State of HIV in the US Deep South

Associations between perceived discrimination experiences, treatment adherence self-efficacy, and depressive symptoms among people living with HIV in the Southern United States

This study examined associations between perceived discrimination, treatment adherence self-efficacy, and depressive symptoms among people living with HIV (PLHIV) in the Southern United States. Cross-sectional survey data were collected from 402 PLHIV who self-reported on interpersonal discrimination experiences based on HIV status, sexuality, gender, income, and living condition. Participants also reported on adherence self-efficacy and depressive symptoms. We employed K-means clustering to identify groups based on discrimination experiences, and logistic regressions to examine group differences on adherence self-efficacy and depressive symptoms. Results suggested three groups: a cluster with high perceived discrimination across all identities/conditions (n = 41; 11%; Cluster 1); a cluster with high perceived discrimination based on HIV status, income, and living condition (n = 49; 13%; Cluster 2); and a cluster with low perceived discrimination across all identities/conditions (n = 288; 76%; Cluster 3). Compared to Cluster 3, Cluster 1 and 2 had 2.22 times (p = .037) and 3.98 times (p<.001) greater odds of reporting depressive symptoms. Compared to Cluster 3, Cluster 2 had 3.40 times (p = .003) greater odds of reporting lower adherence self-efficacy. Findings demonstrate the need for individual-level support for PLHIV with discrimination histories, and broader efforts to end the stigma, discrimination, and marginalization of PLHIV based on HIV status and other characteristics.

Correlates of subjective and objective everyday functioning in middle-aged and older adults with human immunodeficiency virus

People with human immunodeficiency virus (HIV) (PWH) are at an increased risk for impaired everyday functioning and they may also experience poor awareness of their functional status. This study identified factors associated with (1) subjective and objective instrumental activities of daily living (IADLs) and (2) awareness of functional capacity in PWH. In this cross-sectional study, 236 PWH completed a neurobehavioral assessment, including self-report and performance-based measures of IADLs. Multiple regressions were performed to identify demographic, personality, and cognitive factors contributing to subjective and objective evaluation of everyday functioning, as well as discrepancy between self-report and performance-based measures of IADLs. Results indicated that increased depression was associated with worsened self-report of everyday functioning but not performance of IADLs. Cognitive function and age were associated with IADL performance. Most participants (58.1%) demonstrated a discrepancy between self-report and actual performance of IADLs. Worse processing speed was correlated with greater discrepancy. Inaccurate self-reporters had worse overall cognitive functioning and lower levels of personality traits, including openness, conscientiousness, and agreeableness. In conclusion, self-report and actual performance of IADLs in PWH is influenced by different factors. Self-report may be more affected by psychological variables, such as mood and personality, while actual performance is more sensitive to age and cognitive function.

Who declines "opt-out" HIV/HCV testing? Experience of an internal medicine resident continuity clinic serving a predominantly Black adult population in South Carolina

BACKGROUND

Universal "opt-out" human immunodeficiency virus (HIV) or hepatitis C virus (HCV) testing involves testing individuals for HIV or HCV regardless of symptoms, unless they decline. Little is known about the characteristics of individuals who decline.

METHODS

We conducted a retrospective, medical record review of adults evaluated at an outpatient clinic in South Carolina. "Opt-out" HIV/HCV testing was implemented in Feb 2019; we reviewed medical records of individuals evaluated in May - July 2019. We excluded individuals who did not meet age-based screening criteria (HIV: 18-65 years; HCV: 18-74 years), had a prior HIV/HCV diagnosis, were tested for HIV/HCV within the preceding 12 months, and whose "opt-out" decision was not documented. We used multivariable logistic regression to estimate adjusted odds ratios (aOR) and 95 % confidence intervals (CI) for "opt-out" decision, with age, sex, race/ethnicity, insurance status, visit type, and genitourinary vs. non-genitourinary chief complaints as predictors.

RESULTS

The final analyses included 706 individuals for HIV and 818 for HCV. Most individuals were non-Hispanic Black (77 % and 78 %) and female (66 % and 64 %). The mean ages were 49.1 (±11.9) and 51.9 (±13.2). Nearly one-third of individuals declined HIV and HCV testing (31 % and 30 %). Black males were more likely to decline HIV and HCV testing than Black females (aOR = 1.61 [95 % CI. 1.08 - 2.40] and aOR = 1.50 [95 %CI. 1.04 - 2.16]).

CONCLUSION

Despite HIV/HCV testing being the standard of care, approximately one-third of eligible individuals may decline testing, the demographic characteristics of whom may overlap with individuals who are traditionally unaware of their status.

MAIN POINT

Despite HIV/HCV testing being the standard of care, approximately one-third of eligible individuals may decline testing, the demographic characteristics of whom may overlap with individuals who are traditionally unaware of their status.

"Honesty, Communication and Trust Are What Bring Peace of Mind": Narratives of HIV Risk Among Hispanic/Latino Men Who Have Sex with Men in the Southern United States

For Hispanic/Latino MSM (HLMSM) in the South, HIV burden remains high, and HIV elimination is a national priority. Between July and September 2016, using a strengths-based approach informed by resilience theory, we conducted qualitative interviews with HIV-negative HLMSM in five southern cities in the United States with elevated HIV prevalence. We analyzed data using a qualitative content analysis approach, assessing for interrater reliability. A brief behavioral survey was also conducted. We enrolled 51 HLMSM (mean age = 33 years, range = 15-63). HLMSM discussed the climate of fear about HIV and homosexuality impeding HIV prevention, including the impact of stigma and taboo. Three main strengths-based strategies emerged for preventing HIV: assessing partner risk, establishing boundaries for sexual interactions, and self-education. Future HIV prevention efforts may benefit from balancing risk-based approaches with those that emphasize resilience, address partner trustworthiness and safety, and focus on providing novel outlets for HIV prevention education.

Population Density and Health Outcomes in Women with HIV in the Southern United States: A Retrospective Longitudinal Analysis

Purpose: Published studies have revealed challenges for people with human immunodeficiency virus (HIV) living in rural areas compared to those in urban areas, such as poor access to HIV care, insufficient transportation, and isolation. The purpose of this study was to examine associations between population density and multiple psychosocial and clinical outcomes in the largest cohort of women with HIV (WWH) in the United States. Methods: Women's Interagency HIV Study (WIHS) participants from Southern sites (n = 561) in 2013-2018 were categorized and compared by population density quartiles. The most urban quartile was compared with the most rural quartile in several psychosocial and clinical variables, including HIV viral load suppression, HIV medication adherence, HIV care attendance, depression, internalized HIV stigma, and perceived discrimination in healthcare settings. Results: Although women in the lowest density quartile were unexpectedly more highly resourced, women in that quartile had greater odds of not attending an HIV care visit in the last six months (odds ratio [OR] = 0.64, 95% confidence interval [CI] [0.43-0.95]), yet higher odds for having fully suppressed HIV when compared to women in the highest density quartile (OR = 1.64, 95% CI [1.13-2.38]). Highly urban WWH had greater likelihood of unsuppressed HIV, even after controlling for income, employment, and health insurance, despite reporting greater HIV care adherence and similar medication adherence. Discussion: Further investigation into the reasons for these disparities by population density is needed, and particular clinical attention should be focused on individuals from high population density areas to help maximize their health outcomes.

Interest in and Willingness to Use PrEP: A Cross-Sectional Study of Individuals with Problematic Substance Use Residing in a High HIV Prevalence Jurisdiction

Although it is an effective HIV prevention method, pre-exposure prophylaxis (PrEP) is underutilized in the Southern US. Many people who use drugs (PWUD) have increased susceptibility to HIV which could be lessened by using PrEP. Potential barriers to PrEP use include lack of awareness of PrEP, low knowledge about HIV prevention, low self-efficacy for HIV prevention, inaccurate risk perceptions, and anticipated stigma. The current study examined predisposing, enabling, and reinforcing factors that may predict interest in PrEP. The purpose of the current study was to explore factors associated with interest in and willingness to use daily oral and long acting injectable PrEP among sexually active adult PWUD. The data were collected from adult participants (n = 270) residing in Harris County, TX, who self-reported problematic substance use and who reported oral, anal, or vaginal sex in the six months prior to completing the survey. The survey was distributed and completed online via Qualtrics Panels in March of 2022 and included measures of PrEP and HIV knowledge, PrEP stigma, sexual health self-efficacy, experiences of discrimination, health literacy, and medical mistrust. The majority of participants reported circumstances or behaviors that increased their susceptibility to HIV. Findings indicated that PrEP user stereotypes and PrEP anticipated disapproval by others were associated with interest in using daily oral PrEP and willingness to use long acting injectable PrEP. These results provide insight into reasons for low PrEP uptake among PWUD who live in a high HIV prevalence jurisdiction. Implications for HIV prevention intervention are discussed.

