Healthy Choices Intervention is Associated with Reductions in Stigma Among Youth Living with HIV in the United States (ATN 129)

Stigmas experienced by sexual and gender minority people with HIV in the Dominican Republic: a qualitative study

BACKGROUND

As part of a study to test the feasibility and acceptability of the Finding Respect and Ending Stigma around HIV (FRESH) intervention to reduce stigmas and improve HIV viral suppression, our team collected qualitative data from men who have sex with men (MSM) with HIV, transgender women with HIV, and HIV healthcare providers for their perspectives on different stigmas in Dominican Republic healthcare settings.

PURPOSE

We aimed to develop an understanding of the causes, consequences, and domains of stigma among sexual and gender minorities with HIV in Dominican Republic HIV clinics.

METHODS

Data collection occurred in Santo Domingo and Santiago (2020-2021) and included four focus groups with MSM with HIV (n = 26), in-depth interviews with transgender women with HIV (n = 14), and in-depth interviews with HIV healthcare providers (n = 16). All data collection occurred in person and was audio recorded. Standardized guides were used for focus groups and in-depth interviews. Using a deductive process, 2 research associates thematically coded data in the NVivo software.

RESULTS

On average, focus groups were 81 minutes, provider in-depth interviews were 24 minutes, and transgender women in-depth interviews were 32 minutes. We identified 4 key themes that mapped to 4 domains of stigma affecting MSM and transgender women with HIV: migrant stigma, religious stigma, sexual and gender minorities (SGM) stigma, and HIV stigma. All participant types noted the persistence of stigma and discrimination in healthcare settings in the Dominican Republic. The consequences of these stigmas were reported as being significant, including attempted suicide.

CONCLUSIONS

Interventions to reduce stigma experienced by SGM populations with HIV should address structural barriers, including inner and outer contexts of HIV care provision and cultural norms and values that propagate stigma. Findings offer insights about which stigmas could be targeted in future studies and how to potentially address stigma to improve population health in the Dominican Republic.

The Young Adult Centered Healthforce Training (YACHT) Program to Increase HIV Testing and Pre-Exposure Prophylaxis Referrals Among Young Sexual Minority Men in Florida: Protocol for a Type 2 Implementation-Effectiveness Hybrid Trial With a Stepped Wedge Design

BACKGROUND

There is a high incidence of HIV among young sexual minority men in Florida. Many are unaware of their status due to low testing rates. Counseling, testing, and referral (CTR) services are essential for diagnosis and prevention of HIV and are integral to the Ending the HIV Epidemic (EHE) strategic plan. However, efforts to increase CTR among young sexual minority men have not been successful.

OBJECTIVE

The Young Adult Centered Healthforce Training (YACHT) program promotes developmentally sensitive, culturally appropriate, and evidence-based CTR services for young sexual minority men. This study tests whether the YACHT program increases HIV testing among young sexual minority men and fidelity to evidence-based CTR among testing providers.

METHODS

Agencies in Florida EHE counties that tested at least 24 young sexual minority men aged 18 to 29 years in 2021 will be invited to participate. The sites (N=42) will be randomized in blocks of 6 to participate in the YACHT program, following a stepped wedge design. Through YACHT, all sites will receive visits from mystery shoppers (MSs), who are trained to evaluate HIV testing services and complete postvisit quality monitoring assessments. Sites will be offered the opportunity to review their MS feedback and to receive tailored motivational interviewing training and evidence-based technical assistance to address areas of need identified through MS assessments. The study will evaluate whether YACHT leads to increased HIV testing by comparing numbers of young sexual minority men testing for HIV before versus after YACHT's implementation. The Exploration, Preparation, Implementation and Sustainment framework will help understand the barriers to and facilitators of the program's implementation and sustainment.

RESULTS

YACHT was funded in August 2022. Data collection began in June 2023. As of June 2024, 194 MS visits have taken place at 42 sites; 4 (67%) sites from the first block and 1 (33%) site from the second block have engaged with the study. At baseline, sites exhibited the lowest competencies in relationship context, counseling sessions, and safer sex education and the highest competency in privacy and confidentiality. Data collection will continue through May 2027, with results published by the end of 2027.

CONCLUSIONS

To address the high incidence of HIV among young sexual minority men in Florida, YACHT aims to support testing sites with tailored motivational interviewing training and technical assistance to address needs identified by MS assessments. The program seeks to improve delivery of evidence-based CTR services, thereby increasing HIV testing, counseling, and pre-exposure prophylaxis referrals and reducing HIV incidence among this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06015581; https://classic.clinicaltrials.gov/ct2/show/NCT06015581.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63191.

