicaltrials.gov/study/NCT06158607?term=NCT06158607&rank=1.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64961.

Improving Cognitive and Psychological Functioning in Older Latinos With HIV: Results From a Pilot Health Promotion Intervention

BACKGROUND/OBJECTIVES

Older Latino persons with HIV (OLPWH) experience early-onset cognitive decline due to specific factors associated with accelerated aging as well as more established risk factors like depression, anxiety, and sedentary behavior. Yet, few behavioral interventions to improve OLPWH's psychological and cognitive health have been assessed. Thus, this pilot study evaluated the feasibility, acceptability, and preliminary intervention effects of the Happy Older Latinos are Active (HOLA) physical activity health promotion intervention on cognition and mental health among this underserved population.

RESEARCH DESIGN/METHODS

Thirty OLPWH (Age: M = 61.7 years, SD = 6.00 years 40% female, 46.7% less than high-school education) enrolled in a pilot single-arm selective prevention intervention trial evaluating changes in psychological and neurocognitive outcomes at two timepoints (baseline and postintervention). Participants were asked at the end of the study to offer qualitative feedback on their acceptance of and interest in the intervention. Results: Within 7-months, enrollment targets were met (<5% of eligible participants refusing participation) and lost-to-follow up was minimal (10%). Participants attended an average of 54% of sessions and reported a high degree of satisfaction with the intervention via the Client-Satisfaction-Questionnaire-8 (M = 30.5, SD = 2.2). Significant improvements in cognitive (delayed recall [aRR = 1.16], working memory [aRR = 0.79], verbal fluency [aRR = 1.09]) and psychological (depression [aRR = 0.63], and anxiety severity [aRR = 0.73]) domains were observed when controlling for age, gender, and education.

DISCUSSION/IMPLICATIONS

Results indicate that HOLA is an innovative and promising health promotion program that is uniquely tailored to address the multiple cognitive and psychological concerns affecting OLPWH in a nonstigmatizing and culturally acceptable manner.

Race-Based Discrimination, Internalized Racism, and Anticipatory Stigma Among Sexual Minority Men in Same-Race and Interracial Relationships

Sexual minority men (SMM) of color in inter-racial/ethnic relationships experience more stress than those in same-race/ethnic relationships. While minority stress in SMM couples has been studied, few studies have examined race/ethnicity and SMM relationship dynamics in an integrative manner, especially at the individual level. This study examined race-based discrimination, internalized racism, and anticipatory stigma among 391 U.S. SMM who reported being in romantic relationships. A MANOVA model analyzed differences in these outcomes across six groups: a) Latinx SMM with a Latinx partner, b) White SMM with a White partner, c) Black SMM with a Black partner, d) Asian SMM with an Asian partner, e) White SMM with a partner of color, and f) SMM of color with a White partner. There were significant differences in internalized racism across Asian, Latinx, and White SMM with a partner who shared the same racial/ethnic background. Anticipatory stigma was significantly higher for Black SMM with a Black partner than for Asian SMM with an Asian partner. SMM of color with a partner of color reported greater internalized racism and race-based discrimination than White SMM with a White partner. Racism and stigma were consistently higher among SMM of color with a White partner than White SMM with a partner of color. Our findings highlight the importance of considering the intersectionality between racial/ethnic identity and relationship dynamics when designing relationship-based interventions.

Factors Influencing Oral Pre-, Post-, and Doxycycline Post-Exposure Prophylaxis Uptake Among Substance-Using Men Who Have Sex with Men in the Rural Southern US

Substance-using men who have sex with men (MSM), especially those in rural areas, face a heightened risk of HIV and sexually transmitted infections (STIs). Despite increased risk, uptake of HIV pre-exposure prophylaxis (PrEP), HIV post-exposure prophylaxis (PEP), and doxycycline post-exposure prophylaxis (Doxy-PEP) remains low among rural MSM. The multi-domain factors influencing past-year use of oral PrEP, PEP, and Doxy-PEP among substance-using MSM in the rural southern US remain unknown. A cross-sectional study of rural substance-using MSM (n = 345) in the Southern US was conducted from February 29 to March 23, 2024. Three series of bivariate and multivariate logistic regression analyses were conducted. Past-year PrEP use was significantly associated with HIV-negative status (adjusted odds ratio [aOR] = 2.55, 95% confidence interval [CI]: 1.12-5.80, p = 0.025), past-year STI diagnosis (aOR = 2.23, 95% CI: 1.19-4.15, p = 0.012), past-year HIV testing (aOR = 3.40, 95% CI: 1.05-10.9, p = 0.040), and past-year STI testing (aOR = 10.09, 95% CI: 2.25-45.37, p = 0.003). Past-year PEP use was significantly associated with past-year STI diagnosis (aOR = 3.70, 95% CI: 1.33-10.32, p = 0.012) and oral sex (aOR = 0.09, 95% CI: 0.01-0.63, p = 0.015). Finally, past-year Doxy-PEP use was significantly associated with past year-STI diagnosis (aOR = 4.44, 95% CI: 2.03-9.71, p < 0.001). Results underscore the need for integrated care across primary care, pharmacy, and substance use treatment settings to improve screening, education, and prescription of HIV/STI preventative biomedical pharmaceuticals for substance-using MSM.

Analysis of HIV transmission characteristics and intervention effects in Guangxi based on molecular networks

OBJECTIVE

This study evaluates changes in HIV transmission and the effectiveness of interventions after two rounds of the Guangxi AIDS Conquering Project (GACP) in Guangxi, China.

METHODS

Samples and epidemiological data from newly diagnosed people with HIV (PWH) between 2014 and 2020 were analyzed. Molecular networks were constructed using nested PCR amplification and sequencing of the pol region, and multivariable logistic regression identified factors associated with clustering and high-degree nodes.

RESULTS

A total of 4227 valid sequences (73.12% inclusion rate) were analyzed. Demographic changes included an increasing proportion of individuals aged at least 50 years (49.66%), with lower education (50.51%), peasants (76.82%), and heterosexual transmission (90.29%). The overall clustering rate was 86.89%, with higher clustering among individuals aged at least 50 years (92.57%), those with primary school or below (89.09%), peasants (88.11%), and CRF08_BC infections (91.48%). Annual declines in cluster growth rate and clustering rates were observed, particularly among individuals aged less than 30 years, college graduates, MSM, and people who inject drugs (PWID). Key transmission hotspots were identified in Lingshan, particularly among older, less-educated individuals, and peasants. Factors associated with clustering included being male (aOR: 1.27), aged at least 50 years (aOR: 3.84), and infected with CRF08_BC (aOR: 2.12). From 2017 to 2020, the risk of clustering and high-degree nodes was lower compared to 2014-2016, suggesting the effectiveness of interventions.

CONCLUSION

Interventions in Guangxi effectively reduced HIV transmission among younger, high-degree populations. However, older, less-educated individuals remain at high risk, necessitating targeted strategies to address their specific needs and achieve better HIV control.

Digital HIV information seeking and willingness to use a smartphone application for PrEP care among persons who inject drugs in Northeast Georgia, United States

Georgia has one of the highest rates of new HIV diagnoses in the United States, while rates of PrEP uptake are among the lowest. This study examines the association between seeking digital HIV information and willingness to use smartphone applications (app) for PrEP resources and services among people who inject drugs (PWID) living in northeast Georgia. Data were collected from adult HIV-negative PWID who reported using the internet (N = 130). Most participants were cisgender men (67.7%), uninsured (53.3%), and were heavily drug dependent (74.6%). A majority were aware of PrEP (51.5%), used the internet daily (65.4%), and had a mobile device with internet access (89.2%). However, most reported they did not seek HIV information on the internet (72.3%). Almost half of participants (49.2%) were willing to use a PrEP-focused app. In the multivariable logistic regression model, willingness to use a PrEP app was more likely among PWID who sought HIV information (adjusted OR: 2.69, 95%CI: 1.06-6.86) than those who did not, who had never or rarely engaged in HIV testing (adjusted OR: 4.11, 95%CI: 1.52-11.14) than those who tested more frequently. The results show that a PrEP app may be a promising strategy for increasing PrEP awareness and uptake among PWID.