A multi-informant qualitative analysis of desired features for an mHealth tool for youth living with HIV in South Carolina

OBJECTIVE

Youth living with HIV (YLHIV) in the southern United States experience poor outcomes across the HIV care continuum and are at high-risk for virologic failure. This study used a qualitative, community-engaged approach to inform the development of a tailored mobile Health (mHealth) tool for YLHIV in South Carolina (SC).

METHODS

Semistructured qualitative interviews were conducted with YLHIV in SC (n = 16) and their HIV care providers (n = 15). Focus group discussions (FGDs) were also conducted with HIV-focused community-based organization staff (n = 23). Interviews and FGDs queried desired components for a future mHealth tool tailored for YLHIV. Data were analyzed using a team-based rapid qualitative approach.

RESULTS

Across informants, key themes emerged related to medical management of HIV, including a desire for connections with medical providers, appointment and medication reminders, and accurate HIV information. In addition, informants voiced a desire for mental health resources to be integrated into the app. Connection with HIV-positive peers also emerged as a key desire from youth informants. In terms of app design, informants emphasized the need for strict privacy practices, a youth-friendly design, compensation for use, and integration with existing healthcare systems.

CONCLUSIONS

mHealth interventions developed for YLHIV should meet the mental health and social needs of YLHIV in addition to their medical needs. In addition, the highly stigmatized nature of HIV requires careful consideration when designing digital tools-youth want their privacy prioritized, but also express strong desire for social support to help cope with the isolation and stigma of this chronic health condition.

Differences in internalized HIV stigma across subpopulations of people with HIV in care across the United States

BACKGROUND

Few studies have examined which subgroups of people with HIV (PWH) carry the greatest burden of internalized HIV stigma (IHS), which may be important to care provision and interventions.

METHODS

PWH in the CFAR Network of Integrated Clinical Systems (CNICS) longitudinal, US-based, multisite, clinical care cohort completed tablet-based assessments during clinic visits including a four-item, Likert scale (low 1-5 high), IHS instrument. Associations between sociodemographic characteristics and IHS scores were assessed in adjusted linear regression models.

RESULTS

Twelve thousand six hundred and fifty-six PWH completed the IHS assessment at least once from February 2016 to November 2022, providing 28 559 IHS assessments. At baseline IHS assessment, the mean age was 49 years, 41% reported White, 38% Black/African American, and 16% Latine race/ethnicity, and 80% were cisgender men. The mean IHS score was 2.04, with all subgroups represented among those endorsing IHS. In regression analyses, younger PWH and those in care fewer years had higher IHS scores. In addition, cisgender women vs. cisgender men, PWH residing in the West vs. the Southeast, and those with sexual identities other than gay/lesbian had higher IHS scores. Compared with White-identifying PWH, those who identified with Black/African American or Latine race/ethnicity had lower IHS scores. Age stratification revealed patterns related to age category, including specific age-related differences by gender, geographic region and race/ethnicity.

DISCUSSION

IHS is prevalent among PWH, with differential burden by subgroups of PWH. These findings highlight the benefits of routine screening for IHS and suggest the need for targeting/tailoring interventions to reduce IHS among PWH.

Disparities in mortality trends of adults with HIV in the USA: A comprehensive examination across 2 decades

Approximately 38 million people worldwide are affected by human immunodeficiency virus (HIV), with 4000 new infections daily. While literature explores HIV mortality among the elderly in the US, there is an underrepresentation of mortality data for adults. By scrutinizing mortality trends based on demographic factors such as gender, race or ethnicity, age groups, and geographic location, the study seeks to uncover patterns that may facilitate a longitudinal perspective for tailoring interventions and allocating resources effectively. Crude death rates and age-adjusted mortality rates (AAMR) per 100,000 individuals were calculated using HIV mortality data (ICD-10 Codes B20-24) from CDC WONDER database. Permutation test was used to calculate annual percentage changes in AAMR with 95% confidence interval. Average annual percentage changes were computed as weighted average of annual percentage changes. Between 1999 to 2020, US adult HIV deaths totaled 225,396 (AAMR: 5.03), with a significantly decreasing average annual percentage changes (-5.94). Males exhibited a 3-fold higher AAMR (7.50) than females (2.67). Non-Hispanic Blacks had the highest AAMR (21.82), while Non-Hispanic Asians had the lowest (0.67). The South and Northeast regions had the highest AAMRs (6.91 and 6.33, respectively). Notably, the District of Columbia had an alarmingly high mortality rate of 39.9, while North Dakota had the lowest (0.7). Urban regions (5.47) had double the mortality rates of rural regions (2.70). Mortality rate peaked in age groups 45 to 54 (8.65) and 35 to 44 (7.42). While overall HIV mortality is declining, disparities persist among demographics. Targeted interventions are crucial to improve preventive measures and healthcare access for disproportionately affected groups.

A Geospatial Analysis of Social and Structural Determinants of Health and High HIV Prevalence in Alabama, USA

OBJECTIVE

This study utilizes geospatial analytic techniques to examine HIV hotspots in Alabama leveraging Medicaid utilization data.

METHODS

This cross-sectional study leveraged Medicaid utilization data from Alabama's 67 counties, averaging 9,861 Medicaid recipients aged > 18 years old per county. We used Alabama Medicaid administrative claims data from January 1, 2016, to December 31, 2020, to identify individuals with HIV. Using Microsoft SQL Server, we obtained the average annual count of HIV Medicaid claims in each of the 67 Alabama counties (numerator) and the number of adult Medicaid recipients in each county (denominator), and standardized with a multiplier of 100,000. We also examined several other area-level summary variables (e.g., non-high school completion, income greater than four times the federal poverty level, social associations, urbanicity/rurality) as social and structural determinants of health. County-boundary choropleth maps were created representing the geographic distribution of HIV rates per 100,000 adult Medicaid recipients in Alabama. Leveraging ESRI ArcGIS and local indicators of spatial association (LISA), results were examined using local Moran's I to identify geographic hotspots.

RESULTS

Eleven counties had HIV rates higher than 100 per 100,000. Three were hotspots. Being an HIV hotspot was significantly associated with relatively low educational attainment and less severe poverty than other areas in the state.

CONCLUSIONS

Findings suggesting that the HIV clusters in Alabama were categorized by significantly less severe poverty and lower educational attainment can aid ongoing efforts to strategically target resources and end the HIV epidemic in U.S.' Deep South.

Exploring the impact of therapeutic advances in HIV-related mortality in the United States

Objectives

Mortality from HIV has significantly declined with the introduction of highly active antiretroviral therapy (HAART). This study sought to examine the longitudinal trends in mortality from HIV-related diseases by race, sex, geographical region, and over time as HAART trends changed.

Methods

We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database and performed serial cross-sectional analyses of national death certificate data for all-cause mortality with comorbid HIV from 1999 to 2020. HIV diseases (International Classification of Diseases, Tenth Revision codes B20-B24, O98.7, R75) were listed as the contributing cause of death. We calculated the age-adjusted mortality ratio (AAMR) per 1,000,000 individuals and determined mortality trends using the Joinpoint Regression Program. Subgroup analyses were performed by sex, race, region, and organ system. The study period was further stratified into three groups when specific drug regimens were more prevalent.

Results

In the 22-year study period, 251,759 all-cause mortalities with comorbid HIV were identified. The leading cause of death was infectious disease (84.0%, N = 211,438). Men recorded a higher AAMR than women (4.66 vs 1.65, P < 0.01). African American individuals had the highest AAMR (13.46) compared to White, American Indian, and Asian individuals (1.70 vs 1.65 vs 0.47). The South region had the highest AAMR (4.32) and urban areas had a higher AAMR compared to rural areas (1.77 vs 0.88).

Conclusions

More than 80% of deaths occurred because of infectious disease over the last 2 decades with a decreasing trend over time when stratified by race, sex, and geographical region. Despite advances in HAART, mortality disparities persist which emphasizes the need for targeted interventions in these populations.

Undiagnosed HIV in Patients on Immunosuppressive Medications Presenting with HIV-Associated Kidney Disease

Approximately 158,500 adults and adolescents in the United States live with undiagnosed human immunodeficiency virus (HIV). Missed or delayed diagnoses adversely affect disease management and outcomes. This is particularly salient for patients receiving immunosuppressive and immunomodulatory therapy for the management of chronic inflammatory conditions, in which additional immunosuppression may increase the risk and severity of opportunistic infections. Despite this risk, comprehensive HIV testing before the initiation of immunosuppressive therapy is not yet the norm. We describe a case series containing the narratives of three patients recently treated with immunosuppressive agents, who presented with signs concerning for HIV-associated kidney diseases and who were found to have undiagnosed HIV later in the treatment course, which, unfortunately, resulted in poor outcomes. Screening for HIV or related illnesses, such as viral hepatitis or mycobacterial co-infections including tuberculosis, is essential before initiating biologic immunosuppression.