Interventions for Improving HIV Care Continuum Outcomes Among LGBTQ+ Youth in the United States: A Narrative Review

Lesbian, gay, bisexual, transgender, queer, and all sexually and gender diverse (LGBTQ+) youth with HIV face multiple barriers to progression along the HIV care continuum. We searched PubMed, PsycInfo, clinicaltrials.gov, and the Adolescent Medicine Trials Network for HIV/AIDS Interventions for interventions focused on improving linkage to care, retention in care, adherence to antiretroviral therapy, or viral suppression (VS) among LGBTQ+ youth with HIV in the United States. Included studies were published in English between January 1, 2017 and December 31, 2022, took place in the United States, and had samples with a minimum age of 12 years, a median or mean age of 24 years or less, and with ≥50% reporting an LGBTQ+ identity. Our search identified 11 interventions that met our criteria, of which only three were designed and tailored exclusively for LGBTQ+ populations. Interventions used a variety of modalities, including remote electronic delivery, in-person delivery, or both. Interventions most commonly aimed to enhance self-efficacy, HIV health knowledge, and medication self-management to facilitate improvements in HIV care continuum outcomes. Only two interventions showed statistically significant improvements in VS. More interventions tailored for LGBTQ+ youth are needed to end the HIV epidemic in the United States.

Prevalence and Correlates of Intimate Partner Violence Victimization Among Urban Adolescents and Young Adults Living With Perinatally-Acquired HIV Infection or Perinatal HIV Exposure

INTRODUCTION

Because of privacy and ethical concerns, the data cannot be made available because of the sensitivity of the HIV data and the relatively small sample and ease of identifying people if a few demographics are known.Few studies have examined intimate partner violence (IPV) victimization among adolescents and young adults (AYAs) with perinatally acquired HIV-infection (PHIV) or perinatal HIV exposure without infection (PHEU) in the United States. The purpose of this study was to (1) estimate lifetime and past-year prevalence of IPV victimization and (2) examine correlates of IPV victimization by subtype (physical, psychological, and sexual) and severity (low, moderate, and severe).

METHODS

Data came from the sixth interview of an ongoing New York City-based longitudinal study of primarily Black and Latinx AYAPHIV and AYAPHEU. We examined 232 participants (142 PHIV; 90 PHEU) who had reported having been in at least 1 romantic relationship. We used logistic regression models to explore the association between IPV victimization outcomes and select sociodemographic, psychiatric, and environmental factors. Models were adjusted for age, gender, race, ethnicity, and HIV status.

RESULTS

IPV victimization prevalence was 84% for lifetime and 65% for the past year. There were no differences in IPV victimization prevalence by PHIV status. Having a recent substance use disorder, reporting higher levels of neighborhood stress, and being male were all positively associated with at least 1 IPV outcome; stronger familial relationships exhibited a protective effect.

CONCLUSIONS

The present study suggests that the prevalence of IPV victimization among AYAPHIV and AYAPHEU is exceedingly high that warrants targeted IPV screening and programming for this population.

Viral load and sexually transmitted infection testing among youth with HIV in a southern United States clinic

Background: As compared to their older peers, youth with HIV (YWH) are less likely to attain viral suppression and have higher rates of sexually transmitted infections (STI). In this exploratory study, we examine the relationship between HIV viral suppression, STI testing, and STI diagnosis among YWH receiving care at a clinic in the southern United States.Methods: Data from 933 clinical visits (2017-2020) were aggregated into singular patient records for YWH aged 10-24 years in Alabama (N = 139). Analyses included univariate generalized linear mixed models performed with the PROC GLIMMIX procedure approximating the marginal likelihood by using Laplace's method.Results: Sample median age was 22 years at the index visit. Most YWH were 20-24 years old (69.1%), male (67.6%), and identified as Black (77%); 58.3% were virally unsuppressed at index visit. YWH who identified as White or of other races had 4.79 times higher odds of being virally suppressed as compared to Black YWH (p < .01); STI testing behavior and STI positive diagnosis were associated with lower odds of being virally suppression.Conclusions: Findings suggest that among YWH, receiving STI testing and having an STI diagnosis is associated with a lack of viral suppression, suggesting that extra efforts may be necessary to support YWH who have an STI to attain suppression. Research is needed to examine individual behaviors, structural forces, and clinic features that could impact STI care engagement, specifically among unsuppressed YWH.

