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Hickey MD, Grochowski J, Mayorga-Munoz F, Oskarsson J, Imbert E, Spinelli M, Szumowski JD, Appa A, Koester K, Dauria EF, McNulty M, Colasanti J, Havlir DV, Gandhi M, Christopoulos KA. Identifying Implementation Determinants and Strategies for Long-Acting Injectable Cabotegravir-Rilpivirine in People With HIV Who Are Virally Unsuppressed. J Acquir Immune Defic Syndr 2024; 96:280-289. [PMID: 38534179 PMCID: PMC11192618 DOI: 10.1097/qai.0000000000003421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/13/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Early evidence suggests long-acting injectable cabotegravir and rilpivirine (LA-CAB/RPV) may be beneficial for people with HIV (PWH) who are unable to attain viral suppression (VS) on oral therapy. Limited guidance exists on implementation strategies for this population. SETTING Ward 86, a clinic serving publicly insured PWH in San Francisco. METHODS We describe multilevel determinants of and strategies for LA-CAB/RPV implementation for PWH without VS, using the Consolidated Framework for Implementation Research. To assess patient and provider-level determinants, we drew on pre-implementation qualitative data. To assess inner and outer context determinants, we undertook a structured mapping process. RESULTS Key patient-level determinants included perceived ability to adhere to injections despite oral adherence difficulties and care engagement challenges posed by unmet subsistence needs; strategies to address these determinants included a direct-to-inject approach, small financial incentives, and designated drop-in days. Provider-level determinants included lack of time to obtain LA-CAB/RPV, assess injection response, and follow-up late injections; strategies included centralizing eligibility review with the clinic pharmacist, a pharmacy technician to handle procurement and monitoring, regular multidisciplinary review of patients, and development of a clinic protocol. Ward 86 did not experience many outer context barriers because of rapid and unconstrained inclusion of LA-CAB/RPV on local formularies and ability of its affiliated hospital pharmacy to stock the medication. CONCLUSIONS Multilevel strategies to support LA-CAB/RPV implementation for PWH without VS are required, which may necessitate additional resources in some settings to implement safely and effectively. Advocacy to eliminate outer-context barriers, including prior authorizations and specialty pharmacy restrictions, is needed.
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Affiliation(s)
- Matthew D. Hickey
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Janet Grochowski
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Francis Mayorga-Munoz
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Jon Oskarsson
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Elizabeth Imbert
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Matthew Spinelli
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - John D. Szumowski
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Ayesha Appa
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Kimberly Koester
- Division of Prevention Science, University of California, San Francisco
| | - Emily F. Dauria
- Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh
| | - Moira McNulty
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago
| | | | - Diane V Havlir
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
| | - Katerina A. Christopoulos
- Division of HIV, Infectious Diseases, & Global Medicine, San Francisco General Hospital, University of California, San Francisco
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Greene E, Walcott M, Guerra L, Tieu HV, Nandi V, Soler J, Diaz J, Curriero F, Latkin C, Bosompem A, Frye V. Correlates of concordance between self-reported and lab-confirmed viral load among Black and Latine men who have sex with men (BLMSM) living with HIV in New York City. AIDS Care 2024; 36:661-671. [PMID: 37399515 PMCID: PMC10761596 DOI: 10.1080/09540121.2023.2229816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/20/2023] [Indexed: 07/05/2023]
Abstract
Sustained viral suppression is one of the four strategies in the U.S. Department of Health and Human Services' (HHS) plan to end the HIV epidemic in the United States. Individuals living with HIV must understand their viral load accurately for this strategy to be effective. We conducted cross-sectional analyses using baseline data from the NNHIV longitudinal study among men who have sex with men (MSM) living with HIV in New York City to identify factors associated with concordant knowledge between self-reported and lab-confirmed viral load. Of 164 Black and/or Latine participants, 67% (n = 110) reported that their viral load was undetectable, however lab tests showed only 44% (n = 72) had an undetectable viral load (<20 copies/ml). Overall, 62% of the sample (n = 102) had concordant HIV viral load knowledge (agreement of self-reported and lab viral load). In multivariable regression, those with unstable housing (PR = 0.52, 0.30-0.92) and those who had higher levels of beliefs of racism in medicine scale (PR = 0.76, 0.59-0.97) were less likely to have concordant knowledge. Our study underscores the need for implementing measures to improve viral load knowledge, U = U messaging, and strategies to achieve and maintain undetectable viral load status to reduce the burden of HIV at the population level.
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Affiliation(s)
| | - Melonie Walcott
- Laboratory of Infectious Disease Prevention, Lindsley F. Kimball Research Institute, New York Blood Center, NY, NY
| | - Lauren Guerra
- Department of Epidemiology, Columbia University Mailman School of Public Health, NY, NY
| | - Hong-Van Tieu
- Laboratory of Infectious Disease Prevention, Lindsley F. Kimball Research Institute, New York Blood Center, NY, NY
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, NY, NY
| | - Vijay Nandi
- Laboratory of Data Analytic Services, Lindsley F. Kimball Research Institute, New York Blood Center, NY, NY
| | - Jorge Soler
- Laboratory of Infectious Disease Prevention, Lindsley F. Kimball Research Institute, New York Blood Center, NY, NY
| | - Jose Diaz
- Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY
| | - Frank Curriero
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Carl Latkin
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | | | - Victoria Frye
- CUNY School of Medicine, NY, NY
- Laboratory of Infectious Disease Prevention, Lindsley F. Kimball Research Institute, New York Blood Center, NY, NY
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Mars SG, Spinelli MA, Ondocsin J, Koester KA, Rodriguez ES, Jain J, Arreguin M, Johnson MO, Gandhi M. Pandemic expertise: qualitative findings on the experiences of living with HIV during the COVID-19 pandemic. AIDS Care 2024; 36:382-389. [PMID: 37621106 PMCID: PMC10891295 DOI: 10.1080/09540121.2023.2248579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
This qualitative study explored the experiences of people living with HIV (PLWH) in the San Francisco Bay Area, United States, during the COVID-19 pandemic and subsequent public health restrictions at a safety net HIV clinic. Patients (N = 30) were recruited for Spanish/English language semi-structured interviews (n = 30), translated when necessary, and analyzed thematically. The recurring theme of "pandemic expertise" emerged from the data: skills and attitudes developed through living with HIV helped PLWH cope with the COVID-19 pandemic, including effective strategies for dealing with anxiety and depression; appreciation for life; and practical experience of changing behavior to protect their health. A subset did not consider living with HIV helped them adapt to the COVID-19 pandemic, with some describing their lives as chaotic due to housing issues and/or ongoing substance use. Overall, interviewees reported finding trustworthy health information that helped them follow COVID-19 prevention strategies. Although living with HIV is associated with a higher prevalence of mental health concerns, substance use, and stigma, these challenges can also contribute to increased self-efficacy, adaptation, and resilience. Addressing structural issues such as housing appears to be key to responding to both pandemics.