The Role of Community Pharmacies in Providing Access to HIV Post-exposure Prophylaxis (PEP)

HIV affects an estimated 1.2 million individuals in the United States and is disproportionately concentrated among African Americans, Latinos, and people of multiple races. Post-exposure prophylaxis (PEP) substantially decreases HIV transmission when started within 72 h after exposure, but problems of accessibility have hindered its widespread usage in communities at risk for HIV infection. Pharmacy-initiated PEP access was first permitted in New York City in 2017, allowing pharmacists to provide a 7-day supply of PEP without a prescription for consumers at high risk for HIV infection. It was expected that the broad reach and accessibility of community pharmacies would increase timely access to PEP for all individuals, especially those who already face significant barriers to accessing the healthcare system. Since then, eleven other states have followed suit and expanded the scope of outpatient pharmacy practice in order to increase the availability of HIV PEP but prescribing laws in over 75% of the US have not been changed. Much of the existing literature on HIV prevention focuses on PrEP access barriers with limited information on PEP access in the US. In this paper, we review the current status of pharmacist-initiated PEP in the US as part of the End the HIV Epidemic (EHE) initiative.

Symptomatology and Quality of Life of Older People With HIV and Comorbid Chronic Obstructive Pulmonary Diseases From an HIV Clinic in Birmingham, Alabama

ABSTRACT

Psychological symptomatology and quality of life (QoL) have been studied in older people with HIV (PWH) and those with chronic obstructive pulmonary disease (COPD), respectively, but there is a dearth of studies in older PWH with COPD. Our study compared depressive symptoms, anxiety, and QoL between older PWH with and without COPD using data from an HIV clinic in Birmingham, Alabama, from January 2018 to February 2020. Data on depressive symptoms (Patient Health Questionnaire-9), anxiety (Patient Health Questionnaire-5 Anxiety), and QoL (EuroQoL-5 Dimension) were analyzed. Among 690 PWH aged 50 years or older, 102 individuals (14.8%) had COPD. Significant differences were found between the two groups in depressive symptoms and components of QoL (e.g., mobility, self-care, usual activities, and pain/discomfort), but not in anxiety and general health. Experiencing COPD may worsen depressive symptomatology and QoL in older PWH, highlighting the need for tailored health care and research for this population.

"Just the Stigma Associated with PrEP Makes You Feel Like It's HIV Itself": Exploring PrEP Stigma, Skepticism, and Medical Mistrust Among Black Cisgender Women in Urban and Rural Counties in the U.S. Deep South

Despite its effectiveness in HIV prevention, PrEP use among Black women is suboptimal. Notably in the Deep South, Black women have the lowest PrEP uptake rates among all US regions. To increase PrEP engagement, research suggests the implementation of structural and social interventions particular to the needs of Black women. The state of Alabama is of priority to federal HIV prevention initiatives; therefore, this study conducted focus groups among 47 cis-gender Black women in rural and urban Alabama counties, with the highest statewide HIV incidence rates, to understand perceptions of PrEP and decision-making processes. Deductive coding analysis was conducted and themes were finalized based on consensus among the two coders. Four themes were identified. Findings show stigma undergirds Alabaman Black women's decisions to engage in PrEP care. Moreover, women reported stigma stifled community-level education about PrEP. Despite these experiences, education was regarded as a strategy to decrease stigma and PrEP skepticism, the latter of which emerged as a prominent theme. Medical mistrust and healthcare engagement were the other emergent themes influencing participation in PrEP care. To ensure PrEP efforts meet the needs of Black cisgender women in Alabama counties, interventions must address longstanding stigma, increase educational initiatives, and ensure interventions consider women's experiences with medical mistrust and health care engagement.

Building an HIV Learning Health Care Community for Youth in Florida: Opportunities and Challenges

In Florida, 33% of new HIV infections among men and 21% of new infections among women are among those younger than 29 years of age. We describe the development of a Learning Health Care Community for youth (Y-LHCC) in Orange County, FL. Its core implementation team (iTeam) was composed of representatives from community agencies and academics, whose work was informed by data from the Florida Department of Health (FDOH) and regional research, in-depth interviews (IDIs) with agency representatives, and a pilot implementation of Tailored Motivational Interviewing (TMI) to improve service provision. IDIs revealed limited programming specifically for youth, significant structural challenges providing them with PrEP, and differences in use of evidence-based behavioral interventions to improve HIV services. FDOH provided data on new HIV infections, linkage to care, viral suppression, and PrEP coverage, however, limitations such as minimal data on PrEP referrals and use, agency level data, and inability to generate data quarterly (which would facilitate program improvement) were encountered. Thirty staff members from five agencies serving youth in Orange County participated in TMI training. About half the agency staff (n = 16) completed at least three of the four online training sessions. MI skills improved from pre- (n = 28; M = 1.96) to post TMI training (n = 11; M = 2.48, SD = 0.57); (t(37) = - 3.14, p = 0.0033). The iTeam held seven remote meetings and two in-person half-day meetings at the end of the study, during which they reassessed areas of focus for improving youth services. They also reiterated their commitment to continuing to meet beyond the study period and to engage other agencies in the newly established coalition. Findings highlight the potential of creating a Y-LHCC in Florida as well as some of the challenges that will need to be overcome to achieve ending the HIV Epidemic goals for young people in the region.

A Mixed Methods Analysis of Southern HIV Service Organizations' Implementation of Harm Reduction to Address the HIV and Opioid Syndemic

Southern HIV Service Organizations (SHSOs) are promising sites for the adoption and implementation of harm reduction as a means for addressing the HIV and opioid syndemic. However, little research to date has examined exactly how harm reduction is operationalized within and among SHSOs. Using program evaluation data (i.e., organizational assessment data and semi-structured qualitative group interview data with SHSO staff), this study aimed to characterize organizational implementation of harm reduction among SHSOs that sought harm reduction capacity-building assistance (i.e., training, coaching, funding) from the SUSTAIN Center. Authors utilized a convergent mixed methods design in which quantitative and qualitative approaches were employed in parallel to gain simultaneous insights into how harm reduction was operationalized in SHSOs and how the local context influenced implementation. Means and proportions of each organizational assessment domain were compared. Thematic analysis of group interview transcripts examined SHSO staff perceptions of harm reduction implementation in their respective communities. Quantitative results revealed that SHSOs most commonly operationalize harm reduction in the Outreach, Advocacy, and Principles domains but struggle to do so in terms of Services and Organizational Infrastructure. Qualitative results revealed that various factors in SHSOs' local context, such as the community's lack of knowledge and understanding of harm reduction, limited harm reduction services, and a challenging socio-political context, influence SHSOs implementation of harm reduction. Taken together, analyses reveal that (1) SHSOs expend significant effort conducting outreach activities because Southern communities are generally unaware of harm reduction, (2) SHSOs continually advocate for harm reduction in the midst of a challenging socio-political context, and (3) SHSOs offer fewer harm reduction services and integrate harm reduction into their organizational infrastructure to a lesser extent due to external, contextual factors. The combination of organizational-level data and SHSO staff insights provided by this mixed methods study have implications for policy advocacy, funding initiatives, and capacity-building efforts.

Depression and Anxiety Symptoms and Treatment Utilization, and Associated HIV Outcomes among Adults with HIV in Rural Florida

Persons living with HIV (PLWH) and depression or anxiety in the rural South may have suboptimal HIV outcomes. We sought to examine the proportion of PLWH from rural Florida with symptoms of depression or anxiety, the proportion who received depression or anxiety treatment, and the relationship between untreated and treated symptoms of depression or anxiety and HIV outcomes. Cross-sectional survey data collected between 2014 and 2018 were analyzed. Among 187 PLWH residing in rural Florida (median age 49 years, 61.5%, male 45.5% Black), 127 (67.9%) met criteria for symptoms of depression and/or anxiety. Among these 127 participants, 60 (47.2%) were not on depression or anxiety treatment. Participants with untreated symptoms of depression and anxiety (OR 3.2, 95% CI 1.2-9.2, p = 0.03) and treated depression and anxiety with uncontrolled symptoms (OR 1.4, 95% CI 0.5-4.0, p = 0.52) were more likely to have viral non-suppression compared to those without depression or anxiety in an unadjusted bivariate analysis. Only the association between untreated symptoms of depression and anxiety and viral non-suppression was statistically significant, and when adjusting for social and structural confounders the association was attenuated and was no longer statistically significant. This suggests that social and structural barriers impact both mental health and HIV outcomes. Our findings support the need for increased mental health services and resources that address the social and structural barriers to care for PLWH in the rural South.

