Patient and Facility Correlates of Racial Differences in Viral Control for Black and White Veterans with HIV Infection in the Veterans Administration

Developing an mHealth program to improve HIV care continuum outcomes among young Black gay and bisexual men

BACKGROUND

Young Black gay and bisexual men (YBGBM) in the United States face significant disparities in HIV care outcomes. Mobile health (mHealth) interventions have shown promise with improving outcomes for YBGBM across the HIV care continuum.

METHODS

We developed an mHealth application using human-centered design (HCD) from 2019-2021 in collaboration with YBGBM living with HIV and with HIV service providers. Our HCD process began with six focus groups with 50 YBGBM and interviews with 12 providers. These insights were used to inform rapid prototyping, which involved iterative testing and refining of program features and content, with 31 YBGBM and 12 providers. We then collected user feedback via an online survey with 200 YBGBM nationwide and usability testing of a functional prototype with 21 YBGBM.

RESULTS

Focus groups and interviews illuminated challenges faced by YBGBM living with HIV, including coping with an HIV diagnosis, stigma, need for social support, and a dearth of suitable information sources. YBGBM desired a holistic approach that could meet the needs of those newly diagnosed as well as those who have been living with HIV for many years. Program preferences included video-based content where users could learn from peers and experts, a range of topics, a community of people living with HIV, and tools to support their health and well-being. Providers expressed enthusiasm for an mHealth program to improve HIV care outcomes and help them serve clients. Rapid prototyping resulted in a list of content topics, resources, video characteristics, community features, and mHealth tools to support adherence, retention, goal setting, and laboratory results tracking, as well as tools to help organization staff to support clients. Online survey and usability testing confirmed the feasibility, acceptability, and usability of the content, tools, and features.

CONCLUSIONS

This study demonstrates the potential of a video-based mHealth program to address the unique needs of YBGBM living with HIV, offering support and comprehensive information through a user-friendly interface and videos of peers living with HIV and of experts. The HCD approach allowed for continuous improvements to the concept to maximize cultural appropriateness, utility, and potential effectiveness for both YBGBM and HIV service organizations.

Relationship Between Patient Portal Tool Use and Medication Adherence and Viral Load Among Patients Living with HIV

BACKGROUND

Patient portals play an increasingly critical role in engaging patients in their health care. They have the potential to significantly impact the health of those living with chronic diseases, such as HIV, for whom consistent care engagement is both critical and complex.

OBJECTIVE

The primary aim was to examine the longitudinal relationships between individual portal tool use and health-related outcomes in patients living with HIV.

DESIGN

Retrospective cohort study using electronic health record data to examine the relationship between patient portal tool use and key HIV-specific, health-related outcomes in patients engaged in care in the Veterans Health Administration (VA) through the application of marginal structural models.

PARTICIPANTS

A national sample of patients living with HIV (PLWH) active in VA care who were registered to use the VA's patient portal, My HealtheVet (MHV; n = 18,390) between 10/1/2012 and 4/1/2017.

MAIN MEASURES

The MHV tools examined were prescription refill (including prescription refill of an antiretroviral (ART) medication and any medication), secure messaging, view appointments, and view labs. Primary outcomes were viral load test receipt, viral load suppression, and ART medication adherence (measured as proportion of days covered).

KEY RESULTS

The use of prescription refill for any medication or for ART was positively associated with ART adherence. Secure messaging was positively associated with ART adherence but not with viral load test receipt or viral load suppression. The use of view appointments was positively associated with ART adherence and viral load test receipt but not viral load suppression. The use of view labs was positively associated with viral load suppression but not ART adherence or viral load test receipt.

CONCLUSIONS

These findings highlight the valuable role patient portals may play in improving health-related outcomes among PLWH and have implications for patients living with other types of chronic disease.

The Mediating Role of Social Support and Resilience Between HIV-Related Stigmas and Patient Activation Among Young Black Women Living With HIV in the Southern United States: A Cross-sectional Study

ABSTRACT

Little is known about the construct of patient activation for engaging in favorable self-management behaviors in people with HIV. We conducted a cross-sectional study among young Black women with HIV (n = 84) to examine the association between stigma and patient activation and the mediating role of social support and resilience. Social support mediated the relationship between the following dimensions of stigma and patient activation: internalized (β = -0.20, SE = 0.08, CI [-0.369 to -0.071]) and anticipated in health care settings (β = -0.06, SE = 0.04, CI [-0.177 to -0.001]). Resilience mediated the relationship between the following dimensions of stigma and patient activation: anticipated in health care (β = -0.20, SE = 0.08, CI [-0.387 to -0.057]) and community settings (β = -0.15, SE = 0.08, CI [-0.318 to -0.017]), and enacted in community settings (β = -0.14, SE = 0.09, CI [-0.332 to -0.001]). Our findings suggest intrapersonal and interpersonal mechanisms by which various dimensions of stigma contribute to patient activation, thus identifying social support, resilience, and patient activation as potential intervention targets.

Correlates of personal health record registration and utilization among veterans with HIV

Objective

We examined correlates of registration and utilization of the Veteran Health Administration's (VHA) personal health record (PHR), My HealtheVet (MHV), among a national cohort of veterans living with HIV.

Materials and Methods

Using VHA administrative data, we matched veterans with HIV who registered for MHV in fiscal year 2012-2018 (n = 8589) to 8589 veterans with HIV who did not register for MHV. We compared demographic and geographic characteristics, housing status, comorbidities, and non-VHA care between MHV registrants and nonregistrants to identify correlates of MHV registration. Among registrants, we examined the association between these characteristics and MHV tool use (prescription refill, record download, secure messaging, view labs, and view appointments).