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Affiliation(s)
- Sarah G Mars
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - Matthew A Spinelli
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Jeff Ondocsin
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - Kim A Koester
- Department of Medicine, University of California, San Francisco, CA, USA
| | | | - Jennifer Jain
- Department of Psychiatry and Behavior Sciences, University of California, San Francisco, CA, USA
| | - Mireya Arreguin
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Mallory O Johnson
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Monica Gandhi
- Department of Medicine, University of California, San Francisco, CA, USA
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Hickey MD, Sergi F, Zhang K, Spinelli MA, Black D, Sola C, Blaz V, Nguyen JQ, Oskarsson J, Gandhi M, Havlir DV. Pragmatic randomized trial of a pre-visit intervention to improve the quality of telemedicine visits for vulnerable patients living with HIV. J Telemed Telecare 2023; 29:187-195. [PMID: 33342328 PMCID: PMC8214632 DOI: 10.1177/1357633x20976036] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The COVID-19 pandemic has required a shift of many routine primary care visits to telemedicine, potentially widening disparities in care access among vulnerable populations. In a publicly-funded HIV clinic, we aimed to evaluate a pre-visit phone-based planning intervention to address anticipated barriers to telemedicine. METHODS We conducted a pragmatic randomized controlled trial of patients scheduled for a phone-based HIV primary care visit at the Ward 86 HIV clinic in San Francisco from 15 April to 15 May 2020. Once reached by phone, patients were randomized to either have a structured pre-visit planning intervention to address barriers to an upcoming telemedicine visit versus a standard reminder call. The primary outcome was telemedicine visit attendance. RESULTS Of 476 scheduled telemedicine visits, 280 patients were reached by a pre-visit call to offer enrollment. Patients were less likely to be reached if virally unsuppressed (odds ratio (OR) 0.11, 95% confidence intervals (CI) 0.03-0.48), CD4 < 200 (OR 0.24, 95% CI 0.07-0.85), or were homeless (OR 0.24, 95% CI 0.07-0.87). There was no difference between intervention and control in scheduled visit attendance (83% v. 78%, OR 1.38, 95% CI 0.67-2.81). CONCLUSIONS A structured phone-based planning call to address barriers to telemedicine in a public HIV clinic was less likely to reach patients with poorly-controlled HIV and patients experiencing homelessness, suggesting additional interventions may be needed in this population to ensure access to telemedicine-based care. Among patients reachable by phone, telemedicine visit attendance was high and not improved with a structured pre-visit intervention, suggesting that standard reminders may be adequate in this population.
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Affiliation(s)
- Matthew D Hickey
- Division of HIV, ID and Global Medicine, University of California, USA
| | | | - Kevin Zhang
- Feinberg School of Medicine, Northwestern University, USA
| | | | - Douglas Black
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Cyril Sola
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Vanessa Blaz
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Janet Q Nguyen
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Jon Oskarsson
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Monica Gandhi
- Division of HIV, ID and Global Medicine, University of California, USA
| | - Diane V Havlir
- Division of HIV, ID and Global Medicine, University of California, USA
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5
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Christopoulos KA, Grochowski J, Mayorga-Munoz F, Hickey MD, Imbert E, Szumowski JD, Dilworth S, Oskarsson J, Shiels M, Havlir D, Gandhi M. First Demonstration Project of Long-Acting Injectable Antiretroviral Therapy for Persons With and Without Detectable Human Immunodeficiency Virus (HIV) Viremia in an Urban HIV Clinic. Clin Infect Dis 2023; 76:e645-e651. [PMID: 35913500 PMCID: PMC9907477 DOI: 10.1093/cid/ciac631] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Long-acting injectable antiretroviral therapy (LAI-ART) is approved for treatment-naive or experienced people with human immunodeficiency virus (HIV; PWH) based on trials that only included participants with viral suppression. We performed the first LAI-ART demonstration project to include PWH unable to achieve or maintain viral suppression due to challenges adhering to oral ART. METHODS Ward 86 is a large HIV clinic in San Francisco that serves publicly insured and underinsured patients. We started patients on LAI-ART via a structured process of provider referral, multidisciplinary review (MD, RN, pharmacist), and monitoring for on-time injections. Inclusion criteria were willingness to receive monthly injections and a reliable contact method. RESULTS Between June 2021 and April 2022, 51 patients initiated LAI-ART, with 39 receiving at least 2 follow-up injections by database closure (median age, 46 years; 90% cisgender men, 61% non-White, 41% marginally housed, 54% currently using stimulants). Of 24 patients who initiated injections with viral suppression (median CD4 cell count, 706 cells/mm3), 100% (95% confidence interval [CI], 86%-100%) maintained viral suppression. Of 15 patients who initiated injections with detectable viremia (median CD4 cell count, 99 cells/mm3; mean log10 viral load, 4.67; standard deviation, 1.16), 12 (80%; 95% CI, 55%-93%) achieved viral suppression, and the other 3 had a 2-log viral load decline by a median of 22 days. CONCLUSIONS This small demonstration project of LAI-ART in a diverse group of patients with high levels of substance use and marginal housing demonstrated promising early treatment outcomes, including in those with detectable viremia due to adherence challenges. More data on LAI-ART in hard-to-reach populations are needed.