Self-reported Impacts of the COVID-19 Pandemic and Economic Inflation on the Well-being of Low-income U.S. Veterans

The health and well-being of low-income populations may be disproportionately impacted by major public health and economic events. This study examined written self-reported impacts of the Coronavirus Disease-2019 (COVID-19) pandemic and the economic inflationary period on health from a national sample of 854 low-income U.S. veterans. Responses were analyzed using rapid assessment procedures. In response to the COVID-19 pandemic, 59% of participants reported the pandemic had "no effect" on their health, 7% reported increased social isolation, and small proportions of participants reported negative effects on physical and mental health. In response to economic inflation, 43% of participants reported inflation had "no effect" on their health, 11% reported concerns about personal finances, and only small proportions reported other negative psychosocial impacts. Collectively, these findings suggest many low-income veterans are resilient during major events. Further research is needed on long-term health effects of inflation on this population.

HIV Prevention and Care Among Black Cisgender Sexual Minority Men and Transgender Women: Protocol for an HIV Status-Neutral Cohort Study Using an Observational-Implementation Hybrid Approach

BACKGROUND

Black cisgender gay, bisexual, and other sexual minority men (SMM) and transgender women (TW) continue to be heavily affected by HIV. Further research is needed to better understand HIV prevention and care outcomes in this population. In particular, there is a need for research examining the impact of substance use and sleep health on HIV prevention and treatment outcomes among Black SMM and TW.

OBJECTIVE

This paper outlines the study methods being used in the recently launched follow-up study to the Neighborhoods and Networks (N2) study, which we refer to as N2 Part 2 (N2P2). N2P2 aims to address this gap in the literature, build off the findings of the original N2 study, and identify socioenvironmental determinants of health, including whether neighborhood and network factors mediate and moderate these relationships.

METHODS

Building on the N2 cohort study in Chicago from 2018 to 2022, N2P2 used a prospective longitudinal cohort design and an observational-implementation hybrid approach. With sustained high levels of community engagement, we aim to recruit a new sample of 600 Black SMM and TW participants residing in the Chicago metropolitan statistical area. Participants are asked to participate in 3 study visits across an 18-month study period (1 visit every 9 months). Four different forms of data are collected per wave: (1) an in-person survey, (2) biological specimen collection, (3) a daily remote ecological momentary assessment for 14 days after each study visit, and (4) data from electronic health records. These forms of data collection continue to assess neighborhood and network factors and specifically explore substance use, sleep, immune function, obesity, and the implementation of potential interventions that address relevant constructs (eg, alcohol use and pre-exposure prophylaxis adherence).

RESULTS

The N2P2 study was funded in August 2021 by the National Institute of Drug Abuse (R01DA054553 and R21DA053156) and National Heart, Lung, and Blood Institute (R01HL160325). This study was launched in November 2022. Recruitment and enrollment for the first wave of data collection are currently ongoing.

CONCLUSIONS

The N2P2 study is applying innovative methods to comprehensively explore the impacts of substance use and sleep health on HIV-related outcomes among an HIV status-neutral cohort of Black SMM and TW in Chicago. This study is applying an observational-implementation hybrid design to help us achieve findings that support rapid translation, a critical priority among populations such as Black SMM and TW that experience long-standing inequities with regard to HIV and other health-related outcomes. N2P2 will directly build off the findings that have resulted from the original N2 study among Black SMM and TW in Chicago. These findings provide a better understanding of multilevel (eg, individual, network, and neighborhood) factors that contribute to HIV-related outcomes and viral suppression among Black SMM and TW.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48548.

HIV Knowledge, Risk Factors, and Utilization of Services in the US Rural Deep South

BACKGROUND

HIV prevalence in the rural South remains high among Black Americans due to limited access to prevention and treatment services and poverty. HIV care inequities for Black Americans living in the rural South are further intensified by high mortality rates, low HIV health literacy, stigma, and discrimination. Few studies have focused on HIV knowledge and risk factors within Black Americans in the rural South.

METHODS

This cross-sectional study examined the association between HIV risk factors, HIV knowledge, and utilization of HIV and/or sexually transmitted infection (STI) testing services among Black Americans (N = 200) living in the rural South. HIV knowledge, risk factors, and utilization of testing services were assessed via The HIV Knowledge Questionnaire, The HIV Risk Factor Questionnaire, and three investigator-generated questions, respectively. Linear regression was used to examine the relationship between demographic characteristics, HIV knowledge, utilization of testing services, and HIV risk factors.

RESULTS

Among 200 participants, a smaller percentage (37.7%, n = 75) reported using HIV/STI testing services compared to non-users. Controlling for demographic covariates in the model, HIV knowledge (p < .0001) and marital status (p = .010) were significantly associated with HIV risk factors. HIV risk factors decreased as HIV knowledge increased. Individuals who reported being single also reported having fewer risk factors.

CONCLUSION

Future research should examine the impact of HIV education tailored for individuals with greater HIV risk factors within rural Black Americans. Studies exploring barriers to the utilization of HIV/STI testing services within Black American rural communities are warranted.

Implementation of trauma-informed care and trauma-responsive services in clinical settings: a latent class regression analysis

Introduction

Engagement and retention in health care is vital to sustained health among people living with HIV (PLWH), yet clinical environments can deter health-seeking behavior, particularly for survivors of interpersonal violence. PLWH face disproportionate rates of interpersonal violence; clinical interactions can provoke a re-experiencing of the sequalae of trauma from violence, called re-traumatization. Trauma-informed care (TIC) is a strengths-based approach to case that minimizes potential triggers of re-traumatization and promotes patient empowerment, increasing acceptability of care. Yet, Ryan White HIV/AIDS clinics, at which over 50% of PLWH received care, have struggled to IMPLEMENT TIC. In this analysis, we sought to (1) identify unique sub-groups of HIV clinics based on clinical attributes (i.e., resources, leadership, culture, climate, access to knowledge about trauma-informed care) and (2) assess relationships between sub-group membership and degree of implementation of TIC and trauma-responsive services offered.

Methods

A total of 317 participants from 47 Ryan White Federally-funded HIV/AIDS clinics completed a quantitative survey between December 2019 and April 2020. Questions included assessment of inner setting constructs from the Consolidated Framework for Implementation Research (CFIR), perceived level of TIC implementation, and trauma-responsive services offered by each respondent's clinic. We employed latent class analysis to identify four sub-groups of clinics with unique inner setting profiles: Weak Inner Setting (n = 124, 39.1%), Siloed and Resource Scarce (n = 80, 25.2%), Low Communication (n = 49, 15.5%), and Robust Inner Robust (n = 64, 20.2%). We used multilevel regressions to predict degree of TIC implementation and provision of trauma-responsive services.

Results

Results demonstrate that clinics can be distinctly classified by inner setting characteristics. Further, inner setting robustness is associated with a higher degree of TIC implementation, wherein classes with resources (Robust Inner Setting, Low Communication) are associated with significantly higher odds reporting early stages of implementation or active implementation compared to Weak class membership. Resourced class membership is also associated with availability of twice as many trauma-responsive services compared to Weak class membership.

Discussion

Assessment of CFIR inner setting constructs may reveal modifiable implementation setting attributes key to implementing TIC and trauma-responsive services in clinical settings. Introduction.

Place Visitation Data Reveals the Geographic and Racial Disparities of COVID-19 Impact on HIV Service Utilization in the Deep South

BACKGROUND

The COVID-19 pandemic has posed unprecedented pressure to health care systems, and interrupted health care delivery and access including HIV care in the United States' Deep South, which endures a double epidemic of HIV and COVID-19. Ryan White programs cover HIV care services for over half of PLWH in the Deep South. Given the important role of Ryan White programs, examining the visitation changes to Ryan White facilities during the pandemic offers insights into the impact of the pandemic on HIV healthcare utilization.

OBJECTIVES

Analyze the geographic distribution of HIV facility visitors at the county level before and during the pandemic in the nine US states of Deep South (Alabama, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Texas) to reveal the geographic and racial disparity in visitation disruption caused by the pandemic.

METHODS

We first extracted mobile device-based visitation data for Ryan White HIV facilities in the Deep South during 2019 and 2020. To quantify the disruption in visitations during 2020, we calculated the visitation reduction rate (VRR) for each county, using 2019 data as the baseline. Next, we conducted a spatial analysis of the VRR values to uncover geographical disparities in visitation interruptions. To investigate racial disparities, we performed spatial regression analyses with VRR as the dependent variable, and the percentages of Black, Hispanic, and Asian populations as the independent variables. In this analysis, we controlled for potential confounders.