Cardiovascular Risk Assessment Among Adolescents and Youths Living With HIV: Evaluation of Electronic Health Record Findings and Implications

BACKGROUND

The HIV epidemic remains a major public health concern, particularly among youths living with HIV. While the availability of antiretroviral therapy has significantly improved the health outcomes of people living with HIV, there is growing evidence that youths living with HIV may be at increased risk of cardiovascular disease. However, the underlying mechanisms linking HIV and cardiovascular disease among youths living with HIV remain poorly understood. One potential explanation is that HIV-related biomarkers, including detectable viral load (VL) and low cluster of differentiation 4 (CD4) lymphocyte counts, may contribute to increased cardiovascular risk. Despite the potential importance of these biomarkers, the relationship between HIV-related biomarkers and cardiovascular risk among youths living with HIV has been understudied.

OBJECTIVE

To address this gap, we examined whether detectable VL and low CD4 lymphocyte counts, both of which are indications of unsuppressed HIV, were associated with cardiovascular risk among youths living with HIV.

METHODS

We analyzed electronic health record data from 7 adolescent HIV clinics in the United States (813 youths living with HIV). We used multivariable linear regression to examine the relationship between detectable VL and CD4 lymphocyte counts of ≤200 and cardiovascular risk scores, which were adapted from the gender-specific Framingham algorithm.

RESULTS

In our study, nearly half of the participants (366/766, 47.8%) had detectable VL, indicating unsuppressed HIV, while 8.6% (51/593) of them had CD4 lymphocyte counts of ≤200, suggesting weakened immune function. We found that those with CD4 lymphocyte counts of ≤200 had significantly higher cardiovascular risk, as assessed by Cardiac Risk Score2, than those with CD4 lymphocyte counts of >200 (P=.002). After adjusting for demographic and clinical factors, we found that for every 1000-point increase in VL copies/mL, the probability of having cardiovascular risk (Cardiac Risk Score2) increased by 38%. When measuring the strength of this connection, we observed a minor effect of VL on increased cardiovascular risk (β=.134, SE 0.014; P=.006). We obtained similar results with Cardiac Risk Score1, but the effect of CD4 lymphocyte counts of ≤200 was no longer significant. Overall, our findings suggest that detectable VL is associated with increased cardiovascular risk among youths living with HIV, and that CD4 lymphocyte counts may play a role in this relationship as well.

CONCLUSIONS

Our study highlights a significant association between unsuppressed HIV, indicated by detectable VL, and increased cardiovascular risk in youths living with HIV. These findings emphasize the importance of implementing interventions that address both VL suppression and cardiovascular risk reduction in this population. By tailoring interventions to meet the unique needs of youths, we can promote overall well-being throughout the HIV care continuum and across the life span. Ultimately, these efforts have the potential to improve the health outcomes and quality of life of youths living with HIV.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11185.

Examining Recruitment Strategies in the Enrollment Cascade of Youth Living With HIV: Descriptive Findings From a Nationwide Web-Based Adherence Protocol

BACKGROUND

Digital strategies and broadened eligibility criteria may optimize the enrollment of youth living with HIV in mobile health adaptive interventions. Prior research suggests that digital recruitment strategies are more efficient than traditional methods for overcoming enrollment challenges of youth living with HIV in the United States.

OBJECTIVE

This study highlights the challenges and strategies that explain screening and enrollment milestones in a national web-based adherence protocol for youth living with HIV.

METHODS

Baseline data from a national web-based HIV adherence protocol for youth living with HIV, collected from July 2018 to February 2021, were analyzed. A centralized recruitment procedure was developed, which used web-based recruitment via Online Master Screener; paid targeted advertisements on social media platforms (eg, Facebook and Reddit) and geosocial networking dating apps (eg, Grindr and Jack'd); and site and provider referrals from Subject Recruitment Venues and other AIDS service organizations, website referrals, and text-in recruitment.

RESULTS

A total of 3 distinct cohorts of youth living with HIV were identified, marked by changes in recruitment strategies. Overall, 3270 individuals consented to screening, 2721 completed screening, 581 were eligible, and 83 completed enrollment. We examined sociodemographic and behavioral differences in completing milestones from eligibility to full enrollment (ie, submitting antiretroviral therapy and viral load data and completing the baseline web-based survey). Those with the most recent viral load tests >6 months ago were half as likely to enroll (odds ratio 0.45, 95% CI 0.21-0.94). Moreover, eligible participants with self-reported antiretroviral therapy adherence (SRA) between 50% and 80% were statistically significant (P<.001 to P=.03) and more likely to enroll than those with SRA >80%.