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Affiliation(s)
- Katerina A Christopoulos
- Correspondence: K. A. Christopoulos, Division of HIV, ID, and Global Medicine, San Francisco General Hospital, University of California San Francisco, 995 Potrero Avenue, 4th Floor, San Francisco, CA 94110 ()
| | - Janet Grochowski
- Division of HIV, ID, and Global Medicine, University of California–San Francisco, San Francisco, California, USA
| | - Francis Mayorga-Munoz
- Division of HIV, ID, and Global Medicine, University of California–San Francisco, San Francisco, California, USA
| | - Matthew D Hickey
- Division of HIV, ID, and Global Medicine, University of California–San Francisco, San Francisco, California, USA
| | - Elizabeth Imbert
- Division of HIV, ID, and Global Medicine, University of California–San Francisco, San Francisco, California, USA
| | - John D Szumowski
- Division of HIV, ID, and Global Medicine, University of California–San Francisco, San Francisco, California, USA
| | - Samantha Dilworth
- Division of Prevention Science, University of California–San Francisco, San Francisco, California, USA
| | - Jon Oskarsson
- Division of HIV, ID, and Global Medicine, University of California–San Francisco, San Francisco, California, USA
| | - Mary Shiels
- Division of HIV, ID, and Global Medicine, University of California–San Francisco, San Francisco, California, USA
| | - Diane Havlir
- Division of HIV, ID, and Global Medicine, University of California–San Francisco, San Francisco, California, USA
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6
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Fernandez SB, Lopez C, Ibarra C, Sheehan DM, Ladner RA, Trepka MJ. Examining Barriers to Medication Adherence and Retention in Care among Women Living with HIV in the Face of Homelessness and Unstable Housing. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11484. [PMID: 36141757 PMCID: PMC9517674 DOI: 10.3390/ijerph191811484] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 06/16/2023]
Abstract
Despite advances in biomedical treatments, women living with HIV (WLH) who experience homelessness and housing instability suffer suboptimal HIV outcomes, even when linked to treatment. The purpose of this study was to explore experiences of housing instability among WLH and to understand its role in their ability to adhere to antiretroviral medication and remain retained in care. Sixteen women who were linked to Ryan White Program HIV care in South Florida participated in in-depth interviews. The findings focus around four larger themes: difficulty storing medication, privacy- and stigma-related issues, inconsistent access to medication and health care disruptions, and competing and unmet physical and mental health needs. Findings underscore the importance of strategies that are responsive to the disruption of routines and are sensitive to privacy issues in shared dwelling spaces; the proactive inquiry of behavioral and environmental considerations when prescribing antiretroviral medication; and the identification and treatment of comorbid conditions. This study provides evidence for strategies to facilitate self-management and improve modifiable system realities to augment larger-level policy and funding shifts that are critically needed to end the epidemic among vulnerable populations living with HIV.
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Affiliation(s)
- Sofia B. Fernandez
- School of Social Work, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
- Research Center in Minority Institutions (RCMI), Florida International University, Miami, FL 33199, USA
| | - Cindy Lopez
- Research Center in Minority Institutions (RCMI), Florida International University, Miami, FL 33199, USA
| | - Cynthia Ibarra
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
| | - Diana M. Sheehan
- Research Center in Minority Institutions (RCMI), Florida International University, Miami, FL 33199, USA
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
- Center for Substance Use and HIV/AIDS Research on Latinos in the United States (C-SALUD), Florida International University, Miami, FL 33199, USA
| | | | - Mary Jo Trepka
- Research Center in Minority Institutions (RCMI), Florida International University, Miami, FL 33199, USA
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL 33199, USA
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Papageorgiou V, Davies B, Cooper E, Singer A, Ward H. Influence of Material Deprivation on Clinical Outcomes Among People Living with HIV in High-Income Countries: A Systematic Review and Meta-analysis. AIDS Behav 2022; 26:2026-2054. [PMID: 34894331 PMCID: PMC9046343 DOI: 10.1007/s10461-021-03551-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2021] [Indexed: 11/06/2022]
Abstract
Despite developments in HIV treatment and care, disparities persist with some not fully benefiting from improvements in the HIV care continuum. We conducted a systematic review to explore associations between social determinants and HIV treatment outcomes (viral suppression and treatment adherence) in high-income countries. A random effects meta-analysis was performed where there were consistent measurements of exposures. We identified 83 observational studies eligible for inclusion. Social determinants linked to material deprivation were identified as education, employment, food security, housing, income, poverty/deprivation, socioeconomic status/position, and social class; however, their measurement and definition varied across studies. Our review suggests a social gradient of health persists in the HIV care continuum; people living with HIV who reported material deprivation were less likely to be virologically suppressed or adherent to antiretrovirals. Future research should use an ecosocial approach to explore these interactions across the lifecourse to help propose a causal pathway.
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Affiliation(s)
- Vasiliki Papageorgiou
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK.
| | - Bethan Davies
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Emily Cooper
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
| | - Ariana Singer
- School of Public Health, Imperial College London, London, UK
| | - Helen Ward
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
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Imbert E, Hickey MD, Del Rosario JB, Conte M, Kerkoff AD, Clemenzi-Allen A, Riley ED, Havlir DV, Gandhi M. Brief Report: Heterogeneous Preferences for Care Engagement Among People With HIV Experiencing Homelessness or Unstable Housing During the COVID-19 Pandemic. J Acquir Immune Defic Syndr 2022; 90:140-145. [PMID: 35262529 PMCID: PMC9203876 DOI: 10.1097/qai.0000000000002929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND/SETTING In San Francisco, HIV viral suppression is 71% among housed individuals but only 20% among unhoused individuals. We conducted a discrete choice experiment at a San Francisco public HIV clinic to evaluate care preferences among people living with HIV (PLH) experiencing homelessness/unstable housing during the COVID-19 pandemic. METHODS From July to November 2020, we conducted a discrete choice experiment among PLH experiencing homelessness/unstable housing who accessed care through (1) an incentivized, drop-in program (POP-UP) or (2) traditional primary care. We investigated 5 program features: single provider vs team of providers; visit incentives ($0, $10, and $20); location (current site vs current + additional site); drop-in vs scheduled visits; in-person only vs optional telehealth visits; and navigator assistance. We estimated relative preferences using mixed-effects logistic regression and conducted latent class analysis to evaluate preference heterogeneity. RESULTS We enrolled 115 PLH experiencing homelessness/unstable housing, 40% of whom lived outdoors. The strongest preferences were for the same provider (β = 0.94, 95% CI: 0.48 to 1.41), visit incentives (β = 0.56 per $5; 95% CI: 0.47 to 0.66), and drop-in visits (β = 0.47, 95% CI: 0.12 to 0.82). Telehealth was not preferred. Latent class analysis revealed 2 distinct groups: 78 (68%) preferred a flexible care model, whereas 37 (32%) preferred a single provider. CONCLUSIONS We identified heterogeneous care preferences among PLH experiencing homelessness/unstable housing during the COVID-19 pandemic, with two-thirds preferring greater flexibility and one-third preferring provider continuity. Telehealth was not preferred, even with navigator facilitation. Including patient choice in service delivery design can improve care engagement, particularly for marginalized populations, and is an essential tool for ending the HIV epidemic.