RESULTS

Geographic disparities in visitation reduction were observed, with all nine Deep South states experiencing significant drops. Georgia experienced the highest visitation loss (VRR = -0.58), followed by Texas (-0.47), Alabama (0.47), and Tennessee (-0.46), while South Carolina had the smallest reductions (-0.11). All the regression models consistently revealed racial disparities in visitation interruption. That is, counties with a higher proportion of Black population tended to have higher RW facility visitation reductions.

CONCLUSIONS

Our analysis revealed distinct geographic disparities in visitation interruptions at Ryan White HIV facilities in the Deep South during the COVID-19 pandemic in 2020. Furthermore, we found that the Black/African American population experienced a greater disruption at the county level in the Deep South during this period.

Association between Racial Residential Segregation and COVID-19 Mortality

This study investigates the impact of racial residential segregation on COVID-19 mortality during the first year of the US epidemic. Data comes from the Center for Disease Control and Prevention (CDC), and the Robert Wood Johnson Foundation's and the University of Wisconsin's joint county health rankings project. The observation includes a record of 8,670,781 individuals in 1488 counties. We regressed COVID-19 deaths, using hierarchical logistic regression models, on individual and county-level predictors. We found that as racial residential segregation increased, mortality rates increased. Controlling for segregation, Blacks and Asians had a greater risk of mortality, while Hispanics and other racial groups had a lower risk of mortality, compared to Whites. The impact of racial residential segregation on COVID-19 mortality did not vary by racial group.

Cultural interventions addressing disparities in the HIV prevention and treatment cascade among Black/African Americans: a scoping review

Culture is an important determinant of HIV risk and protective behaviors; yet, we know little about how it is integrated in HIV interventions. This scoping review characterizes the integration of culture in HIV prevention and treatment interventions focused on Black/African Americans. We searched MEDLINE, PsycINFO, CINAHL, and Google Scholar for peer-reviewed manuscripts published between July 1, 2011, and June 28, 2021. Twenty-five interventions were identified, with 96% focused on prevention. Most (40%) targeted men who have sex with men or transgender women. Only three were grounded in cultural theory. Although all interventions were labeled "culturally based," only two explicitly defined culture. Moreover, there was much diversity regarding the ways in which interventions integrated cultural elements, with some conflating race/ethnicity with culture. To improve uptake and HIV-related outcomes, interventions integrating culture are greatly needed. Additionally, HIV interventions purporting to be "culturally based" must include basic information to support rigor and reproducibility.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sexual Orientation, HIV Vulnerability-Enhancing Behaviors and HIV Status Neutral Care Among Black Cisgender Sexual Minority Men in the Deep South: The N2 Cohort Study

Black sexual minority men (SMM) in the Deep South are heavily impacted by HIV; yet studies fail to consider discordance across aspects of sexual orientation (i.e., identity, attraction, behavior) or how a lack of concordance enhances vulnerability to HIV. We sought to explore the overlap across aspects of sexual orientation and examine associations between each aspect and the number of sexual partners who engaged in HIV vulnerability-enhancing behaviors, and HIV prevention and care outcomes. A total of 204 Black SMM completed surveys, reporting their sexual identity, attraction, and behavior (i.e., sex with men only vs. sex with men and women), number of condomless sex or transactional sex (e.g., buyers vs. sellers) partners in the past 6 months, and adherence to pre-exposure prophylaxis (PrEP) or antiretroviral therapy (ART) among users. Less than one in four participants (22.5%) reported overlap in same-sex sexual orientations, while 17.1% of bisexual men reported overlap across aspects. In multivariable models, differences were found in how aspects of sexual orientation were associated with the number of partners who bought or sold sex; as well as how often participants tested for HIV in the past 12 months. Results suggest different aspects of sexual orientation have implications for addressing HIV among Black SMM in the Deep South.

Variation in HIV Transmission Behaviors Among People Who Use Drugs in Rural US Communities

Importance

People who use drugs (PWUD) continue to be at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within various rural communities is poorly understood.

Objective

To examine the association of characteristics of rural PWUD with HIV transmission behaviors.

Design, Setting, and Participants

In this cross-sectional study, surveys of PWUD in rural communities in 10 states (Illinois, Kentucky, New Hampshire, Massachusetts, North Carolina, Ohio, Oregon, Vermont, West Virginia, and Wisconsin) were collected January 2018 through March 2020 and analyzed August through December 2022. A chain-referral sampling strategy identified convenience sample seeds who referred others who used drugs. Rural PWUD who reported any past 30-day injection drug use or noninjection opioid use "to get high" were included.

Exposures

Individual characteristics, including age, race, gender identity, sexual orientation, partnership status, drug of choice, and location, were collected.

Main Outcomes and Measures

Past 30-day frequency of behaviors associated with HIV transmission, including drug injection, syringe sharing, opposite- and same-gender partners, transactional sex, and condomless sex, was assessed.

Results

Of 3048 rural PWUD (mean [SD] age, 36.1 [10.3] years; 225 American Indian [7.4%], 96 Black [3.2%], and 2576 White [84.5%] among 3045 with responses; and 1737 men [57.0%] among 3046 with responses), most participants were heterosexual (1771 individuals [86.8%] among 2040 with responses) and single (1974 individuals [68.6%] among 2879 with responses). Opioids and stimulants were reported as drug of choice by 1636 individuals (53.9%) and 1258 individuals (41.5%), respectively, among 3033 individuals with responses. Most participants reported recent injection (2587 of 3046 individuals [84.9%] with responses) and condomless sex (1406 of 1757 individuals [80.0%] with responses), among whom 904 of 1391 individuals (65.0%) with responses indicated that it occurred with people who inject drugs. Syringe sharing (1016 of 2433 individuals [41.8%] with responses) and transactional sex (230 of 1799 individuals [12.8%] with responses) were reported less frequently. All characteristics and behaviors, except the number of men partners reported by women, varied significantly across locations (eg, mean [SD] age ranged from 34.5 [10.0] years in Wisconsin to 39.7 [11.0] years in Illinois; P < .001). In multivariable modeling, younger age (adjusted odds ratio [aOR] for ages 15-33 vs ≥34 years, 1.36; 95% CI, 1.08-1.72) and being single (aOR, 1.37; 95% CI, 1.08-1.74) were associated with recent injection; younger age (aOR, 1.49; 95% CI, 1.20-1.85) and bisexual orientation (aOR vs heterosexual orientation, 2.27; 95% CI, 1.60-3.23) with syringe sharing; gender identity as a woman (aOR vs gender identity as a man, 1.46; 95% CI, 1.01-2.12), bisexual orientation (aOR vs heterosexual orientation, 2.59; 95% CI, 1.67-4.03), and being single (aOR, 1.71; 95% CI, 1.15-2.55) with transactional sex; and bisexual orientation (aOR vs heterosexual orientation, 1.60; 95% CI, 1.04-2.46) and stimulants as the drug of choice (aOR vs opioids, 1.45; 95 CI, 1.09-1.93) with condomless sex with someone who injects drugs.

Conclusions and Relevance

This study found that behaviors associated with HIV transmission were common and varied across communities. These findings suggest that interventions to reduce HIV risk among rural PWUD may need to be tailored to locally relevant factors.

Individual, Social, and Structural Vulnerability for Black Women in the South: Implications for PrEP

Pre-exposure prophylaxis (PrEP) is an effective biomedical HIV prevention option, yet adoption among Black women, who are disproportionately impacted by HIV, is low. A nuanced understanding of the multi-level factors that contribute to elevated risk is necessary to better contextualize PrEP uptake. Qualitative data from Black women residing in the Southern U.S. who self-screened as HIV-negative, were collected via four focus groups (N = 27) to understand influences on HIV vulnerability and the potential role of PrEP in mitigating risk. Content analysis of transcribed data yielded multiple themes addressing: the pervasiveness of sexual partner sharing; lack of transparency regarding HIV status, disclosure, and testing; and social/cultural influences on HIV risk. Experiences with the health care system and providers were of particular concern. Findings demonstrate support for PrEP in this population and contribute to our understanding of individual, social, and structural factors to better inform PrEP promotion.

A community health worker and mobile health app intervention to improve adherence to HIV medication among persons with HIV: the CHAMPS study protocol

BACKGROUND

Persons with HIV (PWH) can now achieve a near-normal life expectancy due to antiretroviral therapy (ART). Despite widespread availability of ART in the United States (US), many of the country's approximate 1.1 million PWH are not achieving viral suppression due to poor ART adherence. Viral suppression rates are particularly low in Alabama (AL, 62%) and New York City (NYC, 67%). There is mixed evidence on the efficacy of community health workers (CHW) and mHealth interventions for improving ART adherence and viral suppression in PWH thus, we sought to combine these interventions and test the efficacy for improving health outcomes in PWH.