Pre-exposure Prophylaxis: Clinical Considerations for Overcoming Barriers to Uptake and Persistence

ABSTRACT

Pre-exposure prophylaxis (PrEP) is the administration of antiretroviral medications before HIV exposure to prevent HIV infection. PrEP or biomedical prevention is an essential part of the ending the HIV epidemic strategy. Currently, there are 4 guideline-approved dosing approaches to PrEP, which include 2 oral formulations and 1 long-acting injectable. Unfortunately, most individuals who would benefit from PrEP do not receive a prescription, and even fewer initiate and continue PrEP. Barriers to PrEP uptake and persistence are complex and extend along a socio-ecologic framework from individual through structural. In this article, we highlight the barriers to PrEP care among priority populations, discuss evidence-based solutions, and offer multilevel considerations for clinicians, researchers, and community members to increase access, uptake, and persistence in PrEP care for all.

HIV mortality trends among the United States population, from 1999-2023: a CDC wonder database study

BACKGROUND

Despite the progress made in managing HIV, the mortality trends among general population in the US remains understudied. Our aim is to analyse the trends in HIV-related mortality among US residents by demographic characteristics and association with social vulnerability index (SVI).

METHODS

We abstracted national mortality data from the multiple cause of death files in the CDC WONDER database. The ICD-10 Codes (B20-B24) were used to identify HIV deaths among US population from 1999 to 2023. Trends in age-adjusted mortality rate (AAMR) were assessed using Joinpoint regression analysis. For 10-year increment age-groups, crude mortality rates were reported. Results were expressed as annual percentage changes (APC), average annual percentage changes (AAPC), and 95% confidence intervals (CI). SVI was obtained from CDC for each county.

RESULTS

Between 1999 and 2023, a total of 271,932 HIV-infected patients died within the US (AAMR= 3.4 per 100,000; 95% CI: 3.3-3.5). Overall mortality trends decreased at an annual rate of -4.34% (95% CI: -5.25, -3.41) from 1999 through 2023 in the whole population. Specifically, the trends are higher among males age groups 45-54 years (overall rising in age 65 and above), African Americans, South Region and Large metropolitan areas. States in the top 90th percentile included District of Columbia, Florida, Maryland, Louisiana, New York, and Georgia. Union county followed by Miami-Dade are highly affected within Florida State which ranks second after District of Columbia. SVI was independently associated with HIV mortality with strong association throughout the United States counties.

CONCLUSIONS

HIV mortality among US population has decreased overall from 1999 to 2023, but with varying trends by race and ethnicity. This highlights the need for enhanced public health surveillance to better understand the scope of HIV mortality and identify high-risk demographic and regional subgroups for targeted interventions.

Ongoing crisis across the HIV care continuum: high mortality among PWH admitted to the ICU in an urban safety-net hospital in the South

We present a retrospective study of people with HIV (PWH) admitted to the medical intensive care unit (MICU) of an 862-bed academic, safety-net hospital. We aimed to determine the characteristics of ICU admissions among PWH, measure the mortality in this population and identify predictors of mortality. All patients ≥ 18 years old with a diagnosis of HIV infection admitted to the MICU between January 1, 2017 and December 31, 2019 were included. A total of 195 ICU admissions occurred during the study period. The mean age was 46.2 years, 77.4% were male and the majority were people of color. Overall, 125 (64.8%) patients had CD4<200 cells/mL and 12 (6.7%) were newly diagnosed with HIV. ICU mortality was 21.5% and hospital mortality was 24.6%. High APACHE score and CD4<200 were independent predictors of ICU mortality. Our three-year retrospective analysis of PWH admitted to the ICU in a large urban safety-net hospital in the US South during the recent modern ART era identified high ICU- and hospital mortality. We also identified a higher mortality risk at each step of the HIV care cascade, reinforcing the importance of proactive interventions including expanded HIV testing and implementation of strategies which improve engagement in care, ART adherence and virologic suppression.

Updates to HIV Transmission Rate Estimates Along the HIV Care Continuum in the United States, 2019

BACKGROUND

In 2019, there were an estimated 1.2 million persons with HIV (PWH) and 35,100 new infections in the United States. The HIV care continuum has a large influence on transmission dynamics.

METHODS

We updated Progression and Transmission of HIV 3.0, an agent-based simulation model, to estimate 2019 HIV transmission rates and distribution of transmissions by the HIV care continuum, race/ethnicity, transmission group, and age group.

RESULTS

In 2019, the estimated transmission rate in the United States was 2.94 new infections per 100 person-years ( inf/100p-y) . Transmission rates decreased along the HIV care continuum; the highest transmission rate was associated with persons with acute HIV infection and unaware of their HIV status at 16.35 inf/100p-y , followed by PWH (nonacute) and unaware of their HIV status (9.52), persons aware of their HIV status and not in care (5.96), persons receiving HIV care (on antiretroviral therapy) but not virally suppressed (4.53), and persons virally suppressed (0). The highest transmission rate by transmission group was among men who have sex with men at 3.68 inf/100p-y . Transmission rates decreased as age increased and are similar by race/ethnicity, after accounting for the HIV care continuum.

CONCLUSIONS

Our results support a continued emphasis on helping PWH move along the care continuum through early diagnosis, linkage to care, and adherence to ART, resulting in viral suppression to reduce HIV transmissions. Furthermore, efforts should focus on reducing disparities in the provision of HIV prevention and care services, particularly for populations disproportionally affected by HIV.

Nationwide Implementation of HIV Molecular Cluster Detection by Centers for Disease Control and Prevention and State and Local Health Departments, United States

Detecting and responding to clusters of rapid HIV transmission is a core HIV prevention strategy in the United States, guiding public health interventions and identifying gaps in prevention and care services. In 2016, the Centers for Disease Control and Prevention (CDC) initiated molecular cluster detection using data from 27 jurisdictions. During 2016-2023, CDC expanded sequence reporting nationwide and deployed Secure HIV-TRACE, an application supporting health department (HD) molecular cluster detection. CDC conducts molecular cluster detection quarterly; state and local HDs analyze local data monthly. HDs began routinely reporting clusters to CDC by using cluster report forms in 2020. During 2018-2023, CDC identified 404 molecular clusters of rapid HIV transmission; 325 (80%) involved multiple jurisdictions. During 2020-2023, HDs reported 298 molecular clusters to CDC; 249 were first detected by HDs. Expanding molecular cluster detection has provided a foundation for improving service delivery to networks experiencing rapid HIV transmission.

Implementation Determinants of PrEP and Behavioral Health Treatment Referral among HIV Test Counselors

Pre-exposure prophylaxis (PrEP), an effective biomedical prevention intervention, is not sufficiently reaching populations experiencing high HIV incidence. Behavioral health (BH) treatment addressing mental health and substance use similarly requires increased reach to HIV-affected populations. HIV testing is an opportunity to refer individuals to PrEP and BH treatment. This study, conducted in Miami-Dade County, FL, a domestic HIV epicenter, aimed to assess (1) self-reported rates at which HIV test counselors refer clients to PrEP and BH treatment, (2) barriers and facilitators to PrEP and BH treatment referral, and (3) the relationship between barriers and facilitators and test counselors' referral rates. Among 127 HIV test counselors, the average PrEP referral rate was 63.8% (SD = 41.5) of those potentially meeting PrEP indications. Insufficient time was associated with lower PrEP referral (OR: 0.64, 95% CI: 0.42-0.99, p = 0.023) and training in PrEP screening was associated with higher rates of PrEP referral (OR: 1.27, 95% CI: 0.98-1.64, p = 0.034). The average BH treatment referral rate was 52.7% (SD = 44.4) of clients who the counselor felt would potentially benefit from treatment. Counselors lacking knowledge of screening (OR: 0.4, 95% CI: 0.2-0.78, p = 0.004), referral procedures (OR: 0.45, 95% CI: 0.23-0.87, p = 0.008), or locations to refer clients (OR: 0.47, 95% CI: 0.25-0.86, p = 0.008), as well as those with higher caseloads (OR: 0.998, 95% CI: 0.997-0.999, p < 0.001) were less likely to refer for BH. Training in substance use screening (OR: 1.26, 95% CI: 0.96-1.64, p = 0.046) and referral (OR: 1.28, 95% CI: 0.99-1.66, p = 0.029) were associated with increased BH referral. Implementation strategies are needed to address key barriers to PrEP and BH referrals in HIV testing contexts.