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Affiliation(s)
- Elizabeth Imbert
- Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
| | - Matthew D. Hickey
- Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
| | - Jan Bing Del Rosario
- Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
| | - Madellena Conte
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
| | - Andrew D. Kerkoff
- Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
| | - Angelo Clemenzi-Allen
- Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
- San Francisco Department of Public Health, San Francisco, USA
| | - Elise D Riley
- Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
| | - Diane V. Havlir
- Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
| | - Monica Gandhi
- Division of HIV, ID and Global Medicine, University of California, San Francisco, USA
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9
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Molecular Epidemiology of Individuals Experiencing Unstable Housing or Living Homeless at HIV Diagnosis: Analysis of HIV Surveillance Data in King County, Washington. AIDS Behav 2022; 26:3459-3468. [PMID: 35445995 DOI: 10.1007/s10461-022-03689-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/01/2022]
Abstract
We examined patterns of genetic clustering among individuals diagnosed with HIV between 2010 and 2018 using data from King County, Washington's National HIV Surveillance System. Among 2,371 individuals newly diagnosed with HIV, 231 (10%) experienced unstable housing or were living homeless at the time of diagnosis. Among the 1,658 (70%) people with an available HIV-1 pol gene sequence, 1,071 (65%) were identified to be part of 296 genetic clusters. In our analysis, housing status was not associated with genetic clustering (OR 1.02; 95%CI:0.75,1.39). After adjusting for demographic and behavioral factors, people who were living homeless at HIV diagnosis had 35% lower odds of being identified as part of a genetic cluster (AOR 0.65; 95%CI:0.44,0.95) compared to people with stable housing. Our findings highlight that people experiencing unstable housing are disproportionately burdened by HIV, and that within this population in King County, being in a genetic cluster is predominantly associated with substance use.
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10
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Plotzker RE, Burghardt NO, Murphy RD, McLean R, Jacobson K, Tang EC, Seidman D. Congenital syphilis prevention in the context of methamphetamine use and homelessness. Am J Addict 2022; 31:210-218. [PMID: 35340101 PMCID: PMC9507168 DOI: 10.1111/ajad.13265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Congenital syphilis (CS) is increasing in the United States and is associated with intersecting social and structural determinants of health. This study aimed to delineate birthing parent characteristics associated with CS in an adjusted model. METHODS (N = 720): People diagnosed with syphilis during pregnancy from 2017 to 2018 who were interviewed and linked to infants in the California state surveillance system were included (herein, "birthing parents"). Sociodemographic and clinical CS risk factors informed a stepwise multivariable logistic regression model in which the outcome of interest was infants born with CS. CS prevention continuums delineated the proportion of pregnant people with syphilis who completed steps (e.g., prenatal care entry, syphilis testing, treatment) needed to prevent CS; the outcome was delivering an infant without CS. We stratified continuums by homelessness and methamphetamine use to explore differences in CS outcomes. RESULTS Of 720 birthing parents, 245 (34%) delivered an infant with CS. Although CS was initially associated with homelessness (odds ratio [OR] = 2.5, 95% confidence interval [CI]: 1.6, 4.0) and methamphetamine use (OR = 2.1, 95% CI: 1.4, 3.1), the addition of prenatal care into a final adjusted model attenuated these associations to not significant. In CS prevention continuums, delivering an infant without CS was less likely for people who reported methamphetamine use (p < .001) and/or homelessness (p < .001). However, when examining only those who received prenatal care, statistical differences for these predictors no longer existed. In the final adjusted model the following were associated with CS: no prenatal care (OR = 16.7, 95% CI: 9.2, 30.3) or late prenatal care (OR = 2.9, 95% CI: 1.9, 4.2); early stage of syphilis (OR = 2.6, 95% CI: 1.8, 3.7); living in Central California (OR = 2.1, 95% CI: 1.1, 4.2). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE This is the first analysis to explore birthing parent characteristics associated with delivering an infant with CS in an adjusted model. We demonstrate that prenatal care, when accessed, can result in effective CS prevention among people who are unhoused and/or using methamphetamine equally well compared to counterparts without these risk factors.
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Affiliation(s)
- Rosalyn E Plotzker
- California Department of Public Health, Sexually Transmitted Diseases Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, Richmond, California, USA
| | - Nicole O Burghardt
- California Department of Public Health, Sexually Transmitted Diseases Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, Richmond, California, USA
| | - Ryan D Murphy
- California Department of Public Health, Sexually Transmitted Diseases Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, Richmond, California, USA
| | - Rachel McLean
- California Department of Public Health, Sexually Transmitted Diseases Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, Richmond, California, USA
| | - Kathleen Jacobson
- California Department of Public Health, Sexually Transmitted Diseases Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, Richmond, California, USA
| | - Eric C Tang
- California Department of Public Health, Sexually Transmitted Diseases Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, Richmond, California, USA
| | - Dominika Seidman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
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11
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Berthaud V, Johnson L, Jennings R, Chandler-Auguste M, Osijo A, Baldwin MT, Matthews-Juarez P, Juarez P, Wilus D, Tabatabai M. The effect of homelessness on viral suppression in an underserved metropolitan area of middle Tennessee: potential implications for ending the HIV epidemic. BMC Infect Dis 2022; 22:144. [PMID: 35144557 PMCID: PMC8830956 DOI: 10.1186/s12879-022-07105-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A wealth of scientific evidence supports the effectiveness of HIV prophylaxis and treatment. Homelessness is strongly associated with the health status and viral suppression among underserved populations and can undermine the national plan to eliminate HIV by 2030. This retrospective observational study examined the extent in which homelessness affects HIV treatment in an underserved urban area of Middle Tennessee in 2014-2019. RESULTS Among 692 HIV-seropositive patients, the proportion of homeless patients increased from 13.5% in 2014 to 27.7% in 2019, thrice the national average for HIV-seropositive people (8.4%) and twice that of HIV positive patients who are participating in Ryan White programs nationwide (12.9%). Our findings suggest that homeless patients were half as likely to achieve viral suppression as compared to those who had a permanent/stable home [OR 0.48 (0.32-0.72), p-value < 0.001]. CONCLUSION Our study indicates that homelessness may play an important role in viral suppression among persons living with HIV/AIDS in Middle Tennessee.