CONCLUSIONS

The findings add to our knowledge on the use of digital technologies for youth living with HIV before and during the COVID-19 pandemic and provide insight into the impact of expanding eligibility criteria on enrollment. As the COVID-19 pandemic continues and the use of and engagement with social media and dating apps among youth living with HIV changes, these platforms should continue to be investigated as potential recruitment tools. Using a wide variety of recruitment strategies such as using social media and dating apps as well as provider referral mechanisms, increasing compensation amounts, and including SRA in enrollment criteria should continue to be studied with respect to their ability to successfully recruit and enroll eligible participants.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11183.

Development and Validation of the Youth Pre-Exposure Prophylaxis (PrEP) Stigma Scale

To date, there are no established scales to assess PrEP stigma among youth. We validated the Youth PrEP Stigma Scale within the Adolescent Trials Network P3 study (2019-2021). Data from sexual and gender minority youth (16-24 years) who were prescribed PrEP across nine domestic sites were evaluated (N = 235). Descriptive statistics, exploratory factor analysis, and correlation coefficients are reported. Results yielded a three-factor solution (PrEP Disapproval by Others, Enacted PrEP Stigma, and PrEP User Stereotypes) with strong factor loadings and Cronbach's alphas ranging from 0.83 to 0.90, suggesting excellent internal consistency. Correlations between this Scale, anticipated HIV stigma, perceived HIV risk, and disclosure of sexual identity were significant, indicating potential for robust application. Given the persistence of HIV infections among youth, stigma as a barrier to prevention, and expansion of PrEP modalities, the Youth PrEP Stigma Scale could enhance intervention and mechanistic research among youth at elevated risk for HIV acquisition.

Relations between provider adherence to a tailored motivational intervention protocol and competence in motivational interviewing

OBJECTIVES

To evaluate the association between provider adherence to Tailored Motivational Interviewing implementation strategy and motivational interviewing (MI) competence.

METHODS

156 youth-focused HIV providers enrolled in a parent implementation science trial completed: a) quarterly standardized patient assessments (SPI) during Baseline; b) a workshop, individual coaching sessions, and quarterly SPI plus feedback during Implementation; and c) quarterly SPI during Sustainment. Competence was measured using the MI-CRS and tracking data was used to assess adherence. We examined overall adherence as well as adherence to each implementation strategy in relation to MI competence.

RESULTS

Overall adherence was not associated with overall MI competence. MI competence significantly increased from Baseline to Implementation and Baseline to Sustainment. Some individual implementation strategies were associated with change in competence and the probability of achieving Intermediate/Advanced competence.

CONCLUSIONS

The results suggest that 100% percent adherence to all TMI implementation strategies may not be necessary. Completing some of the TMI implementation strategies yielded improvements in MI competence. The use of routine tracking data to measure adherence maybe more pragmatic than using observational coders and more objective than self-reports.

PRACTICE IMPLICATIONS

In busy HIV clinics, MI training should focus on strategies most directly associated with increased provider competence.

Information, Motivation, Behavioral Skills Model in Youth Newly Starting Antiretroviral Treatment

An understanding of adherence among youth newly starting antiretroviral therapy (ART) is critical but understudied. The information-motivation-behavioral skills (IMB) model is often used to understand health behaviors, but has rarely been studied in youth with HIV. In a multi-site sample of 153 youth newly starting ART, structural equation modeling was utilized to test this model. The model was generally supported with information and behavioral skills directly related to the decision to adhere, while motivation was indirectly related through behavioral skills. Results suggest that interventions focusing on improving IMB constructs for medication adherence are important for preventing non-adherence in youth newly starting ART.

Influence of provider openness and leadership behaviors on adherence to motivational interviewing training implementation strategies: Considerations for evidence-based practice delivery

Background

Adherence to intervention training implementation strategies is at the foundation of fidelity; however, few studies have linked training adherence to trainee attitudes and leadership behaviors to identify what practically matters for the adoption and dissemination of evidence-based practices. Through the conduct of this hybrid type 3 effectiveness-implementation cluster randomized controlled trial, we collected Exploration, Preparation, Implementation, and Sustainment (EPIS) data and merged it with tailored motivational interviewing training adherence data, to elucidate the relationship between provider attitudes toward evidence-based practices, leadership behaviors, and training implementation strategy (e.g., workshop attendance and participation in one-on-one coaching) adherence.