"I'm Trusting You with My Body": A Qualitative Examination of the Role of Trust in Safer Sexual Decision-Making Among Black Women

Black women are disproportionately impacted by HIV, such that they are diagnosed at eight times the rate of White women and three times that of Latinas. Given that HIV transmission among Black women is primarily attributed to heterosexual sex, it is imperative to better understand factors that influence Black women's sexual health decision-making. Previous studies have highlighted the influence of trust on sexual decision-making; however, scant literature focuses on trust in the relationships of Black women, for whom it may differentially impact their sexual health. Nine focus groups were conducted to examine how trust affects sexual health decision-making among Black women who have sex with men (N = 56). Qualitative analyses revealed three themes that highlight how trust can influence sexual behavior: (1) Trust Buffers Risk of Physical and Emotional Harm; (2) Broken Trust Encourages Safer Sex Behavior; (3) Trust Dynamics Influence Sexual Communication Anxiety. This analysis expands on extant literature by identifying how differing forms of trust can be understood and leveraged in the context of HIV/STI prevention and sexual health for women engaging in heterosexual sex. Implications of the study indicate that concepts of trust should be addressed in interventions seeking to improve the sexual health of Black women.

Preventing Premature Pre-Exposure Prophylaxis Discontinuation and Sexually Transmitted Infections Among Men Who Have Sex With Men (Project PEACH): Protocol for a Prospective Cohort Study

BACKGROUND

There is an ongoing syndemic of HIV and sexually transmitted infections (STIs) in the United States, particularly among men who have sex with men (MSM). We have increasingly effective and diverse measures of prevention, including various types of pre-exposure prophylaxis (PrEP) for HIV prevention and doxycycline postexposure prophylaxis (doxyPEP) for STI prevention. As options expand, we need to understand how to use a combination of these strategies and other supports for MSM to best curb the syndemic.

OBJECTIVE

We designed a patient-preference trial to understand patient preferences for PrEP and doxyPEP, how preferences may change over time, and methods for preventing premature discontinuation of PrEP.

METHODS

We enrolled HIV-negative MSM in metropolitan Atlanta, Georgia. Participants could elect to take PrEP (daily or on-demand), doxyPEP, both, or neither, along with app-based support to evaluate for risk factors of discontinuation or behavioral changes that might affect their choice of prevention methods. Participants were able to switch prevention methods at any time. Oral PrEP and doxyPEP users are currently being offered quarterly in-person or at-home HIV, syphilis, gonorrhea, and chlamydia testing along with opportunities for motivational interviewing.

RESULTS

We enrolled individuals from November 2021 to September 2023. Among 240 participants, the median age was 30 (IQR 25-35), 63% (n=150) self-identified as non-Hispanic Black, and 69% (n=166) were insured. Most participants (n=144, 60%) elected to take daily PrEP plus doxyPEP, with a smaller proportion taking on-demand PrEP plus doxyPEP (n=34, 14%) or daily PrEP without doxyPEP (n=33, 14%).

CONCLUSIONS

We designed an ongoing study to evaluate the preferences for PrEP and doxyPEP among MSM in metropolitan Atlanta. Enrollment was completed in 22 months and included a diverse cohort of MSM that will be followed longitudinally to evaluate prevention preferences over time. At baseline, most participants preferred to take a combination of daily PrEP and doxyPEP for HIV and STI prevention.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05072093; https://clinicaltrials.gov/study/NCT05072093.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56096.

"When Somebody Comes into This Country and You Are Trans on Top of That Is Like You Got… Two Strikes on You": Intersectional Barriers to PrEP Use Among Latina Transgender Women in the Eastern and Southern United States

In the United States (U.S.), Latina transgender women (LTW) are highly burdened by HIV and are prioritized for pre-exposure prophylaxis (PrEP). This study explored intersectional barriers and facilitators to PrEP uptake among LTW. Between February-November 2022, in-depth interviews were conducted with 27 LTW in the LITE Study. Participants were purposively sampled from 196 LTW in the cohort based on PrEP uptake (PrEP-naïve n = 8, PrEP-eligible and not user n = 5, current PrEP user n = 6, previous PrEP user n = 8). We conducted content analysis guided by a Modified Social Ecological Model and Intersectionality Framework. The mean age of participants was 32.3 (SD = 12.9). Themes were: (1) Intrapersonal: Medical distrust, acceptability of PrEP modalities, and concerns about long-term health; (2) Interpersonal: Mistreatment in healthcare, discrimination-related healthcare avoidance, difficulty finding trans-competent providers, language barriers, and shame and stigma; and (3) Structural: PrEP in the context of limited access to gender-affirming care and widespread silicone use, immigration status, economic marginalization, lack of community outreach, transphobia and anti-transgender legislative contexts, and xenophobia. This study found multilevel intersectional barriers influence PrEP uptake and persistence. Culturally tailored HIV prevention efforts are needed to address LTW-specific barriers, provide information on programs subsidizing PrEP, and implement policy change to ensure equitable PrEP access.

PrEP Use Among Black Transgender Women: A Qualitative Study on Barriers to PrEP Use and the Power and Promise of Community

Black transgender women (TW) have disproportionately low uptake and use of HIV pre-exposure prophylaxis (PrEP), despite high vulnerability to HIV. Community and peer support may be important intervention targets to improve PrEP use among Black TW. We conducted qualitative interviews with 42 Black TW in the midwestern United States to understand Black TW's experiences with PrEP and explore barriers to PrEP use and the ways peers and Black trans communities may support PrEP use. Using inductive thematic analysis, we identified three primary themes. First, many Black TW see themselves as PrEP advocates and look out for other Black TW. Second, participants described a desire to support the broader Black trans community thrive. Finally, participants described the importance of supporting Black TW involved in sex work, including by supporting the use of PrEP. Data from this study show that, despite numerous health care and structural-level barriers, Black TW play a vital role in supporting PrEP use among other Black TW and supporting their communities. Our results highlight the promise of community-driven interventions among Black TW in supporting PrEP use.

Preliminary Outcomes from PrEP Well: A Community-led, Multicomponent HIV Prevention Strategy Implemented in a Transgender Community Health Center

Transgender and nonbinary (TGNB) individuals are disproportionately impacted by HIV, particularly those who identify as racial/ethnic minorities and those who are socioeconomically disadvantaged. Pre-exposure prophylaxis (PrEP) is a highly effective medication to prevent HIV infection, but many TGNB individuals encounter barriers to PrEP uptake and adherence that limit fully realized preventive benefits. We developed PrEP Well, a multicomponent community-led program, to scale and sustain comprehensive PrEP services from a TGNB-led community organization that provides gender-affirming healthcare and social services. We used implementation science frameworks to evaluate initial program outcomes and contextual influences on program implementation. Preliminary data from August 2022 through January 2024 showed promising implementation and effectiveness outcomes. During that time, 113 primarily low-resourced TGNB clients were educated about PrEP and received an HIV test, of whom 60 (53%) attended a visit with a provider and received a PrEP prescription. At 30-day follow-up, urinalysis confirmed uptake of PrEP among 50 (83%) of the clients prescribed PrEP. At 90-day follow-up, 43 (72%) demonstrated continued use of PrEP and 40 (67%) showed protective levels of PrEP adherence. Qualitative interviews and surveys indicated that clients, staff, and leadership viewed the PrEP Well program as highly acceptable, feasible, and sustainable (including willingness to address persistent implementation barriers). Referral patterns and rates of PrEP uptake suggested increasing integration of PrEP Well into the TGNB community center over time. The PrEP Well program demonstrates the potential for TGNB communities to address HIV inequities by integrating community-led HIV prevention services with gender-affirming healthcare in TGNB-specific health centers.