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Affiliation(s)
- Vladimir Berthaud
- Division of Infectious Diseases, Meharry Community Wellness Center, Meharry Medical College, Nashville, TN, USA.
| | - Livette Johnson
- Division of Infectious Diseases, Meharry Community Wellness Center, Meharry Medical College, Nashville, TN, USA
| | - Ronda Jennings
- Division of Infectious Diseases, Meharry Community Wellness Center, Meharry Medical College, Nashville, TN, USA
| | - Maxine Chandler-Auguste
- Division of Infectious Diseases, Meharry Community Wellness Center, Meharry Medical College, Nashville, TN, USA
| | - Abosede Osijo
- Division of Infectious Diseases, Meharry Community Wellness Center, Meharry Medical College, Nashville, TN, USA
| | - Marie T Baldwin
- Division of Infectious Diseases, Meharry Community Wellness Center, Meharry Medical College, Nashville, TN, USA
| | | | - Paul Juarez
- Department of Family and Community Medicine, Meharry Medical College, Nashville, TN, USA
| | - Derek Wilus
- School of Graduate Studies and Research, Meharry Medical College, Nashville, TN, USA
| | - Mohammad Tabatabai
- School of Graduate Studies and Research, Meharry Medical College, Nashville, TN, USA
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12
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Zelner J, Masters NB, Naraharisetti R, Mojola SA, Chowkwanyun M, Malosh R. There are no equal opportunity infectors: Epidemiological modelers must rethink our approach to inequality in infection risk. PLoS Comput Biol 2022; 18:e1009795. [PMID: 35139067 PMCID: PMC8827449 DOI: 10.1371/journal.pcbi.1009795] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Mathematical models have come to play a key role in global pandemic preparedness and outbreak response: helping to plan for disease burden, hospital capacity, and inform nonpharmaceutical interventions. Such models have played a pivotal role in the COVID-19 pandemic, with transmission models—and, by consequence, modelers—guiding global, national, and local responses to SARS-CoV-2. However, these models have largely not accounted for the social and structural factors, which lead to socioeconomic, racial, and geographic health disparities. In this piece, we raise and attempt to clarify several questions relating to this important gap in the research and practice of infectious disease modeling: Why do epidemiologic models of emerging infections typically ignore known structural drivers of disparate health outcomes? What have been the consequences of a framework focused primarily on aggregate outcomes on infection equity? What should be done to develop a more holistic approach to modeling-based decision-making during pandemics? In this review, we evaluate potential historical and political explanations for the exclusion of drivers of disparity in infectious disease models for emerging infections, which have often been characterized as “equal opportunity infectors” despite ample evidence to the contrary. We look to examples from other disease systems (HIV, STIs) and successes in including social inequity in models of acute infection transmission as a blueprint for how social connections, environmental, and structural factors can be integrated into a coherent, rigorous, and interpretable modeling framework. We conclude by outlining principles to guide modeling of emerging infections in ways that represent the causes of inequity in infection as central rather than peripheral mechanisms.
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Affiliation(s)
- Jon Zelner
- Dept. of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
- Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Nina B. Masters
- Dept. of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Ramya Naraharisetti
- Dept. of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
- Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Sanyu A. Mojola
- Dept. of Sociology, School of Public and International Affairs & Office of Population Research, Princeton University, Princeton, New Jersey, United States of America
| | - Merlin Chowkwanyun
- Dept. of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Ryan Malosh
- Dept. of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
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13
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Khazanchi R, Sayles H, Bares SH, Swindells S, Marcelin JR. Neighborhood Deprivation and Racial/Ethnic Disparities in Human Immunodeficiency Virus Viral Suppression: A Single-center, Cross-sectional Study in the United States Midwest. Clin Infect Dis 2021; 72:e642-e645. [PMID: 32845985 DOI: 10.1093/cid/ciaa1254] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 08/20/2020] [Indexed: 11/12/2022] Open
Abstract
Combating disparities is a crucial goal of ongoing efforts to end the human immunodeficiency virus (HIV) epidemic. In a multivariable analysis of a cohort in the Midwestern United States, racial/ethnic disparities in HIV viral suppression were no longer robust after accounting for other sociodemographic factors. Neighborhood deprivation and low income were independently inversely associated with viral suppression.
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Affiliation(s)
- Rohan Khazanchi
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Harlan Sayles
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sara H Bares
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Susan Swindells
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jasmine R Marcelin
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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14
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Imbert E, Hickey MD, Clemenzi-Allen A, Lynch E, Friend J, Kelley J, Conte M, Das D, Del Rosario JB, Collins E, Oskarsson J, Hicks ML, Riley ED, Havlir DV, Gandhi M. Evaluation of the POP-UP programme: a multicomponent model of care for people living with HIV with homelessness or unstable housing. AIDS 2021; 35:1241-1246. [PMID: 34076613 PMCID: PMC8186736 DOI: 10.1097/qad.0000000000002843] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Homelessness is the greatest risk factor for HIV viremia in San Francisco. Innovative care models for people with HIV (PWH) with homelessness or unstable housing (HUH) are needed to address this inequity. We developed a novel low-barrier clinic-based program for PWH-HUH in an urban safety-net clinic ('POP-UP') and report outcomes on care engagement and viral suppression. DESIGN A prospective cohort study. SETTING San Francisco General Hospital HIV Clinic (Ward 86). PARTICIPANTS We enrolled PWH who are HUH, viraemic and for whom usual care is not working (at least one missed primary care appointment and at least two drop-in visits at Ward 86 in the last year). INTERVENTION POP-UP provides drop-in comprehensive primary care, housing assistance and case management, financial incentives and patient navigation with frequent contact. MAIN OUTCOME MEASURES We describe uptake of eligible patients into POP-UP, and cumulative incidence of antiretroviral therapy (ART) initiation, return to care and virologic suppression 6 months post-enrolment, estimated via Kaplan--Meier. RESULTS Out of 192 referred patients, 152 were eligible, and 75 enrolled. All 75 were off ART and viraemic; 100% had a substance use disorder; and 77% had a mental health diagnosis. Over three-quarters restarted ART within 7 days of enrolment, and 91% returned for follow-up within 90 days. The cumulative incidence of viral suppression at 6 months was 55% (95% confidence interval 43-68). CONCLUSION A novel care model for PWH-HUH demonstrates early success in engaging viraemic patients in care and improving viral suppression. Low-barrier, high-contact primary care programmes offering comprehensive services and incentives may improve outcomes for this vulnerable population.