Method

Our sample included data from providers who completed baseline (pre-intervention) surveys that captured inner and outer contexts affecting implementation and participated in tailored motivational interviewing training, producing a dataset that included training implementation strategies adherence and barriers and facilitators to implementation (N = 77). Leadership was assessed by two scales: the director leadership scale and implementation leadership scale. Attitudes were measured with the evidence-based practice attitude scale (EBPAS-50). Adherence to training implementation strategies was modeled as a continuous outcome with a Gaussian distribution. Analyses were conducted in SPSS.

Results

Of the nine general attitudes toward evidence-based practice, openness was associated with training adherence (estimate [EST] = 0.096, p < .001; 95% CI = [0.040, 0.151]). Provider general (EST = 0.054, 95% CI = [0.007, 0.102]) and motivational interviewing-specific (EST = 0.044, 95% CI = [0.002, 0.086]) leadership behaviors were positively associated with training adherence (p < .05). Of the four motivational interviewing-specific leadership domains, knowledge and perseverant were associated with training adherence (p < .05). As these leadership behaviors increased, knowledge (EST = 0.042, 95% CI = [0.001, 0.083]) and perseverant (EST = 0.039, 95% CI = [0.004, 0.075]), so did provider adherence to training implementation strategies.

Conclusions

As implementation science places more emphasis on assessing readiness prior to delivering evidence-based practices by evaluating organizational climate, funding streams, and change culture, consideration should also be given to metrics of leadership. A potential mechanism to overcome resistance is via the implementation of training strategies focused on addressing leadership prior to conducting training for the evidence-based practice of interest.

Training Providers in Motivational Interviewing to Promote Behavior Change

Motivational Interviewing (MI) is a highly specified behavior change communication approach to improve patient-provider relationships, provider communication, and patient health outcomes. Because MI is built on a foundation of patient autonomy support, a feature known to positively influence behavior change during adolescence and emerging adulthood, MI is an evidence-based framework that can inform interventions targeting improvements in health outcomes among youth. MI can be difficult to implement with adequate fidelity, because learning MI requires time and commitment from busy providers with competing priorities. This review addresses best practices for implementing MI within adolescent serving medical settings (eg, pediatrics, family practices, rural health clinics, community health organizations, and so forth), including an orientation to MI, examples of efficacious interventions that were developed leveraging MI, and consideration for the design of training programs that include ongoing support to maximize the likelihood of sustainment.

Adapting a Motivational Interviewing Intervention to Improve HIV Prevention Among Young, Black, Sexual Minority Men in Alabama: Protocol for the Development of the Kings Digital Health Intervention

BACKGROUND

African American or Black young men who have sex with men (BYMSM) are at a disproportionate risk for contracting HIV and have high rates of undiagnosed, and therefore untreated, HIV infection. In the southern United States, BYMSM face region-specific hurdles to HIV prevention, such as limited access to care and high levels of racism and intersectional stigma, necessitating HIV testing and pre-exposure prophylaxis interventions that address sociocultural and structural barriers while motivating BYMSM to engage in prevention. Brothers Saving Brothers (BSB) is a motivational interviewing behavioral intervention that successfully and simultaneously increased community-based HIV testing and prevention counseling and education among BYMSM in the midwestern United States.

OBJECTIVE

The aim of this protocol is to detail the process for the adaption of the BSB intervention for midwestern BYMSM to the Kings intervention for southern BYMSM. During the adaptation process, the intervention will be modernized to include rapid HIV testing, as opposed to HIV testing that requires BYMSM to return for test results, pre-exposure prophylaxis, and the provision of structural supports, and for relevance in the southern United States.

METHODS

Aim 1 is to gather qualitative data through focus groups and in-depth interviews with BYMSM aged 18 to 29 years in Alabama and in-depth interviews with prevention and outreach workers who routinely work with BYMSM in Alabama. NVivo qualitative software (QSR International) will be used for the coding and analysis of the transcripts via a thematic analysis approach. For aim 2, intervention mapping will guide the adaptation process, intervention content, components, and design. Both aims 1 and 2 will leverage the Exploration, Preparation, Implementation, Sustainment implementation science framework, with emphasis on the exploration and preparation phases of this model. By applying these frameworks, the original midwestern BSB intervention will be scientifically adapted to the southern BYMSM Kings intervention.