Disparities in United States Nationwide County-Level PrEP Rate and PrEP to Need Ratio During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic created numerous barriers to pre-exposure prophylaxis (PrEP) access in the United States (US). The present study aimed to understand changes in county-level PrEP use relative to the need for PrEP during the COVID-19 pandemic, particularly for racial minorities.

METHOD

Public county-level data from 2019 to 2022 were used. Linear mixed models with multiple imputations and adjusting for covariates were used to examine changes in PrEP rate and PrEP to need ratio (PNR) across time. We also assessed PNR and PrEP rate across time allowing for race and time interactions. Finally, we examined PNR and PrEP rate among age groups over time.

RESULTS

There was no difference in PrEP prevalence between 2019 and 2020 (p > 0.05). However, compared to 2019, PrEP prevalence was higher in 2021 and 2022 (p < .05). There was no change in PNR in 2020 or 2021 from 2019 (p > 0.05). Compared with 2019, PNR increased in 2022 (p < 0.05). Non-Hispanic Black population concentration did not predict the PrEP rate in 2020 or 2021 (p > 0.05), though it did predict a slight increase in PrEP prevalence in 2022 relative to 2019 (p < 0.05). Concentration non-Hispanic Black population did not predict PNR in any year (p > 0.05).

CONCLUSION

Although PrEP use began increasing from pre-pandemic levels by 2021, PNR increases did not occur until 2022. Increases in PNR did not occur in areas with greater concentrations non-Hispanic Black individuals, suggesting disparities worsened during the pandemic. Addressing racial disparities is key in responding to COVID-19 related disruptions to HIV prevention efforts.

Implementation Science Methods, Challenges, and Associated Solutions: Transportable Lessons Learned and Best Practices From the Second National Meeting for Research and Community Collaboration Toward Ending the HIV Epidemic in the United States

AIM

To share insights on Implementation Science (IS) methods, challenges, solutions, and best practices derived from the second National Meeting for Research and Community Collaboration toward "Ending the HIV Epidemic (EHE) in the United States."

METHODS

This 2022 hybrid, one-day conference featured presentations from 13 projects funded as NIH supplements to CFARs and ARCs between 2019 and 2022. Selected for their robust findings, projects were grouped into four topics: (1) community-based outreach strategies, (2) taking the clinic to the community, (3) strategies to improve clinical care, and (4) exploring intersectional vulnerabilities and social/structural determinants of health. Standardized presentation formats were used to ensure comparability in gathering insights on IS methodologies, challenges, solutions, and lessons learned. Structured breakout discussions advanced actionable recommendations. Rapid qualitative analysis summarized insights, emphasizing lessons transportability across diverse implementation contexts.

RESULTS

Common IS methods included rapid qualitative analysis, usability testing, surveys, engagement logs, mapping, and administrative data analysis. Recurring challenges were identified, including pandemic-related disruptions, staff turnover, recruitment barriers, communication gaps, and variations in organizational capacity. Effective solutions involved leveraging community partnerships, providing digital tools, conducting flexible training, and securing funding for sustainability. Best practices emphasized early partner engagement, iterative design, equitable power-sharing with communities, and culturally tailored approaches.

CONCLUSIONS

Collaborative engagement with community partners, clinicians, and participants was pivotal to adapting and scaling interventions. Synthesizing transferable methodologies and lessons strengthens the framework for advancing HIV-related IS and achieving sustainable impact in diverse contexts.

Not a Monolith: Regional HIV Implementation Science Lessons With Latino/a/x Populations

ABSTRACT

HIV incidence is increasing among Latino/a/x individuals in the United States, especially among young Latino/x gay, bisexual, and sexual minority men. Latino/a/x populations face heightened structural and social barriers to effective interventions for HIV prevention, including pre-exposure prophylaxis, and across the HIV care continuum. Implementation science provides a timely methodology for developing, testing, and scaling effective interventions into practice. Implementation science considers a specific population's priorities and environment, which is especially relevant given the diversity of Latino/a/x populations. In this article, we present lessons learned from our group's experiences leading HIV-related implementation research with various Latino/a/x populations in the United States and Puerto Rico. We highlight the importance of structural and social determinants of health, community-engaged research, and culturally tailored interventions to address HIV disparities. Implementation researchers and institutional leaders can leverage these lessons learned to drive the multilevel change needed to end the HIV epidemic among Latino/a/x populations.

Community Engagement to Empowerment: Emphasizing Relationships, Process, Resources, and Context to Strengthen Community Engagement in EHE Research Partnerships

BACKGROUND

Community-academic partnerships (C-APs) have been central to advancements in HIV research over the past 4 decades and were specifically called for in the national Ending the HIV Epidemic (EHE) initiative. Community engagement in research, particularly in HIV research, plays a critical role in prioritizing community needs in all stages of HIV research and intervention implementation.

METHODS

To address the known gaps in building strong C-APs, 2 EHE Implementation Science Consultation Hubs collaboratively facilitated 2 webinars with a panel of expert community leaders. The panel discussions explored (1) what researchers need to know to create equitable C-APs and (2) best practices for navigating power in C-APs. After the webinars, we conducted a quantitative analysis of the 131 EHE research projects partnered with community-based organizations or faith-based organizations between 2019 and 2023 to examine the community engagement in research relationships between EHE academic researchers and implementation partners.

RESULTS

Community panelists identified areas for academic researchers to prioritize, including building relationships with community partners, engaging equitably in partnership processes, sharing use of resources, and paying attention to community history. The quantitative analysis found 58% of EHE researchers are in new collaborations, lasting 2 years or less, with their implementation partner, and have not yet established robust partnerships.

CONCLUSIONS

This study identifies strategies for strengthening community engagement in HIV research and sustaining equitable C-APs for existing EHE supplement recipients that can be integrated into future EHE research and implementation strategies to help end the HIV epidemic in the United States.

Pre-Exposure Prophylaxis Awareness and Demand Creation: Overlooked Populations and Opportunities to Move Forward

BACKGROUND

Pre-exposure prophylaxis (PrEP) for HIV prevention has been available since 2012, but uptake remains disappointing and inequitable. Furthermore, there is little evidence on the effectiveness of interventions to increase PrEP demand among priority populations in the United States. The objectives of this article were to describe how consumer perceptions of PrEP vary by distinct population groups and identify gaps in PrEP awareness, knowledge, and interest.

METHODS

We synthesized evidence-based interventions to improve demand for PrEP in populations heavily burdened by HIV. The focus centered on consumer factors, how people's awareness of PrEP, especially people who are likely to benefit, influences PrEP uptake.

RESULTS

Awareness and equity in PrEP use among vulnerable populations in the United States remain low because of both demand-side obstacles and accessibility challenges. Designing an effective package of interventions to increase demand for PrEP involves integrating strategies that address awareness, knowledge, interest/motivation, and access.

CONCLUSIONS

The underutilization of PrEP among the 1.2 million individuals who could benefit from it highlights the need for effective demand creation to reduce disparities. To effectively increase awareness of the benefits of PrEP requires consideration of the characteristics of the target population and the structural inequalities that contribute to PrEP-related disparities. Demand creation activities can increase awareness, correct misconceptions, provide knowledge, and help people decide whether PrEP is a good fit for them. The utilization of implementation science frameworks is essential to address demand generation and supply-side barriers to PrEP use.