METHODS

The CHAMPS study is a two-arm randomized controlled trial among 300 PWH with suboptimal primary care appointment adherence (n = 150 in AL and 150 in NYC) over the course of 12 months. Participants are randomly assigned to CHAMPS (intervention) or a standard-of-care (control) arm. Participants in the intervention arm are given a CleverCap pill bottle that syncs to the WiseApp to track medication adherence, reminds users to take their medication at a set time, and enables communication with CHW. All participants complete baseline, 6-month, and 12-month follow-up visits where surveys are administered and, CD4 and HIV-1 viral load are obtained through blood draw.

DISCUSSION

Maintaining ART adherence has significant implications in HIV management and transmission. mHealth technologies have been shown to optimize the provision of health services, produce positive changes in health behavior, and significantly improve health outcomes. CHW interventions also provide personal support to PWH. The combination of these strategies may provide the necessary intensity to increase ART adherence and clinic attendance among PWH at highest risk for low engagement. Delivering care remotely enables CHW to contact, assess, and support numerous participants throughout the day, reducing burden on CHW and potentially improving intervention durability for PWH. The adoption of the WiseApp coupled with community health worker sessions in the CHAMPS study has the potential to improve HIV health outcomes, and will add to the growing knowledge of mHealth and CHW efforts to improve PWH medication adherence and viral suppression.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov (NCT04562649) on 9/24/20.

Entertainment-education to reduce internalized stigma, increase intimate partner status disclosure intentions, and increase antiretroviral medical adherence intentions: A randomized controlled trial targeting black women living with HIV in the Southern U.S

BACKGROUND

Black women in the Southern U.S. account for 67% of all new HIV diagnoses across women of all races and ethnicities. In comparison to women of other racial and ethnic identities, Black women disproportionately experience internalized stigma, lower levels of disclosure self-efficacy, and lower rates of medical adherence. The disclosure processes model hypothesizes that persons living with HIV can be disclosure avoidance oriented or disclosure approach oriented. Disclosure avoidance is facilitated by various forms of stigma and negative outcome expectations. While disclosure approach orientation is facilitated by factors such as positive disclosure attitudes and disclosure self-efficacy. Despite the important role of disclosure in ending the HIV epidemic, extant interventions are limited. Recent research suggests entertainment-education (EE) may be an effective intervention for HIV status disclosure. Entertainment-education is a persuasive strategy that consists of intentionally embedding health and social messages into entertaining content.

METHODS

The present study evaluated the comparative efficacy of the 90 DAYS film for improving internalized HIV stigma, disclosure beliefs, positive disclosure attitudes, disclosure self-efficacy, HIV disclosure intentions, and medical adherence intentions. A randomized controlled trial was employed consisting of 130 Black women living with HIV in the Southern U.S. Participants were recruited primarily via a Qualtrics panel and randomly assigned to either view the 90 DAYS film or a standard of care brochure.

RESULTS

Results indicated the EE condition significantly outperformed the brochure condition on the following outcomes: disclosure beliefs (p = .046), positive disclosure attitudes (p = .008), disclosure self-efficacy (p = .007), and intentions to disclose to an intimate partner (p = .038). Statistically significant differences were not observed for internalized stigma or medical adherence intentions.

CONCLUSION

Findings suggest that EE is an effective strategy for improving psychosocial influences of disclosure and disclosure intentions. Theoretical and practical implications of this work are discussed.

Context specific HIV risk: evidence from screening into the southern pre-exposure prophylaxis study (SPECS)

While Pre-exposure prophylaxis (PrEP) is efficacious in preventing HIV, little is known about PrEP use among those on community supervision. The Southern Pre-Exposure Prophylaxis Study (SPECS) investigates barriers and facilitators for PrEP initiation and use among adults on community supervision (e.g., probation, parole). Challenges to PrEP use in this setting are abundant. SPECS uses a mixed-methods sequential design, including a multi-site, prospective cohort study in three southern states - North Carolina, Florida, and Kentucky. This analysis describes individual demographic, criminal legal, and HIV risk factor characteristics, by site and enrollment status. Pooled association analyses accounted for site via stratified statistical tests. Between June 2019-March 2020, SPECS screened 702 individuals and enrolled 276 participants (39%). Of those who were eligible, 98% agreed to enroll. Age, gender, and sexual orientation varied by enrollment and by site, while race/ethnicity varied by site but not enrollment status. Criminal legal histories varied by enrollment and HIV risk factors varied by site. SPECS provides a granular and detailed assessment of HIV risk in three diverse southern settings. It highlights how the level and type of HIV risk varies by location and by nature of criminal legal involvement and calls for the need for context-specific interventions for HIV prevention.

Patterns of Pre-exposure Prophylaxis (PrEP) Use in a Population Accessing PrEP in Jackson, Mississippi

Pre-exposure prophylaxis (PrEP) persistence is suboptimal in the United States. In the Deep South, a region with high rates of new HIV diagnosis, patterns of PrEP discontinuation remain unexplored. We evaluated data from a clinic-based PrEP program in Jackson, Mississippi and included patients initiating PrEP between August 2018 and April 2021. We considered patients to have a gap in PrEP coverage if they had at least 30 days without an active PrEP prescription; those who restarted PrEP after 30 days were classified as 'stopped and restarted' and those who never obtained a new PrEP prescription were classified as 'stopped and did not restart'. Patients without a gap in coverage were considered 'continuously on PrEP'. We estimated median time to first PrEP discontinuation and examined factors associated with time to first PrEP discontinuation. Of 171 patients who received an initial 90-day PrEP prescription; 75% were assigned male at birth and 74% identified as Black. The median time to first discontinuation was 90 days (95% CI 90-114). Twenty-two percent were continuously on PrEP, 28% stopped and restarted (median time off PrEP = 102 days), and 50% stopped and did not restart. Associations with early PrEP stoppage were notable for patients assigned sex female vs male (adjusted hazard ratio [aHR] = 1.6, 95% CI 1.0-2.5) and those living over 25 miles from clinic vs. 0-10 miles (aHR 1.89, 95% CI 1.2-3.0). Most patients never refilled an initial PrEP prescription though many patients re-started PrEP. Interventions to improve persistence and facilitate re-starts are needed.

Cardiometabolic Diseases and Quality-of-Life Outcomes in Adults With HIV in the Deep South: A Cross-sectional Study

ABSTRACT

The role of cardiometabolic diseases (CMDs) on physical health-related quality of life (P-HRQoL) and quality of sleep was examined among 261 PLWH ≥40 years, recruited from a university-affiliated HIV clinic in the Deep U.S. South. Using a cross-sectional study design, participants completed the Medical Outcomes Study HIV Health Survey (MOS-HIV; P-HRQoL) and Pittsburgh Sleep Quality Index. The overall prevalence of self-reporting ≥1 CMD was 64.4%. P-HRQoL scores were lower in PLWH with ≥1 CMD compared with those with no CMDs (45.53 ± 11.54 vs. 49.67 ± 10.77, p <.01). Poor sleep quality was higher among participants with ≥1 CMD compared with those with no CMDs (9.28 ± 4.42 vs. 7.26 ± 4.17, p <.01). Each additional CMD resulted in a 1.83-point decrease in P-HRQoL and 0.74-point increase in poor sleep quality scores. Interventions that focus on targeting these quality-of-life domains in PLWH with CMDs are needed.

A Census Tract-Level Examination of HIV Care Outcomes and Social Vulnerability Among Black/African American, Hispanic/Latino, and White Adults in the Southern United States, 2018

We examined the association between social vulnerability and HIV diagnoses, linkage to HIV medical care, and viral suppression among adults in the Southern U.S. Data from CDC's National HIV Surveillance System (NHSS) were used to determine census tract-level HIV diagnosis rates and percentages of persons linked to care within one month and with viral suppression within six months of diagnosis among Black/African American, Hispanic/Latino, and White adults aged ≥ 18 years residing in the Southern U.S. in 2018. Census tract-level social vulnerability data were obtained from the 2018 CDC Social Vulnerability Index (SVI). Rate and proportion ratios were used to determine the difference between the lowest quartile of SVI scores (Q1) and the highest quartile (Q4) by age group, transmission category, and region of residence and stratified by sex assigned at birth. Areas with the highest social vulnerability (Q4) had the highest rates of HIV diagnoses (Black: 56.5, Hispanic/Latino: 27.2, and White: 10.3). Those in Q4 also had the lowest percentages of adults linked to care (Black: 76.1%, Hispanic/Latino: 81.2%, and White: 77.8%), and the lowest percentages of adults with viral suppression (Black: 59.8%, Hispanic/Latino: 68.4%, and White: 65.7%). This ecological study found an association between social vulnerability, HIV diagnoses, and poorer care outcomes among Black/African American, Hispanic/Latino, and White adults. Tailoring interventions and improving access for persons residing in areas with the highest social vulnerability is necessary to reduce HIV transmission and improve health outcomes in the Southern U.S.