RESULTS

This study is ongoing as of 2022 and is expected to conclude in 2024, with aims 1 and 2 being completed in 2023. Qualitative data will offer insight into the current real-world experiences and preferences of BYMSM in Alabama. Feedback will be collected through the adaptation process to inform intervention refinement. Institutional review board approvals have been received.

CONCLUSIONS

The findings will inform next steps, that is, testing the Kings intervention for feasibility, acceptability, and preliminary effectiveness in a pilot hybrid type 1 effective-implementation randomized controlled trial. The study results will provide insights about important considerations for HIV prevention among BYMSM in the southern United States.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03680729; https://clinicaltrials.gov/ct2/show/NCT03680729.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/36655.

Tailored Motivational Interviewing in Adolescent HIV Clinics: Primary Outcome Analysis of a Stepped Wedge Implementation Trial

BACKGROUND

Youth continue to have the poorest outcomes along the HIV prevention and care continua. Motivational Interviewing (MI) may promote behavior change and reduce perceived stigma, but providers often demonstrate inadequate MI competence. This study tested Tailored Motivational Interviewing (TMI), a set of implementation strategies designed to improve MI competence in youth HIV providers.

SETTING

Ten HIV clinics in the Adolescent Trials Network for HIV/AIDS Interventions.

METHODS

In a stepped wedge design, 10 clinics (N = 151 providers) were randomized in 5 clusters every 3 months to receive TMI for a 12-month implementation period. Sites were rerandomized within each cluster to receive communities of practice guidance with or without internal facilitator support in the sustainment period. Standard patient assessments were coded every 3 months for 36 months.

RESULTS

Nesting was addressed using mixed-effects regression models, with random effects for providers and sites. TMI resulted in significantly improved MI competence over baseline. Despite small reductions in competence in the sustainment window, competence was still significantly improved over baseline, with no difference between the 2 sustainment conditions.

CONCLUSIONS

TMI may be an important tool to capacitate the HIV HealthForce to end the HIV epidemic in young people.

Patient Health Literacy and Communication with Providers Among Women Living with HIV: A Mixed Methods Study

In this mixed-methods study, we examine the relationship between provider communication and patient health literacy on HIV continuum of care outcomes among women living with HIV in the United States. We thematically coded qualitative data from focus groups and interviews (N = 92) and conducted mediation analyses with quantitative survey data (N = 1455) collected from Women's Interagency HIV Study participants. Four qualitative themes related to provider communication emerged: importance of respect and non-verbal cues; providers' expressions of condescension and judgement; patient health literacy; and unclear, insufficient provider communication resulting in diminished trust. Quantitative mediation analyses suggest that higher health literacy is associated with higher perceived patient-provider interaction quality, which in turn is associated with higher levels of trust in HIV providers, improved antiretroviral medication adherence, and reduced missed clinical visits. Findings indicate that enhancing provider communication and bolstering patient health literacy could have a positive impact on the HIV continuum of care.

Perceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension

Stigma is one of the most harmful forces affecting population health. When stigma exists in clinical settings, environments that should be pro-patient and stigma-free, stigma may become internalized and affect patients' well-being. Informed by prior stigma research and the Intergroup Contact Theory, the authors elucidate statistical relationships between patients' perceptions of clinic-based stigma and stigma's impact on health among New York City's diverse residents. The authors hypothesize that perceiving stigma in clinical settings would mediate the relationships between depression, general health, diabetes, and hypertension; they tested this through multiple logistic regressions conducted on pooled data from the New York City Community Health Survey (N = 18,596, 2016-2017). Among women, depression was associated with stigma (α = 4.07, P < 0.01), hypertension (γ = 2.31, P < 0.01), diabetes (γ = 2.18, P < 0.01), and poor general health (γ = 6.34, P < 0.01). Among men, depression was associated with stigma (α = 3.7, P < 0.01), hypertension (γ = 2.35, P < 0.01), diabetes (γ = 1.86, P < 0.01), and poor general health (γ = 5.14, P < 0.01). Overall, perceived stigma in clinics significantly increased adjusted odds of self-reporting poor general health (adjusted ORs [AOR] = 1.87 men; AOR = 2.05 women). Findings contribute to the literature on the Intergroup Contact Theory, which suggests that stigma should be low in diverse communities; findings indicate that stigma may be a mediator, justifying inclusion in epidemiological and health services research. In addition, study outcomes suggest that depression may be associated with clinic-based stigma, and this stigma has deleterious effects on physical health. Thus, clinicians should emphasize stigma reduction in their facilities, potentially through the adoption of trauma-informed approaches or delivery of care using non-stigmatizing communication strategies, such as Motivational Interviewing.