Leveraging Implementation Science to End the HIV Epidemic in the United States: Progress and Opportunities for Federal Agencies

ABSTRACT

Implementation science has emerged and matured as an essential field for HIV treatment and prevention, designed to bridge the gap between research and practice by identifying opportunities to overcome barriers to implementation of effective interventions, and to accelerate the replication and scale-up of HIV care innovations. In this article, we describe activities and collaborations among the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the National Institutes of Health to optimize the impact of national federal funding opportunities aimed at identifying effective and replicable HIV care and prevention interventions, improving HIV health outcomes, and reducing HIV incidence in the U.S. These activities are outlined in the context of the Ending the HIV Epidemic in the U.S. Initiative, which was enacted across U.S. Department of Health and Human Services agencies, providing new funding and outlining an operational plan to further guide federal agencies in their specific roles and funding areas.In describing these activities and opportunities, we aim to demonstrate how implementation science is being increasingly leveraged to accelerate progress towards ending HIV through scale-up and dissemination efforts. Continued collaboration through federal implementation science will be instrumental in reaching Ending the HIV Epidemic goals.

Two Pilots of an Implementation Science Training Program for HIV Prevention and Care Service Providers: Lessons Learned and Future Directions

BACKGROUND

Development, implementation, and dissemination of HIV-related implementation strategies require partnerships with affected communities, government agencies, and HIV service organizations. Implementation science (IS) training for partners is needed to ensure they can benefit from, and equally contribute to, implementation research (IR). Building IS knowledge and expertise in real-world practice increases providers' ability to offer evidence-based HIV interventions and effectively implement them at scale to achieve the goals of the national Ending the HIV Epidemic (EHE) initiative.

METHODS

National Institutes of Health funds the Implementation Science Coordination Initiative (ISCI) and the Sociostructural Implementation Science Coordination Initiative (SISCI) to support studies in the conduct of rigorous HIV IR through technical assistance, development of IS tools, and trainings for researchers and implementers. As part of these efforts, we created and evaluated 2 pilot IS training courses for HIV service providers: the Practitioner-Oriented Implementation Science Education (POISE) and the Implementation Practitioner Training (IPT). We discuss the importance of training for implementers, the development of our curriculum, lessons learned, and future directions for IS trainings.

CONCLUSIONS

Implementers play a critical role in IR, because they are the beneficiaries of the knowledge produced and are responsible for effectively implementing HIV interventions to achieve EHE goals. Few training courses in IS are specifically designed to meet the needs of those implementing HIV evidence-based interventions and little is known about how to design and deliver them to maximize training benefit. Both training pilots increased participants' ability to apply IS to their work. Participant input provides valuable feedback to improve future training.

Association Between County-Level Social Vulnerability and Centers for Disease Control and Prevention-Funded HIV Testing Program Outcomes in the United States, 2020-2022

BACKGROUND

Community-level social vulnerabilities may affect HIV outcomes. This analysis assessed the association between county-level social vulnerability and Centers for Disease Control and Prevention (CDC)-funded HIV testing program outcomes.

SETTING

HIV testing data from 60 state and local health departments and 119 community-based organizations were submitted to CDC during 2020-2022.

METHODS

HIV testing data were combined with the county-level Minority Health Social Vulnerability Index, which measures economic, medical, and social vulnerability. We calculated absolute and relative disparity measures for HIV testing program outcomes (ie, HIV positivity, linkage to HIV medical care, interview for partner services, referral to preexposure prophylaxis providers) between high and low social vulnerability counties. We compared differences in HIV testing program outcomes by demographic factors and test site type.

RESULTS

The majority (85.8%) of the 4.9 million tests were conducted in high social vulnerability counties. HIV positivity (1.1%) and linkage to medical care after a new diagnosis (77.5%) were higher in high social vulnerability counties. However, interview for partner services after a new diagnosis (72.1%) and referrals to preexposure prophylaxis providers among eligible HIV-negative persons (48.1%) were lower in high social vulnerability counties. Additionally, the relative disparity in HIV testing program outcomes varied by demographic factors and test site type.

CONCLUSIONS

CDC-funded HIV testing programs reach the most vulnerable communities. However, testing outcomes vary by community vulnerability, demographic factors, and test site type. Continued monitoring of the relationship between county-level social vulnerability and HIV testing program outcomes would guide HIV testing efforts and allocate resources effectively to achieve the national goal of ending the HIV epidemic.

Implementation Science Approaches to Addressing the Social and Structural Determinants of Health of Criminal-Legal Involved People Living With HIV to Improve HIV Care Outcomes

BACKGROUND

People living with HIV in the United States are overrepresented in the criminal-legal system and experience unique barriers to engagement in HIV care postincarceration. Individuals who are criminal-legal involved (CLI) experience worse HIV care outcomes compared to the general population. Interventions aiming to improve engagement and retention in HIV care for CLI populations are urgently needed. This study aims to highlight an array of NIH-funded research projects across the United States leveraging implementation science to investigate and design interventions aimed at addressing social determinants of health and improving HIV care outcomes among CLI populations in the United States.

SETTING

United States.

METHODS

In September 2023, the National Institutes of Health funded 47 new implementation research projects as part of the Ending the HIV Epidemic initiative, including 10 projects focused on addressing HIV among CLI populations. This paper highlights several projects that are addressing the social determinants of health affecting CLI populations living with HIV in the United States.

PROJECT OVERVIEW

The funded projects use innovative, community-engaged approaches to investigate and design interventions to address social determinants of health among CLI populations living with HIV including health care access, legal needs, social support, and holistic needs.

CONCLUSIONS

We believe these projects will substantially contribute to the evidence base to aid the development of guidelines and the implementation of programs that can be adopted and adapted by a wide range of settings working toward improving the health and wellness of CLI people living with HIV.

Generating Evidence for Effective HIV Implementation at Scale: The Value and Feasibility of a Network for Implementation Science in HIV

ABSTRACT

The Network for Implementation Science in HIV (NISH) was established to conduct multisite research to study real-world implementation of evidence-based HIV interventions across US contexts, and to generate generalizable knowledge around implementation strategies to support the achievement of Ending the HIV Epidemic goals. NISH sites represent diverse Ending the HIV Epidemic priority jurisdictions and include participation of multiple units within those sites (eg, multiple clinics and community-based organizations) and bring together research teams from multiple backgrounds within implementation science and the HIV service sector. We argue and provide examples of how NISH studies have and can contribute to the context versus generalizability debate, generate power in numbers, and synthesize, develop, and test implementation strategies that advance both effectiveness and equity. To date, the network has conducted observational studies exploring ongoing implementation and determinants across contexts, and the identification and codesign of strategies to be leveraged in future work. The next stage of network evolution is to leverage this infrastructure to test implementation strategies through nimble study designs built for fast-changing evidence and implementation environments. We argue that the initial successes of NISH warrant future investment to efficiently capitalize on developed infrastructure and optimize science that can effectively be scaled up to address our most critical questions to end the HIV epidemic and support communities most affected.

Strengthening the US Health Workforce to End the HIV Epidemic: Lessons Learned From 11 Ending the HIV Epidemic Jurisdictions

BACKGROUND

Supplements were awarded under the National Institutes of Health, ending the HIV epidemic (EHE) initiative to foster implementation science through community-engaged research. The objective of this study was to synthesize lessons learned, identify areas of research sufficiently studied, and present an agenda for future research on HIV health workforce development from a collaboration across 9 EHE projects in 11 jurisdictions in the United States.