Sexual health discussion practices and HIV clinical care provided by primary care providers in the Southeast United States, K-BAP Study (2017-2018)

OBJECTIVE

Research underscores the importance of providers having routine discussions with patients about their sexual health. We examined the occurrences and association of routine sexual health discussion practices and human immunodeficiency virus (HIV) clinical care among primary care providers (PCPs) in areas with high HIV prevalence.

METHODS

We analysed data collected between April and August 2017 from an online survey that assessed PCPs knowledge, behaviours, attitudes, and practices of HIV-related care in 6 Southeast US jurisdictions (Atlanta, Baltimore, Baton Rouge, District of Columbia, Miami, and New Orleans).

RESULTS

Among PCPs, we found that 39.2% routinely obtained sexual health histories, 78.5% offered HIV testing, and 16.0% ever prescribed preexposure prophylaxis (PrEP). Based on adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs), the proportion of PCPs who routinely obtained sexual histories was higher among female PCPs (aPR = 1.47, 95% CI 1.04, 2.08), PCPs who had a patient population that was >50% men who have sex with men (MSM) (aPR = 1.94, 95% CI 1.72, 2.18), offered HIV testing (aPR = 3.60, 95% CI 2.23, 5.79), and ever prescribed PrEP (aPR = 1.43, 95% CI 1.06, 1.93).

CONCLUSION

Improving patient-provider discussions are needed to reduce HIV-related service barriers for disproportionately affected populations.

PRACTICE IMPLICATIONS

Routine discussions can reduce barriers to important HIV prevention and care services and help reduce disparities among patients living in highly prevalent HIV locations.

HIV geospatially clusters with firearm trauma in 35 Atlanta zip codes

The purpose of this study was to assess if rates of firearm trauma within Atlanta geospatially clustered with HIV prevalence and new HIV diagnosis rates. We retrospectively reviewed our Atlanta trauma center's registry for patients sustaining a ballistic firearm trauma from 2014 through 2018. Using the patient's zip code of home residence, we determined the rate of firearm trauma for that zip code. We obtained publicly available rates for HIV that corresponded with these select zip codes to perform a geospatial cluster analysis. The cohort was comprised of 1495 patients and represented 35 zip codes in Atlanta. The mean rate of firearm trauma for the 35 zip codes was 171.1 (±296.4) per 100,000 people. Compared to all Atlanta, the 35 zip codes' mean HIV prevalence (1863.9 vs 924.1, p < .0001) and new HIV diagnosis rate (396.9 vs 199.7, p < .0001) were significantly higher. Rates of firearm trauma and HIV prevalence demonstrated significant geospatial clustering (β 0.38, 95% CI 0.22-0.53, p < .0001) as did rates of firearm trauma and new HIV diagnoses (β 0.36, 95% CI 0.18-0.54, p = 0.0002). Our findings provide granular geographic data that could guide targeted HIV screening efforts in communities where our firearm-injured patients live.

Diseases spectrum in the field of spatiotemporal patterns mining of infectious diseases epidemics: A bibliometric and content analysis

Numerous investigations of the spatiotemporal patterns of infectious disease epidemics, their potential influences, and their driving mechanisms have greatly contributed to effective interventions in the recent years of increasing pandemic situations. However, systematic reviews of the spatiotemporal patterns of communicable diseases are rare. Using bibliometric analysis, combined with content analysis, this study aimed to summarize the number of publications and trends, the spectrum of infectious diseases, major research directions and data-methodological-theoretical characteristics, and academic communities in this field. Based on 851 relevant publications from the Web of Science core database, from January 1991 to September 2021, the study found that the increasing number of publications and the changes in the disease spectrum have been accompanied by serious outbreaks and pandemics over the past 30 years. Owing to the current pandemic of new, infectious diseases (e.g., COVID-19) and the ravages of old infectious diseases (e.g., dengue and influenza), illustrated by the disease spectrum, the number of publications in this field would continue to rise. Three logically rigorous research directions-the detection of spatiotemporal patterns, identification of potential influencing factors, and risk prediction and simulation-support the research paradigm framework in this field. The role of human mobility in the transmission of insect-borne infectious diseases (e.g., dengue) and scale effects must be extensively studied in the future. Developed countries, such as the USA and England, have stronger leadership in the field. Therefore, much more effort must be made by developing countries, such as China, to improve their contribution and role in international academic collaborations.

Predictors of an Active Lifestyle in Middle-Aged and Older Adults with HIV in the United States Deep South

Background and Purpose

An active lifestyle is important for health maintenance and disease prevention. This study was to examine what factors predict an active lifestyle in HIV+ and HIV- adults from the United States Deep South.

Methods

The sample included 279 participants (174 HIV+ and 105 HIV-) who completed a comprehensive assessment. An active lifestyle composite was created using variables of employment status, level of social support, level of physical activity, and diet. Correlations and regression analyses were conducted between the active lifestyle composite and possible predictors for all (HIV+ and HIV-), HIV+, and HIV- participants, respectively.

Results

Lower levels of depression, higher socioeconomic status (SES), and younger age were significant predictors of a more active lifestyle for the full sample, HIV+, and HIV- participants, respectively.

Conclusion

SES and depression represent important factors influencing engagement in an active lifestyle in PLWH. Such factors should be considered when developing and implementing lifestyle interventions.

Examining Stigma and Disclosure Among Women With HIV in the Southern United States: Qualitative Study Guided by the Adaptive Leadership Framework for Chronic Illness

ABSTRACT

Stigma is a fundamental cause of health inequities. Guided by the Adaptive Leadership Framework for Chronic Illness (ALFCI), this descriptive qualitative study explored the challenges of stigma and disclosure experienced by women with HIV (WWH) in the Southern United States. A convenience sample of 22 WWH aged 36 to 62 years were interviewed for this study. Analysis of participant interviews revealed that WWH face a multitude of stigma-related technical and adaptive challenges, which are consistent with the ALFCI. Once identified, technical challenges, such as recognizing the need for support, lack of trust, and fear of rejection, can be overcome by technical work, including providing assistance with HIV disclosure and building a trusted network. By identifying specific adaptive and technical challenges faced by WWH and engaging in technical and adaptive work, the WWH and the provider can reduce the fear of disclosure and the effect of stigma.

Racial disparities in the association between resilience and ART adherence among people living with HIV: the mediating role of depression

Research examining the mediating role of depressive symptoms in the association between resilience and antiretroviral therapy (ART) adherence is lacking. Therefore, this study aims to examine the mediating role of depression between resilience and ART adherence, as well as to explore whether this relationship varies across racial background. A total of 327 people living with HIV and on ART in South Carolina were surveyed about their ART adherence and mental health, including resilience and depressive symptoms. Path analyses were conducted to determine the direct and indirect effects between resilience, depressive symptoms, and ART adherence. After adjusting for age, gender, income, education, employment and time since diagnosis, among Black individuals, resilience was negatively associated with depressive symptoms (β = --0.248, p < 0.001); depressive symptoms were negatively associated with ART adherence (β = -0.166, p = 0.020); however, resilience was not significantly associated with ART adherence. Among White individuals, there was no statistically significant association. The indirect effect between resilience and ART adherence through depressive symptoms was statistically significant (β = 0.041, p = 0.040) for Black individuals, while not statistically significant for White individuals (β = 0.024, p = 0.578). Interventions aimed at improving ART adherence, which attenuate depressive symptoms through accentuating resilience may be especially beneficial for Black populations living with HIV.

Negative sentiments toward novel coronavirus (COVID-19) vaccines

Addressing negative vaccine sentiments is paramount to COVID-19 prevention efforts. However, assessing population sentiments is challenging due to the desirability bias that can emerge when directly asking respondents for their opinions on vaccination. Social media data, containing people's unfiltered thoughts, have the potential to offer valuable insights that could guide vaccine promotion messaging. We extracted one week's (4/5-4/11, 2020) worth of COVID-19 vaccine posts on Twitter (tweets) from the U.S. (N = 208,973) and segmented tweets with negative sentiments toward COVID-19 vaccines (n = 14,794). We imputed location based on Twitter users' self-reported state of residence. We found that states in the South had significantly higher prevalence of negative tweets compared to states in other parts of the country, and higher-income states reported lower prevalence of negative tweets. Our findings suggest the existence of negative vaccine sentiments and geographic variability in these opinions, warranting tailored vaccine promotion efforts, particularly for the southern U.S.