Behavioral and social interventions to promote optimal HIV prevention and care continua outcomes in the United States

PURPOSE OF REVIEW

This review reports on trends in behavioral and social intervention research in the United States published over the past year (2020-2021) investigating HIV prevention and care outcomes, organized by the level of intervention focus - individual, dyadic, and organizational.

RECENT FINDINGS

Researchers have continued to develop and evaluate behavioral and social interventions to reduce HIV acquisition risk and disease progression. With few exceptions, social and behavioral interventions have primarily focused on individuals as the unit of behavior change. Interventions operating at the individual-, dyadic-, and organizational-level have made strides to reduce HIV transmission risk and disease progressing by addressing mental health, substance use, stigma, peer and romantic relationships, and, to some extent, structural vulnerabilities.

SUMMARY

Social and behavioral interventions continue to be critical in addressing HIV inequities in the United States. An important gap in the literature is the need for multilevel interventions designed and implemented within existing community-based organizations and local healthcare settings. We call on researchers to continue to attend to the structural, environmental, and economic vulnerabilities that shape HIV inequities in the development of multilevel approaches necessary to realize the full potential of existing and emerging HIV prevention and care strategies.

Adapting digital health interventions for the evolving HIV landscape: examples to support prevention and treatment research

PURPOSE OF REVIEW

Although many HIV prevention and/or treatment digital health interventions (DHIs) have shown feasibility and acceptability, fewer have indicated efficacy, and only a subset have been adapted for new contexts. Adaptation is a key element of pragmatic implementation science research. Adaptation is cost effective and time efficient compared with new development. Leveraging adaptation can lead to accelerated scale-up and enhanced public health impact. Considering the value of adaptation, the purpose of this piece is to present examples of DHI to DHI adaptation sequences to inform future HIV prevention and/or treatment research.

RECENT FINDINGS

From an examination of recent academic articles (01 November 2016 to 31 October 2021), we identified adaptation sequences that included an original DHI with at least two adaptations. Four models are presented herein; examples consist of adapted DHIs for new population, health outcome, geography, or a combination thereof.

SUMMARY

Adaptation is a promising scientific approach to expeditiously respond to the evolving HIV landscape. We present examples of DHI adaptations alongside considerations for each type of adaptation; we also present adaptation challenges with responsive strategies. We suggest when conducted with attention to rigor (leveraging adaptation frameworks, community engagement, and tailoring content), adaptation is a powerful tool to pragmatically address the HIV epidemic.

HIV-Related Stigma Research as a Priority at the National Institutes of Health

The National Institutes of Health (NIH) recognizes that, despite HIV scientific advances, stigma and discrimination continue to be critical barriers to the uptake of evidence-based HIV interventions. Achieving the Ending the HIV Epidemic: A Plan for America (EHE) goals will require eliminating HIV-related stigma. NIH has a significant history of supporting HIV stigma research across its Institutes, Centers, and Offices (ICOs) as a research priority. This article provides an overview of NIH HIV stigma research efforts. Each ICO articulates how their mission shapes their interest in HIV stigma research and provides a summary of ICO-relevant scientific findings. Research gaps and/or future opportunities are identified throughout, with key research themes and approaches noted. Taken together, the collective actions on the part of the NIH, in tandem with a whole of government and whole of society approach, will contribute to achieving EHE's milestones.

Transgender Women in Dominican Republic: HIV, Stigma, Substances, and Sex Work

Exposure to stigma, violence, sex work, and substance use are associated with increased HIV risk, but relationships between these factors have not been fully elucidated among transgender women whose data are often aggregated with men who have sex with men and other sexual and gender minorities. Considering this gap, we aimed to identify a serologically confirmed HIV estimate for transgender women and examine the relationships between stigma, sex work, substance use, and HIV among a national sample of transgender women in Dominican Republic. We analyzed biomarkers and self-report data from the third wave of Dominican Republic's Encuesta de Vigilancia y Comportamiento con Vinculación Serológica, employing logistic and negative binomial regression to estimate models (n = 307). HIV rate was 35.8%. Nearly 75% of respondents engaged in sex work. Over 20% reported experiencing violence; 61.6% reported being stigmatized. Participation in sex work was associated with higher levels of stigma [incidence rate ratio (IRR): 1.70, p < 0.05]. Respondents who experienced violence had over three times higher odds of living with HIV relative to respondents who had not been victimized [odds ratio (OR): 3.15, p < 0.05]. Marijuana users were less likely to experience stigma compared with cocaine users (IRR: 1.72, p < 0.05), and a higher risk of alcohol dependency was associated with higher odds of experiencing violence (OR: 1.17, p < 0.001). Findings illustrate the importance of disaggregating data collected from transgender women compared with other sexual and gender minorities to ascertain subpopulation-specific estimates and indicate an urgent need to implement structural interventions and policies to protect transgender women's health and their human rights.