METHODS

EHE supplement recipients completed a semistructured questionnaire to identify shared lessons learned about common themes of workforce development using the Consolidated Framework for Implementation Research and Expert Recommendation for Implementing Change frameworks. Data were synthesized to identify shared lessons learned, topic areas no longer in need of research, and next steps.

RESULTS

Project teams emphasized several strategies including clarifying roles and responsibilities, the need for dynamic training, and stigma mitigation as strategies to enhance the implementation of HIV prevention and treatment services. Strengthening organizational support through supportive supervision structures, ensuring sustainable funding, preventing turnover, addressing salary constraints, and establishing clear promotion and educational pathways were identified as useful workplace development strategies. Supplements identified lessons learned about deploying community engagement strategies to ensure communities were aware of HIV prevention and treatment services. Several areas sufficiently studied that can be deprioritized were identified and discussed.

CONCLUSION

A research agenda for workplace development moving forward is discussed with several recommendations to improve the implementation of HIV prevention and treatment programs.

The Strategies Timeline and Activities Reporting Tables: Improving HIV Care by Improving the Reporting of Implementation Strategies

BACKGROUND

The United States has made significant progress toward achieving the goals of its Ending the HIV Epidemic initiative. However, systematic reviews on HIV implementation research have identified problems regarding strategy specification that limit the research's transparency and replicability, and in turn limit improvements regarding HIV care in real-world practice.

METHODS

The strategies timeline, activities, and resources (STAResources) Table, developed as part of the substance abuse treatment to HIV Care II Project, was completed for it and 3 other HIV implementation research projects funded by the National Institute of Health. Each evaluated it in terms of the extent to which it addressed prior recommendations on strategy specification; issues related to rigor and reproducibility; and the extent to which it seemed pragmatic, simple, adaptable, relevant, helpful, useful, acceptable, appropriate, suitable, applicable, and fitting. Each was rated on a 4-point scale (0 = not at all; 1 = a little; 2 = moderately, and 3 = very much).

RESULTS

Overall, the STAResources Table was rated favorably. It received a mean of 3.0 (SD = 0) in terms of being pragmatic, relevant, helpful, acceptable, appropriate, and applicable. The Strategies Timeline, Activities, and Rationale (STARationale) Table emerged during the process and was also rated favorably.

CONCLUSIONS

To help the Ending the HIV Epidemic initiative achieve its goals, there is a critical need for transparent and replicable implementation research on identifying the most effective strategies for equitably implementing evidence-based practices within real-world settings. Addressing this need, the Strategies Timeline and Activities Reporting (STAReporting)Tables are pragmatic tools for helping improve the transparency and replicability of implementation strategy research.

Impact of Disclosing to Patients the Use of Antiretroviral Resistance Testing Results for Molecular HIV Surveillance: A Randomized Experiment in 2 National Surveys

Background

Molecular HIV surveillance (MHS) can be used to help identify and respond to emerging clusters of rapidly spreading HIV transmissions, a practice known as cluster detection and response (CDR). In the United States, MHS relies on HIV gene sequences obtained from routine clinical antiretroviral resistance testing (ARVRT). By law, ARVRT results are reported to public health agencies for MHS and individuals are not asked for their specific consent to do so. This practice has raised ethical concerns, including the lack of consent for, and transparency surrounding, public health uses of these clinical data. Such concerns have spurred debate and could have a chilling effect on the willingness of people living with HIV to agree to ARVRT when recommended clinically and jeopardize the utility of MHS-informed HIV prevention efforts. In response to the lack of routine disclosure of use of ARVRT results for MHS, in 2022, the Presidential Advisory Council on HIV/AIDS (PACHA) issued a resolution calling on the US Centers for Disease Control to "require that providers explain MHS/CDR and the laboratory test results that are collected and used in these surveillance activities to their patients."

Objective

This study aimed to examine the effect of clinician disclosure of the public health uses of ARVRT results for MHS versus clinician nondisclosure on patient willingness to undergo recommended ARVRT.

Methods

We conducted a randomized survey experiment examining the effect of clinician disclosure of the public health uses of ARVRT results for MHS versus clinician nondisclosure (the current standard of care) and subsequent discovery of such uses through a "trusted media source" on patient willingness to undergo recommended ARVRT. Study participants were respondents to 1 of 2 national web-based surveys conducted annually in the United States: the American Men's Internet Survey (AMIS) and the Transgender Women's Internet Survey and Testing (TWIST).

Results

Overall, 4348 AMIS participants (n=2151 disclosure; n=2197 nondisclosure) and 3314 TWIST participants (n=1670 disclosure; n=1644 nondisclosure) completed survey items regarding the randomly assigned vignettes. The majority were willing to undergo ARVRT regardless of which vignette they saw (1670/2151, 82.7% [AMIS] and 1326/1670, 80.8% [TWIST] in the disclosure group; and 1399/2197, 68% [AMIS] and 1101/1674, 68.45% [TWIST] in the nondisclosure group) after later learning about public health uses of ARVRT results.

Conclusions

The majority of respondents expressed willingness to undergo ARVRT even with disclosure of public health uses of these data, but willingness markedly decreased when learning about these uses after the fact, highlighting the importance of transparency in MHS programs. Accordingly, in line with the ethical principle of respect for autonomy and the likelihood that the potential public health benefits of MHS programs will not be compromised, consideration should be given to encouraging clinicians to disclose public health uses of ARVRT at the time ARVRT is recommended.

State AIDS Drug Assistance Programs' Contribution to the United States' Viral Suppression, 2015-2022

Background

State AIDS Drug Assistance Programs (ADAPs) provide HIV medication access for people with HIV (PWH) with low incomes in the United States (US). We quantified the proportion of viral suppression (VS) that is from ADAP clients for 2015-2022.

Methods

For 2015-2022, we obtained viral load (VL) test results and VS data from publicly available, jurisdiction-level data on ADAP clients and PWH. We report descriptive statistics including the proportion of PWH with a VL who had VS and were supported by ADAPs.

Results

After excluding jurisdictions with missing data, PWH who were included in the analysis for each year was 63.7-96.4%. VS for PWH each year was 60-66.3%. VS for ADAP clients was 81.2%-91.4%. In all years, compared to all PWH, a lower proportion of ADAP clients had a reported VL and a higher proportion had VS. Over 2015-2022, the average proportion of PWH who were ADAP clients was 23.1%, the proportion of PWH with VLs who were ADAP clients was 22.2%, and the proportion of PWH with VS who were ADAP clients was 30.8%.

Conclusions

Almost a third of the entire VS rate was from ADAP clients, despite ADAP serving less than 25% of PWH. A much higher proportion of ADAP clients achieved VS, compared to PWH. ADAPs' impact is not due to ADAP clients being over represented among PWH with reported VLs. ADAP does not directly receive any federal Ending the HIV Epidemic (EHE) Initiative funding. Policymakers should examine how ADAPs can support the EHE Initiative.

A Remote Intervention Based on mHealth and Community Health Workers for Antiretroviral Therapy Adherence in People With HIV: Pilot Randomized Controlled Trial

BACKGROUND

Despite the availability of antiretroviral therapy (ART), only 66% of people with HIV in the United States achieve viral suppression, largely due to suboptimal ART adherence. Barriers such as limited access to care and forgetfulness impact adherence rates, which must be maintained at ≥95% to prevent viral load rebound. Combination interventions leveraging community health worker (CHW) support and mobile health (mHealth) technologies have the potential to overcome previously identified barriers and provide cost-effective support for improving adherence and viral suppression outcomes in people with HIV.

OBJECTIVE

This pilot study aimed to evaluate the feasibility, acceptability, and preliminary efficacy of remote delivery of the Community Health Worker and mHealth to Improve Viral Suppression (CHAMPS) intervention, combining the WiseApp, CHW support, and the CleverCap smart pill bottle. A secondary aim was to gather participants' feedback on the usability of the app and pill bottle as well as to better understand their experiences with remote study procedures.