Results

MHV registrants were more likely to be younger, women, White, and to have bipolar disorder, depression, or post-traumatic stress disorder diagnosis than nonregistrants. Having a substance use disorder (SUD) diagnosis or a higher Elixhauser score was associated with lower odds of MHV registration. Among registrants, women were less likely to use prescription refill. Patients who were at risk of homelessness in the past year were less likely to use secure messaging and, along with those who were homeless, were less likely to use view labs and prescription refill. Bipolar disorder and depression were associated with increased secure messaging use. Diagnoses of SUD and alcohol use disorder were both associated with lower rates of prescription refill.

Discussion

Among veterans living with HIV, we identified significant differences in PHR registration and utilization by race, sex, age, housing status, and diagnosis.

Racial/Ethnic Disparities in the Burden of HIV/Cervical Cancer Comorbidity and Related In-hospital Mortality in the USA

OBJECTIVE

The purpose of this study was to determine whether cervical cancer is a risk factor for early mortality among women with HIV and whether racial/ethnic disparity predicted in-hospital death among women living with HIV and diagnosed with cervical cancer.

METHODS

We conducted a population-based study using the National Inpatient Sample (NIS) database comprising hospitalized HIV-positive women with or without cervical cancer diagnosis, from 2003 through 2015. We compared trends in the rates of cervical cancer, in-hospital death, and years of potential life lost (YPLL) by race/ethnicity.

RESULTS

We identified 2,613,696 women with HIV, and among them, 5398 had cervical cancer. The prevalence of cervical cancer (per 10,000) was 9.3 for NH-Whites, 30.9 among NH-Blacks, and 30.2 for Hispanics. Rates of cervical cancer over time diminished significantly only among NH-Whites (average annual percent change (AAPC), - 5.8 (- 9.7, - 1.8)), and YPLL in women with cervical cancer decreased significantly only in NH-Whites (AAPC, - 6.2 (- 10.1, - 2.0)). Cervical cancer was associated with increased odds of in-hospital death overall (OR 2.24 (1.59-3.15)) and among NH-Blacks (OR 2.03 (1.30-3.18)) only.

CONCLUSIONS

NH-Blacks and Hispanics with HIV remain at increased risk for concurrent diagnosis of cervical cancer compared with NH-Whites. Moreover, NH-Black women with HIV and cervical cancer are at greatest risk for in-hospital death. The findings emphasize the need for a more robust prevention strategy among minority women to reduce the high burden of HIV/cervical cancer and related mortality.

Racial Differences in Change in Physical Functioning in Older Male Veterans with HIV

Little is known about longitudinal change in physical functioning of older African American/Black and White HIV-infected persons. We examined up to 10 years of data on African American (N = 1,157) and White (N = 400) men with HIV infection and comparable HIV-negative men (n = 1,137 and 530, respectively), age 50-91 years from the Veterans Aging Cohort Study Survey sample. Physical functioning was assessed using the SF-12 (12-Item Short Form Health Survey) physical component summary (PCS) score. Mixed-effects models examined association of demographics, health conditions, health behaviors, and selected interactions with PCS score; HIV biomarkers were evaluated for HIV-infected persons. PCS scores were approximately one standard deviation below that of the general U.S. population of similar age. Across the four HIV/race groups, over time and through ages 65-75 years, PCS scores were maintained; differences were not clinically significant. PCS score was not associated with race or with interactions among age, race, and HIV status. CD4 and viral load counts of African American and White HIV-infected men were similar. Older age, low socioeconomic status, chronic health conditions and depression, lower body mass index, and smoking were associated with poorer PCS score in both groups. Exercising and, counterintuitively, being HIV infected were associated with better PCS score. Among these older African American and White male veterans, neither race nor HIV status was associated with PCS score, which remained relatively stable over time. Chronic disease, depression, and lack of exercise were associated with lower PCS score. To maintain independence in this population, attention should be paid to controlling chronic conditions, and emphasizing good health behaviors.

The moral discourse of HIV providers within their organizational context: An ethnographic case study

OBJECTIVE

Providers make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts.

METHODS

Our ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes.

RESULTS

We interviewed 30 providers, observed 43 clinical encounters, and recorded fieldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as "good," "behaving," or "socio-paths," and "flakes." Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients' life-contexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients' life challenges.

CONCLUSIONS AND PRACTICE IMPLICATIONS

When self-management is viewed as an individual's responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients' behaviors as socially embedded.

Gender Differences in HIV Testing, Diagnosis, and Linkage to Care in Healthcare Settings: Identifying African American Women with HIV in Chicago

Women account for 25% of all people living with HIV and 19% of new diagnoses in the United States. African American (AA) women are disproportionately affected. Yet, differences in the care continuum entry are not well understood between patient populations and healthcare sites. We aim to examine gender differences in diagnosis and linkage to care (LTC) in the Expanded HIV Testing and Linkage to Care (X-TLC) program within healthcare settings. Data were collected from 14 sites on the South and West sides of Chicago. Multivariate logistic regression analysis was used to determine the differences in HIV diagnoses and LTC by gender and HIV status. From 2011 to 2016, X-TLC performed 281,017 HIV tests; 63.7% of those tested were women. Overall HIV seroprevalence was 0.57%, and nearly one third (29.4%) of HIV-positive patients identified were cisgender women. Of newly diagnosed HIV-positive women, 89% were AA. 58.5% of new diagnoses in women were made at acute care hospitals, with the remainder at community health centers. Women who were newly diagnosed had a higher baseline CD4 count at diagnosis compared with men. Overall, women had lower odds of LTC compared with men (adjusted odds ratio = 0.58, 95% confidence interval 0.44-0.78) when controlling for patient demographics and newly versus previously diagnosed HIV status. Thus, interventions that focus on optimizing entry into the care continuum for AA women need to be explored.