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Affiliation(s)
- Elizabeth Imbert
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Matthew D. Hickey
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Angelo Clemenzi-Allen
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
- San Francisco Department of Public Health
| | - Elizabeth Lynch
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - John Friend
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Jackelyn Kelley
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | | | | | - Jan Bing Del Rosario
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Erin Collins
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Jon Oskarsson
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Mary Lawrence Hicks
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Elise D. Riley
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, University of California, San Francisco
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15
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Riley ED, Hickey MD, Imbert E, Clemenzi-Allen AA, Gandhi M. Coronavirus Disease 2019 (COVID-19) and HIV Spotlight the United States Imperative for Permanent Affordable Housing. Clin Infect Dis 2021; 72:2042-2043. [PMID: 32887980 PMCID: PMC7499525 DOI: 10.1093/cid/ciaa1327] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/03/2020] [Indexed: 11/30/2022] Open
Abstract
Job loss and evictions tied to the COVID-19 pandemic are expected to significantly increase homelessness in the coming months. Reciprocally, homelessness and the many vulnerabilities that inevitably accompany it are driving COVID-19 outbreaks in U.S. shelters and other congregate living situations. Unless we intervene to address homelessness, these co-existing and synergistic situations will make the current public health crisis even worse. Preventing homelessness and providing permanent affordable housing has reduced the ravages of the HIV epidemic. We must take the lessons learned in 40 years of fighting HIV to respond effectively to the COVID-19 crisis. Housing is an investment that will curb the spread of COVID-19 and help protect all of us from future pandemics.
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Affiliation(s)
- Elise D Riley
- Department of Medicine, Division of HIV, Infectious Disease and Global Medicine, University of California San Francisco, San Francisco, California, USA
| | - Matthew D Hickey
- Department of Medicine, Division of HIV, Infectious Disease and Global Medicine, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Imbert
- Department of Medicine, Division of HIV, Infectious Disease and Global Medicine, University of California San Francisco, San Francisco, California, USA
| | - Angelo A Clemenzi-Allen
- Department of Medicine, Division of HIV, Infectious Disease and Global Medicine, University of California San Francisco, San Francisco, California, USA.,San Francisco Department of Public Health, San Francisco, California, USA
| | - Monica Gandhi
- Department of Medicine, Division of HIV, Infectious Disease and Global Medicine, University of California San Francisco, San Francisco, California, USA
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16
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Housing instability is associated with failure to achieve virologic control among pregnant individuals with HIV. Am J Obstet Gynecol MFM 2021; 3:100406. [PMID: 34058424 DOI: 10.1016/j.ajogmf.2021.100406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/12/2021] [Accepted: 05/25/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Homelessness and housing instability, which are on the rise nationally, are considered important social determinants of health. Among nonpregnant adults living with HIV, both have been associated with decreased linkage to medical care and virologic nonsuppression. This association may be particularly concerning in pregnancy, because virologic control is the primary determinant of HIV perinatal transmission. In addition, housing instability in pregnancy may be an independent risk factor for adverse perinatal outcomes, further amplifying perinatal risks in pregnant individuals living with HIV. However, the role of housing as a social determinant of health among such individuals is largely unstudied. OBJECTIVE The objective was to examine the association between housing instability and virologic control among pregnant individuals living with HIV. STUDY DESIGN This was a retrospective cohort study of pregnant individuals seeking perinatal care in a specialty HIV clinic from 2007 to 2018. Markers of virologic control, including time from antiretroviral therapy initiation to virologic suppression, antiretroviral therapy adherence, and viral load at 36 weeks and at delivery, were assessed. All patients underwent assessment of housing status with a licensed clinical social worker and were classified as experiencing housing instability (ie, staying with family or friends, transitional housing, treatment program, shelter, outdoors or vehicle, hotel, or incarcerated) vs not experiencing instability (renting or owning). Multivariable regression models assessed the associations of housing instability with virologic control. RESULTS Of 232 pregnant patients living with HIV with documented housing status, 41.4% (n=96) experienced housing instability. Patients with housing instability were younger and more likely to self-identify as non-Hispanic Black, have public or no insurance, and have a mental health or substance use disorder. They were less likely to be married, be employed, or have greater than a high school education. There were no differences in parity, number of prenatal visits, or timing of HIV diagnosis between groups. On adjusted analyses, patients with housing instability required an adjusted 2.45 weeks (95% confidence interval, 0.16-4.74) longer to achieve initial viral suppression and had greater odds of missing 5 or more doses of antiretroviral medications (adjusted odds ratio, 2.09; 95% confidence interval, 1.07-4.09) and having a detectable viral load at delivery (adjusted odds ratio, 2.13; 95% confidence interval, 1.02-4.47). CONCLUSION Housing instability among pregnant individuals living with HIV is common and is associated with decreased virologic control during pregnancy. Given the association between virologic control and perinatal transmission, housing instability may be an important social determinant of HIV-related perinatal outcomes. Addressing housing instability during pregnancy may be a critical avenue to improve maternal and neonatal health and reduce the risk of perinatal transmission.
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17
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Spinelli MA, Hessol NA, Schwarcz SK, Scheer S, Gandhi M, Chin Hsu L. Disparities in Integrase Inhibitor Usage in the Modern HIV Treatment Era: A Population-Based Study in a US City. Open Forum Infect Dis 2021; 8:ofab139. [PMID: 34250184 PMCID: PMC8266565 DOI: 10.1093/ofid/ofab139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/18/2021] [Indexed: 11/14/2022] Open
Abstract
Integrase inhibitor–based (INSTI) antiretroviral therapy (ART) regimens are preferred for most people with HIV (PWH). We examined factors associated with INSTI use among PWH in San Francisco who started ART in 2009–2016. PWH who experienced homelessness were less likely, and older PWH were more likely, to use an INSTI.