METHODS

This mixed methods pilot study involved 40 participants with HIV, who were randomly assigned to a control group (n=20, 50%) or the CHAMPS intervention (n=20, 50%) over 3 months. The intervention group participated in up to 12 sessions with CHWs and used the WiseApp, paired with a CleverCap smart pill bottle, to support ART adherence. Remote baseline and follow-up visits were conducted via Zoom and included surveys measuring adherence, self-efficacy, and usability (measured by Health Information Technology Usability Evaluation Scale [Health-ITUES] and Poststudy System Usability Questionnaire [PSSUQ]). Semistructured interviews explored participants' experiences with the intervention. Thematic analysis was used to identify key facilitators and barriers based on the Mobile Health Technology Acceptance Model.

RESULTS

Remote delivery of the CHAMPS intervention was feasible, with high usability ratings for both the WiseApp and CleverCap (overall scores on Health-ITUES: mean 4.35, SD 0.58 and PSSUQ: mean 2.04, SD 1.03). In the intervention group, there were nonsignificant improvements in self-reported adherence scores (P=.29) and in self-efficacy scores (P=.07). The adjusted odds ratio for achieving undetectable viral load in the intervention group compared to the control group was 3.01 (95% CI -1.59 to 4.12), indicating a medium effect size in favor of the intervention. Overall study retention was 75% (30/40), with higher retention in the control group. Participants valued the flexibility of remote study procedures, particularly Zoom-based study visits and mailed blood sample kits. Qualitative feedback highlighted the intervention's acceptability and ability to overcome logistical barriers.

CONCLUSIONS

The remote CHAMPS pilot study demonstrated the feasibility and acceptability of combining mHealth tools with CHW support to promote medication adherence among people with HIV. While further optimization is needed to enhance its impact, this intervention shows potential for improving health outcomes in diverse underserved populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05938413; https://clinicaltrials.gov/study/NCT05938413.

Agreements and Disagreements Between Professionals and Users About the Experience of a Telehealth Service for HIV Pre-Exposure Prophylaxis (TelePrEP): Qualitative Interview Study

BACKGROUND

Men who have sex with men have a disproportionately high prevalence of HIV worldwide. In Brazil, men who have sex with men account for over 15% of HIV cases, substantially higher than the general population prevalence of 0.6%. Pre-exposure prophylaxis (PrEP) is a critical biomedical strategy for reducing HIV transmission, yet adherence remains challenging due to stigma, logistical barriers, and the need for regular clinical follow-ups. TelePrEP, a telehealth-based approach to PrEP follow-up, has emerged as a potential solution to improve accessibility and reduce stigma. However, the perspectives of users and health care providers on this intervention remain understudied in low- and middle-income countries, such as Brazil.

OBJECTIVE

This study aims to examine the experiences and perceptions of users and health care professionals regarding TelePrEP, an asynchronous remote consultation model, in 5 PrEP services across 3 Brazilian regions (southeast, south, and northeast).

METHODS

We conducted 19 in-depth interviews with PrEP users (aged between 23 and 58 years) and 6 interviews with health care professionals (aged between 35 and 61 years). Users were recruited from 5 public health care services, including outpatient HIV clinics and testing centers. The interviews explored motivations for PrEP use, experiences with in-person and remote consultations, perceived advantages and disadvantages of TelePrEP, and overall satisfaction. Thematic analysis was conducted using NVivo software.

RESULTS

Users reported greater convenience, increased autonomy, and reduced stigma, highlighting that the remote consultations eliminated the discomfort of discussing personal topics in person and minimized the need for frequent visits to health care facilities. Many felt that TelePrEP simplified HIV prevention, normalized PrEP use, and contributed to more sustainable adherence while also expressing confidence that periodic laboratory testing was sufficient for monitoring their health. Conversely, health care professionals raised concerns about the loss of personal connection with users, which they perceived as essential for detecting health issues and ensuring PrEP adherence. They also noted that TelePrEP could hinder the identification of sexually transmitted infections due to the absence of direct clinical assessments, and some questioned whether TelePrEP compromised the quality of care, fearing that users might delay reporting symptoms or other health concerns.

CONCLUSIONS

To effectively address the needs of both groups, the successful implementation of telehealth PrEP services must consider these differing perceptions. Further research is essential to explore implementation in diverse settings and enhance the training of health care professionals to address the specific requirements of PrEP care.

HIV Testing Pre- and Post-COVID-19 Pandemic Among Persons who Inject Drugs - National HIV Behavioral Surveillance, 19 Cities, 2018 and 2022

HIV testing decreased during the COVID-19 pandemic among persons who inject drugs (PWID), though it is unclear how these changes in HIV testing affected different sub-groups of PWID. We estimated the change in past-year HIV testing between 2018 and 2022 overall and by sociodemographic and health care characteristics among PWID. Past-year HIV testing significantly decreased between 2018 and 2022 overall and across most sub-groups of PWID, including PWID accessing and not accessing medical and harm reduction services. Integrating HIV testing across medical and harm reduction services accessed by PWID and expanding community-based HIV testing might increase HIV testing among PWID.

Factors Associated with the Awareness of and Willingness to Use HIV Pre-exposure Prophylaxis Among Gay, Bisexual, and Other Men Who Have Sex with Men, Baltimore, MD, 2017-2019

Pre-exposure prophylaxis (PrEP) is an effective tool in protecting persons from acquiring HIV infection through sex or injection drug use. However, awareness and willingness to use PrEP among Black gay, bisexual, and other men who have sex with men (BMSM) remain suboptimal compared to White MSM (WMSM) in the United States. Our aims were to (1) assess the factors associated with PrEP awareness and willingness to use PrEP among MSM and (2) compare the PrEP perceptions among BMSM versus non-Black MSM. Data were drawn from two cross-sectional behavioral surveys in Baltimore, MD: Behavioral Surveillance Research (BESURE) conducted in 2017, and Safe Spaces 4 Sexual Health (SS4SH), conducted in 2018 and 2019. Descriptive statistics were used to summarize the study population. We used Poisson regression models to identify variables associated with awareness of PrEP and willingness to use PrEP. PrEP perceptions were assessed via 13 items scored on a 5-point Likert scale. Finally, we conducted a post-hoc exploratory bivariate analysis of the relationship between PrEP perception and willingness to use PrEP, stratified by race/ethnicity. A total of 261 MSM participated in this study. Many of the participants were aware of PrEP (75.1%). Factors associated with greater PrEP awareness included having greater than a high school education (aRR 1.22, 95% CI 1.04, 1.43); and earning more than $25,000 annually (aRR 1.24, 95% CI 1.08, 1.42). Participants who had received money in exchange for sex one or more times were less likely to be aware of PrEP (aRR 0.59, 95% CI 0.36, 0.95). More than half of the participants were willing to use PrEP (55.3%). In bivariate and multivariable analyses, demographic or behavioral characteristics were not significantly associated with willingness to use PrEP. Higher agreement with the following statements was associated with lower willingness to use PrEP: "Having to take a pill every day is difficult" (RR 0.89, 95% CI 0.82-0.97) and, "I am concerned about the side effects of PrEP" (RR 0.89, 95% CI 0.82-0.96), and "PrEP is for people who have riskier sex lives than I do" (RR 0.86, 95% CI 0.78-0.95). Conversely, higher willingness to use PrEP was associated with comfortable having sex without a condom (RR 1.11, 95% CI 1.02-1.21), less anxious about sex (RR 1.12, 95% CI 1.02-1.24), and my friends think that I should take PrEP (RR 1.19, 95% CI 1.07-1.32). We found BMSM compared to non-Black MSM had higher mean scores related to taking a daily pill (p = 0.041), concerns about side effects (p = 0.012), concerns about people thinking they had HIV (p = 0.001), concerns about the financial costs of PrEP (p = 0.038) and caution when dealing with healthcare organizations/medical mistrust (p = 0.019). Perceptions with a statistically significant lower score among BMSM versus non-Black MSM included statements such as, comfortable having sex without a condom (p = 0.003) and less anxious about sex (p < 0.001). We conclude HIV prevention strategies, programs, and interventions should be cognizant of PrEP perceptions that facilitate or hinder PrEP uptake in Baltimore City, MD.