Psychological resilience is an independent correlate of health-related quality of life in middle-aged and older adults with HIV in the Deep South

Older people living with HIV (PLWH) are at risk for poorer health-related quality of life (HRQoL). Psychological resilience may protect HRQoL in this population. The sample included 174 predominately African American PLWH (age 40-73). Results indicated associations between resilience, socioeconomic status, cognitive performance, instrumental activities of daily living, personality, and depressive symptoms. HIV factors (e.g. viral load, duration of HIV) were not associated with resilience. Adjusting for confounders, resilience was associated with mental HRQoL. Understanding factors associated with resilience among older PLWH and the translation of resilience to HRQoL may inform interventions to improve well-being among individuals aging with HIV.

Integrating HIV and Mental Health Services for Black Gay, Bisexual, and Other Men Who Have Sex with Men Living with HIV: Findings from the STYLE 2.0 Intervention

Black gay, bisexual, and other men who have sex with men (BMSM) in the US South are disproportionately impacted by HIV. We adapted Project Strength Through Youth Livin' Empowered (STYLE) to create STYLE 2.0 to assist young BMSM link and remain engaged in HIV care. The multi-component intervention included (1) health care navigators to facilitate linkage and engagement activities, (2) motivational interviewing by a behavioral health provider, and (3) a mobile app to reduce stigma and social isolation. We enrolled 66 BMSM from North and South Carolina in the 12-month intervention and analyzed longitudinal data to assess service utilization, dose, and delivery characteristics while also examining changes in HIV care continuum outcomes. We examined associations between intervention characteristics and HIV care continuum outcomes using logistic regression. We found that all HIV outcomes improved from baseline to 12-month follow-up, including receipt of HIV care (78.8-84.9%), retention in HIV care (75.9-87.7%), being prescribed antiretroviral therapy (ART) (96.8-98.5%), and achieving viral suppression (82.3-90.8%), although none were statistically significant. In multi-variable analyses, participants with more encounters categorized as food bank were more likely to report being prescribed ART [odds ratio (OR): 41.65; 95% confidence interval (CI): 2.72-637.74]. Clients with more referral to care encounters were less likely to have been prescribed ART (OR: 0.02; 95% CI: <0.001-0.42) and be virally suppressed (OR: 0.39; 95% CI: 0.18-0.84). Findings suggest that an integrated approach to HIV and behavioral health services may help BMSM living with HIV overcome structural and social barriers to HIV care.

Prevalence and risk factors of high cholesterol and triglycerides among people with HIV in Texas

Background

People with HIV (PWH) commonly have elevated cholesterol and triglycerides levels that have been linked to medications. However, healthy behaviors including lifestyle changes can lower high cholesterol (CHOL) or high triglycerides (TG), thereby reducing individual risk for cardiovascular diseases. This study aimed to determine the prevalence and risk factors associated with high CHOL or TG among PWH in Texas.

Methods

Cross-sectional data of 981 PWH from the 2015–2017 Texas and Houston Medical Monitoring Projects were examined. High CHOL or TG was identified by medical chart diagnosis, CHOL or TG medication use, or most recent fasting lab ≥ 200 mg/dl (total CHOL) or ≥ 150 mg/dl (TG). High CHOL or TG associations with sociodemographic and clinical characteristics were assessed using Rao-Scott chi-square tests. Prevalence of high CHOL or TG development was calculated using multivariable logistic regression model.

Results

High CHOL or TG prevalence was 41% with participants being mostly male (73%), ≥ 40 years (68%), with overweight (31%) or obesity (28%), and virally suppressed (62%). Compared with PWH < 40 years of age, PWH in their 40s, 50s, and ≥ 60s were 57%, 64%, and 62% more likely to have high CHOL or TG, respectively. Participants with overweight and obesity were 41% and 30% more likely to have high CHOL or TG than those with normal weight (BMI: 18.5– < 25), respectively.

Conclusion

Since high CHOL and TG are modifiable CVD risk factors, increased education and lifestyle modification interventions are warranted to prevent the development of high CHOL or TG among PWH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-022-00467-y.

Racial disparity in ART adherence is closed in states with high social trust: Results from the Medical Monitoring Project (MMP), 2015

Racial/ethnic disparities persist in antiretroviral therapy (ART) adherence and viral suppression. We examined associations between state-level social trust and individual-level ART adherence and viral suppression and assessed whether these relationships varied by race/ethnicity. The Medical Monitoring Project (MMP) annually reports nationally representative estimates of the behavioral and clinical characteristics of HIV-positive adults in primary care. A total of 3298 adults diagnosed with HIV between 2015 and 2016 from 16 US states were included. We used weighted logistic regression to model the association between state-level social trust, race/ethnicity (Non-Hispanic Black, White, and Hispanic/Latino), and cross-product interactions with ART adherence (a binary measure derived from three self-reported questions), and viral suppression (a binary measure corresponding to plasma HIV RNA < 200 copies/ml). Social trust was the percentage of people in each state who agreed that most people in their neighborhood could be trusted. A high level of social trust was associated with a higher likelihood of ART adherence (PR [prevalence ratio] = 1.17; 95% confidence interval [CI]: 1.05-1.30). In covariate-adjusted analyses, the association between state-level social trust and individual-level ART adherence significantly varied by race/ethnicity (Wald χ2  F = 9.8 [df = 4], p = 0.044). Social trust was positively associated with ART, but the effect was smaller for Blacks than for Whites (PR = 0.66; 95% CI: 0.57-0.82) in states with the lowest social trust. Black-White differences were closed and no longer significant above mean social trust (PP [predicted probability] = 0.50 vs. 0.53, at two standard deviations). Racial/ethnic disparities in ART adherence were closed among individuals living in states with high social trust. Understanding the mechanisms that promote social trust among neighbors may have downstream impacts on reducing disparities in ART adherence among people with HIV (PWH).

Social disorganization and new HIV diagnoses, 2013-2017, Florida: Rural-urban differences

PURPOSE

To compare the role of neighborhood social disorganization factors on human immunodeficiency virus (HIV) diagnosis rates in urban and rural areas in Florida, we conducted an ecologic study of HIV diagnosis rates during 2013-2017 and social disorganization components, including concentrated disadvantage, ethnic heterogeneity, and residential instability.

METHODS

Indices of social disorganization components were obtained from principal component analyses of American Community Survey variables for 910 postal codes. Rural/urban classification was based on the United States Department of Agriculture Rural Urban Commuting Area codes. Using multivariable linear regression, the relationship between social disorganization indices and HIV diagnosis rates was assessed.

FINDINGS

The only social disorganization index that was significantly higher in rural than urban areas was concentrated disadvantage. In rural areas, the concentrated disadvantage index was significantly associated with HIV diagnosis rates (P = .007) when controlling for the other social disorganization factors but was no longer significant after additionally controlling for prevalence of people with an HIV diagnosis who were not virally suppressed. In urban areas, even after controlling for prevalence of people with HIV who were not virally suppressed, lower male-to-female population ratios and higher scores of residential instability, concentrated disadvantage, and LatinX/immigrant density indices were associated with higher HIV diagnosis rates (all P < .01).

CONCLUSIONS

In addition to improving community levels of viral suppression, the community contextual environment, including the rurality of the environment, needs to be considered in strategies to end the HIV epidemic in the United States.

Adverse Childhood Experiences among a Sample of Youth Living with HIV in the Deep South

The southern region of the United States, often referred to as the Deep South, is disproportionately affected by HIV. In fact, the highest rates of new HIV infections occur in the Deep South. Approximately one in five new HIV infections are among youth. Youth living with HIV (YLWH) have several behavioral health risks, including co-occurring mental health and substance abuse disorders, which negatively affect medication adherence, contribute to less engagement in HIV care, and result in poor health outcomes. Research suggests that adverse childhood experiences (ACEs) contribute to HIV risk behaviors and that people living with HIV may be more vulnerable to the negative health outcomes and adverse effects of stressors. Using existing program evaluation data, we examined data from 41 YLWH aged 17-24 screened for ACEs in an integrated care setting. Most participants were Black/African American young men who identified as homosexual, bisexual, or questioning, and who acquired HIV behaviorally. Approximately, one-third of YLWH screened positive or in the high-risk range on an ACEs screener. Scores fell in the intermediate range for nearly half of the sample. Results did not reveal a significant relationship between ACEs and HIV biological indicators. In this paper, we describe these findings and the importance of incorporating trauma-informed approaches into HIV prevention and treatment programs targeting youth in the Deep South.