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Affiliation(s)
- Matthew A Spinelli
- Division of HIV, ID, and Global Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Nancy A Hessol
- Division of HIV, ID, and Global Medicine, University of California, San Francisco, San Francisco, California, USA.,San Francisco Department of Public Health, San Francisco, California, USA
| | - Sandra K Schwarcz
- Division of HIV, ID, and Global Medicine, University of California, San Francisco, San Francisco, California, USA.,San Francisco Department of Public Health, San Francisco, California, USA
| | - Susan Scheer
- San Francisco Department of Public Health, San Francisco, California, USA
| | - Monica Gandhi
- Division of HIV, ID, and Global Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ling Chin Hsu
- San Francisco Department of Public Health, San Francisco, California, USA
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18
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Winetsky D, Burack D, Antoniou P, Garcia B, Gordon P, Scherer M. Psychosocial Factors and the Care Cascade for Hepatitis C Treatment Colocated at a Syringe Service Program. J Infect Dis 2021; 222:S392-S400. [PMID: 32877544 DOI: 10.1093/infdis/jiaa142] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) is highly effective. However, people who inject drugs face significant barriers to DAA access. METHODS We describe a program that colocates HCV management within a syringe service program in New York City. We performed a retrospective chart review of all patients with confirmed HCV viremia. RESULTS From 2015 to 2018, 102 patients with viremia completed intake. Fifty-eight patients started DAAs. Nine patients discontinued treatment or were lost to follow-up before completion; 1 is continuing DAA treatment. Of 48 patients who completed therapy, sustained virologic response (SVR) was achieved in 43 (89.6%). Age and established mental health treatment at intake were associated with SVR. Regular cocaine use was negatively associated with SVR in univariate analysis, but this association was not significant after adjustment for age. Of 30 patients completing DAA therapy with active illicit opioid use at intake, 14 (46.4%) engaged in opioid use disorder (OUD) treatment during therapy, and 9 remained in OUD treatment after completion of DAA treatment. CONCLUSIONS Loss to follow-up is a challenge for people who inject drugs, but among those who completed treatment, SVR was achieved at a high rate. Mental health treatment may facilitate HCV cure. Conversely, HCV therapy may facilitate engagement in OUD treatment and other services.
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Affiliation(s)
- Daniel Winetsky
- Comprehensive Health Program, New York Presbyterian Hospital, New York, USA.,Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, USA.,HIV Center for Clinical and Behavioral Studies at Columbia University and New York State Psychiatric Institute, New York, USA
| | - Daniel Burack
- Department of Medicine, Columbia University Irving Medical Center, New York, USA
| | - Pantelis Antoniou
- Comprehensive Health Program, New York Presbyterian Hospital, New York, USA
| | - Bill Garcia
- Washington Heights Corner Project, New York, USA
| | - Peter Gordon
- Comprehensive Health Program, New York Presbyterian Hospital, New York, USA.,Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, USA
| | - Matthew Scherer
- Comprehensive Health Program, New York Presbyterian Hospital, New York, USA.,Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, USA
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19
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Hickey MD, Imbert E, Glidden DV, Del Rosario JB, Chong M, Clemenzi-Allen A, Oskarsson J, Riley ED, Gandhi M, Havlir DV. Viral suppression during COVID-19 among people with HIV experiencing homelessness in a low-barrier clinic-based program. AIDS 2021; 35:517-519. [PMID: 33306555 PMCID: PMC7861117 DOI: 10.1097/qad.0000000000002793] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Coronavirus disease-2019 (COVID-19) threatens to further worsen HIV outcomes among people experiencing homelessness. We conducted an interrupted time-series analysis of care engagement and viral suppression among unhoused individuals in the 'POP-UP' low-barrier, high-intensity HIV primary care program during COVID-19. Among 85 patients, care engagement and viral suppression did not decrease in the 5 months following implementation of San Francisco's 'shelter-in-place' ordinance. Low-barrier, in-person HIV care for homeless individuals may be important for maintaining HIV outcomes during COVID-19.
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Affiliation(s)
- Matthew D. Hickey
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, California
| | - Elizabeth Imbert
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, California
| | - David V. Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Jan Bing Del Rosario
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, California
| | - Mary Chong
- School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Angelo Clemenzi-Allen
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, California
- San Francisco Department of Public Health, San Francisco, California
| | - Jon Oskarsson
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, California
| | - Elise D. Riley
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, California
| | - Monica Gandhi
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, California
| | - Diane V. Havlir
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, California
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20
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Geng EH. Doctor as Street-Level Bureaucrat. N Engl J Med 2021; 384:101-103. [PMID: 33502832 DOI: 10.1056/nejmp2019939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Elvin H Geng
- From the Division of Infectious Diseases, Department of Medicine, and the Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis
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21
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Brown LB, Spinelli MA, Gandhi M. The interplay between HIV and COVID-19: summary of the data and responses to date. Curr Opin HIV AIDS 2021; 16:63-73. [PMID: 33186229 PMCID: PMC7735216 DOI: 10.1097/coh.0000000000000659] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW We examine the interplay between the HIV and COVID-19 epidemics, including the impact of HIV on COVID-19 susceptibility and severe disease, the effect of the COVID-19 epidemic on HIV prevention and treatment, and the influence of the HIV epidemic on responses to COVID-19. RECENT FINDINGS Evidence to date does not suggest that people living with HIV (PLWH) have a markedly higher susceptibility to SARS-CoV-2 infection, with disparities in the social determinants of health and comorbidities likely having a greater influence. The majority of literature has not supported a higher risk for severe disease among PLWH in Europe and the United States, although a large, population-based study in South Africa reported a higher rate of death due to COVID-19. Higher rates of comorbidities associated with COVID-19 disease severity among PLWH is an urgent concern. COVID-19 is leading to decreased access to HIV prevention services and HIV testing, and worsening HIV treatment access and virologic suppression, which could lead to worsening HIV epidemic control. CONCLUSION COVID-19 is threatening gains against the HIV epidemic, including the U.S. Ending the HIV Epidemic goals. The ongoing collision of these two global pandemics will continue to need both study and interventions to mitigate the effects of COVID-19 on HIV efforts worldwide.