Ending the HIV Epidemic in Black America: Qualitative Insights Following COVID-19

BACKGROUND

The disproportionate effects of the human immunodeficiency virus (HIV) and the Coronavirus 2019 (COVID-19) on Black American communities highlight structural systems rooted in racism and must be addressed with national strategies that improve both biomedicine and social determinants of health.

PURPOSE

The purpose of this study was to qualitatively examine the experiences and interpretations of experts in the HIV workforce (local, state, and national HIV-related organizations) regarding the state of HIV and COVID-19 among Black Americans.

METHODS

Within key informant interviews and a focus group recorded and transcribed verbatim, fifteen members of the HIV workforce and Black community described their experiences and provided insights to inform ending the negative outcomes resulting from HIV and COVID-19.

RESULTS

Data were analyzed using NVivo software, and eight themes emerged to address disease disproportionality through a Black lens. Themes reflected (1) accessing information and care; (2) key potential partners/stakeholders; (3) investing in Black communities; (4) governmental support; (5) increasing engagement and advocacy; (6) HIV-related community conversations; (7) developments since COVID-19; and (8) the Ending the HIV Epidemic (EHE) trajectory.

CONCLUSIONS

Themes directly speak to recommendations to adjust education and policy strategies for HIV and COVID-19 prevention and intervention. Such recommendations, (1) amplifying Black voices, (2) investing sustainable dollars into Black communities, and (3) leaning into advocacy, can bolster the foundation for the HIV workforce and Black community to break ineffective response patterns and lead the fight against these systemic issues of inequity.

Pilot Findings From the First Legalized Mobile Retail Pharmacy Clinic in the United States for Infectious Disease Treatment and Prevention Tailored to Reach People Who Use Drugs

Background

Mobile retail pharmacies were legalized in Connecticut in 2023 to provide primary care, human immunodeficiency virus (HIV) and hepatitis C virus (HCV) testing, preexposure prophylaxis (PrEP), immediate HIV antiretroviral therapy (ART), and medications for substance use disorders directly to people who use drugs (PWUD).

Methods

InMOTION mobile pharmacy and clinic (MPC) pilot findings describe services provided by pharmacists, clinicians, and community health workers.

Results

From 13 December 2023 through 5 November 2024, the MPC engaged with 414 participants, of whom 43% were female, 26% Black/African American, 32% uninsured, and 37% unhoused or unstably housed. Fifty-one had a previous diagnosis of an opioid use disorder (OUD), 163 accepted screening, 1 received a new diagnosis of moderate to severe OUD, and 37 received medication for OUD. Nine participants requested sexually transmitted infection testing; 3 people had positive results, all were prescribed treatment, and 1 received doxycycline postexposure prophylaxis. Four people had existing HIV diagnoses; 166 accepted rapid point-of-care (POC) testing, resulting in 1 positive test; all received ART (2 oral, 3 injectable); 9 who tested HIV negative accepted PrEP, and 1 accepted the injectable formulation. Twenty-two had known HCV, 157 accepted rapid POC HCV testing, 9 tested positive for HCV antibodies, and 11 underwent HCV viral load (VL) testing; 1 self-cleared, and 8 of 10 with detectable HCV VL received direct-acting antivirals from the MPC. Six were treated for xylazine-related wounds.

Conclusions

Health services delivered through an MPC demonstrate the potential to address healthcare gaps for PWUD and warrant exploration and expansion.

Molecular HIV Surveillance: Beyond Cluster Detection and Response

There has been significant controversy surrounding the use of HIV sequence data to identify outbreaks of HIV transmission since the initiation of molecular HIV surveillance (MHS) in the US. The current approach to MHS is comprehensive cluster detection and response (CDR), in which clusters of related infections are identified and used as the basis for cluster-based or population-based interventions. With CDR, there are ethical and stigma concerns around the impingement of individual privacy, as well as legal concerns around the inference of transmission in regions where HIV criminalization laws and statutes exist. Here we propose an alternative approach to the analysis of HIV sequence and public health data that focuses on regions and populations rather than clusters, and still provides useful data for public health agencies.

Physician Attitudes Towards Pharmacist-Prescribed HIV Post-Exposure Prophylaxis (PEP): A Survey of a State Medical Association

Timely initiation of antiretroviral therapy (ART) for non-occupational post-exposure prophylaxis (nPEP) is crucial in preventing HIV infection and advancing efforts to end the HIV epidemic (EHE). nPEP must be administered within 72 h of high-risk exposure, ideally within 24 h. Pharmacies may play a role in increasing access to nPEP and facilitating referrals for additional care, such as PrEP. Recent legislation permits pharmacist-prescribed nPEP (PDP), though provider attitudes toward this change have not been studied. A survey querying physicians and medical trainees (students and residents) was conducted in 2024 during an annual state medical association conference. The survey included 24 questions on nPEP knowledge and attitudes towards pharmacist-prescribed nPEP (PDP). The survey was administered in person using electronic tablets, with voluntary participation incentivized by a monetary reward. Statistical analysis was conducted using SAS (9.4 version) software, with differences in responses between physicians and trainees evaluated. P values < 0.05 were considered statistically significant. Of 89 respondents (56% of attendees), 61 were physicians and 28 were trainees. Notably, 28% of licensed providers indicated that pharmacist-directed prescribing (PDP) should not be allowed in the State of Ohio, while no trainees expressed this same opposition (p = 0.001). Trainees were more likely to view pharmacist prescribing as safe and appropriate ((p = 0.0135, p = 0.013). Urban-based providers were more supportive of pharmacist prescribing than their rural counterparts (p = 0.0195). Trainees showed little opposition to PDP, whereas physicians expressed concerns about safety and appropriateness. Addressing these concerns is essential for integrating pharmacists into the EHE strategy.

HIV Prevention and Sexual Health Conversations Among Women in Ending the HIV Epidemic Priority Communities: A Qualitative Exploration of Experiences and Preferences

Despite significant advances in HIV prevention, women comprise ~ 20% of new HIV infections in the USA. New infections occur primarily in the South and among Black women, with research demonstrating that insufficient knowledge, inaccurate risk assessment, and HIV stigma impair HIV prevention. Understanding how cisgender women wish to communicate about sexual health and HIV prevention is vital to facilitating conversations about, and subsequent uptake of prevention methods. A total of 70 individuals who lived or worked in four HIV prevention priority counties in the state of Georgia were recruited through community-based organizations (CBOs) and flyers. Consenting participants completed 30-45-min interviews. Interviews were transcribed verbatim; transcripts were coded deductively and inductively. Participants were primarily female-identifying (91%) and were primarily Black. Overall, participants noted that community-level conversations about sexual health among women were limited due to stigma, despite endorsed comfort with conversations. Participants noted that media/community sources implied HIV prevention was unneeded for cisgender women. CBOs and informed community members were endorsed as trusted sources for information; clinicians were cited as a theoretically trusted source, particularly sexual health preventative care providers with established patient relationships, though barriers of medical mistrust, lack of cultural concordance, and stigma were noted. Suggestions for improved communication around HIV prevention included use of community members/trusted sources to facilitate conversation, promotion of non-judgment in clinical practice, and prevention awareness building. Participants' responses suggest little-to-no movement in knowledge of HIV prevention for US women. Engagement of CBOs in community education, training of community leaders, and integration of trauma-informed and patient-empowering clinical practices should be explored to promote increased HIV prevention discussion and uptake among cisgender women in the US South.

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

Background

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

Methods

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

Discussion

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

Registration

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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