Examining the Relationships Between Experienced and Anticipated Stigma in Health Care Settings, Patient-Provider Race Concordance, and Trust in Providers Among Women Living with HIV

Stigma in health care settings can have negative consequences on women living with HIV, such as increasing the likelihood of missed visits and reducing trust in their clinical providers. Informed by prior stigma research and considering knowledge gaps related to the effect of patient-provider race concordance, we conducted this study to assess if patient-provider race concordance moderates the expected association between HIV-related stigma in health care settings and patients' trust in their providers. Moderation analyses were conducted using Women's Interagency HIV Study data (N = 931). We found significant main effects for patient-provider race concordance. Higher experienced stigma was associated with lower trust in providers in all patient-provider race combinations [White-White: B = -0.89, standard error (SE) = 0.14, p = 0.000, 95% confidence interval, CI (-1.161 to -0.624); Black patient-White provider: B = -0.19, SE = 0.06, p = 0.003, 95% CI (-0.309 to -0.062); and Black-Black: B = -0.30, SE = 0.14, p = 0.037, 95% CI (-0.575 to -0.017)]. Higher anticipated stigma was also associated with lower trust in providers [White-White: B = -0.42, SE = 0.07, p = 0.000, 95% CI (-0.552 to -0.289); Black patient-White provider: B = -0.17, SE = 0.03, p = 0.000, 95% CI (-0.232 to -0.106); and Black-Black: B = -0.18, SE = 0.06, p = 0.002, 95% CI (-0.293 to -0.066)]. Significant interaction effects indicated that the negative associations between experienced and anticipated HIV-related stigma and trust in providers were stronger for the White-White combination compared with the others. Thus, we found that significant relationships between HIV-related experienced and anticipated stigma in health care settings and trust in providers exist and that these associations vary across different patient-provider race combinations. Given that reduced trust in providers is associated with antiretroviral medication nonadherence and higher rates of missed clinical visits, interventions to address HIV-related stigma in health care settings may improve continuum of care outcomes.

Feasibility of Ethyl Glucuronide Nail Testing Biomarker for Alcohol Use Among Youth Living With HIV

PURPOSE

We assessed the feasibility of the ethyl glucuronide biomarker (EtG) through nail sampling to measure alcohol use among youth living with HIV in the United States (YLWH, N = 183); we also evaluated concordance between this EtG biomarker and self-reported measures of alcohol use, specifically, the Alcohol Timeline Followback (TFLB) and Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).

METHODS

EtG, TFLB, and ASSIST were collected at 4 points over 1 year. At baseline and 52 weeks, 78.1% and 70.1%, respectively, provided a valid (full or partial) sample.

RESULTS

At 16 weeks, EtG was associated with ASSIST (r = .25, p < .05). At 28 weeks and 52 weeks, TFLB and ASSIST were correlated with EtG (at 28 weeks r = .23, p < .05 and r = .41, p < .01, respectively; at 52 weeks r = .34, p < .01 and r = .25, p < .05, respectively).

CONCLUSIONS

We found that nail-based EtG biomarker was feasible to measure alcohol use among YLWH; we also found concordance between EtG, TLFB, and ASSIST, supporting ongoing use of self-reported alcohol use measures with YLWH.

Proof of Concept for the FLEX Intervention: Feasibility of Home Based Coaching to Improve Physical Activity Outcomes and Viral Load Suppression among African American Youth Living with HIV

FLEX is a Motivational Interviewing, home-based coaching program that concurrently targets HIV-related and physical activity goals among African American youth living with HIV in the United States. To create and pilot test FLEX, we leveraged a 2-step exploratory sequential mixed methods design informed by the ORBIT model with initial qualitative work followed by pre-post analysis of quantitative outcomes, concluding with qualitative exit surveys. Data were evaluated pre- and 3-months post-intervention. Recruitment was 90%. Participants reported high program satisfaction and program adherence (76% completion rate). Preliminary findings indicate reductions in participants’ viral loads and improvements across 4 measures of physical activity.