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Affiliation(s)
- Lillian B. Brown
- Division of HIV, ID, and Global Medicine, University of California, San Francisco
| | - Matthew A. Spinelli
- Division of HIV, ID, and Global Medicine, University of California, San Francisco
| | - Monica Gandhi
- Division of HIV, ID, and Global Medicine, University of California, San Francisco
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22
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Conte M, Eshun-Wilson I, Geng E, Imbert E, Hickey MD, Havlir D, Gandhi M, Clemenzi-Allen A. Brief Report: Understanding Preferences for HIV Care Among Patients Experiencing Homelessness or Unstable Housing: A Discrete Choice Experiment. J Acquir Immune Defic Syndr 2020; 85:444-449. [PMID: 33136742 PMCID: PMC8028840 DOI: 10.1097/qai.0000000000002476] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Homelessness and unstable housing (HUH) negatively impact care outcomes for people living with HIV (PLWH). To inform the design of a clinic program for PLWH experiencing HUH, we quantified patient preferences and trade-offs across multiple HIV-service domains using a discrete choice experiment (DCE). METHODS We sequentially sampled PLWH experiencing HUH presenting at an urban HIV clinic with ≥1 missed primary care visit and viremia in the last year to conduct a DCE. Participants chose between 2 hypothetical clinics varying across 5 service attributes: care team "get to know me as a person" versus not; receiving $10, $15, or $20 gift cards for clinic visits; drop-in versus scheduled visits; direct phone communication to care team versus front-desk staff; and staying 2 versus 20 blocks from the clinic. We estimated attribute relative utility (ie, preference) using mixed-effects logistic regression and calculated the monetary trade-off of preferred options. RESULTS Among 65 individuals interviewed, 61% were >40 years old, 45% White, 77% men, 25% heterosexual, 56% lived outdoors/emergency housing, and 44% in temporary housing. Strongest preferences were for patient-centered care team [β = 3.80; 95% confidence interval (CI): 2.57 to 5.02] and drop-in clinic appointments (β = 1.33; 95% CI: 0.85 to 1.80), with a willingness to trade $32.79 (95% CI: 14.75 to 50.81) and $11.45 (95% CI: 2.95 to 19.95) in gift cards/visit, respectively. CONCLUSIONS In this DCE, PLWH experiencing HUH were willing to trade significant financial gain to have a personal relationship with and drop-in access to their care team rather than more resource-intensive services. These findings informed Ward 86's "POP-UP" program for PLWH-HUH and can inform "ending the HIV epidemic" efforts.
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Affiliation(s)
- Madellena Conte
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
- Institute of Global Health Sciences, University of California, San Francisco, San Francisco, CA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO; and
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO; and
| | - Elizabeth Imbert
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Matthew D Hickey
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Diane Havlir
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Monica Gandhi
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Angelo Clemenzi-Allen
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
- San Francisco Department of Public Health, San Francisco, CA
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Spinelli MA, Hickey MD, Glidden DV, Nguyen JQ, Oskarsson JJ, Havlir D, Gandhi M. Viral suppression rates in a safety-net HIV clinic in San Francisco destabilized during COVID-19. AIDS 2020; 34:2328-2331. [PMID: 32910069 DOI: 10.1097/qad.0000000000002677] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: The COVID-19 pandemic is expected to hinder US End the HIV Epidemic goals. We evaluated viral suppression and retention-in-care before and after telemedicine was instituted, in response to shelter-in-place mandates, in a large, urban HIV clinic. The odds of viral nonsuppression were 31% higher postshelter-in-place (95% confidence interval = 1.08-1.53) in spite of stable retention-in-care and visit volume, with disproportionate impact on homeless individuals. Measures to counteract the effect of COVID-19 on HIV outcomes are urgently needed.
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Orlando MS, Vable AM, Holt K, Wingo E, Newmann S, Shapiro BJ, Borne D, Drey EA, Seidman D. Homelessness, housing instability, and abortion outcomes at an urban abortion clinic in the United States. Am J Obstet Gynecol 2020; 223:892.e1-892.e12. [PMID: 32640198 DOI: 10.1016/j.ajog.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/14/2020] [Accepted: 07/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adverse reproductive health outcomes are well documented among people experiencing homelessness or housing instability. Little is known about abortion outcomes among this population. OBJECTIVE This study aimed to investigate the relationship between housing status and abortion outcomes and whether gestational age mediates this relationship. STUDY DESIGN Our sample comprised 1903 individuals who had abortions at an urban clinic in San Francisco, CA, from 2015 to 2017. We defined homelessness or housing instability as a binary exposure, which included staying outside, with friends and/or family, or in a tent, vehicle, shelter, transitional program, or hotel. We evaluated gestational duration of ≥20 weeks as a mediator variable. Our primary outcome was any abortion complication. Logistic regression models were adjusted for age, race, substance use, mental health diagnoses, and previous vaginal and cesarean deliveries. RESULTS Approximately 19% (n=356) of abortions were among people experiencing homelessness or housing instability. Compared with those with stable housing, people experiencing homelessness or housing instability presented later in pregnancy (mean gestational duration, 13.3 vs 9.5 weeks; P<.001) and had more frequent complications (6.5% vs 2.8%; P<.001; odds ratio, 2.2; 95% confidence interval, 1.2-3.9). Adjusting for race, substance use, mental health diagnoses, and previous cesarean deliveries, individuals experiencing homelessness or housing instability were more likely to have abortion complications (odds ratio, 2.3; 95% confidence interval, 1.3-4.0). However, the relationship was attenuated after adjusting for gestational duration (odds ratio, 1.4; 95% confidence interval, 0.7-2.6), suggesting that gestational duration mediates the relationship between housing status and abortion complications. CONCLUSION Patients experiencing homelessness or housing instability presented later in gestation, which seems to contribute to the increased frequency of abortion complications.
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Affiliation(s)
- Megan S Orlando
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Anusha M Vable
- Family and Community Medicine, University of California, San Francisco, San Francisco, CA
| | - Kelsey Holt
- Bixby Center for Global Reproductive Health, San Francisco, CA; Family and Community Medicine, University of California, San Francisco, San Francisco, CA
| | - Erin Wingo
- Bixby Center for Global Reproductive Health, San Francisco, CA
| | - Sara Newmann
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; Bixby Center for Global Reproductive Health, San Francisco, CA
| | - Bradley J Shapiro
- Psychiatry, University of California, San Francisco, San Francisco, CA
| | - Deborah Borne
- San Francisco Health Network Transitions Division, San Francisco Department of Public Health, San Francisco, CA
| | - Eleanor A Drey
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; Bixby Center for Global Reproductive Health, San Francisco, CA
| | - Dominika Seidman
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; Bixby Center for Global Reproductive Health, San Francisco, CA.
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Improving Care Outcomes for PLWH Experiencing Homelessness and Unstable Housing: a Synthetic Review of Clinic-Based Strategies. Curr HIV/AIDS Rep 2020; 17:259-267. [PMID: 32382919 DOI: 10.1007/s11904-020-00488-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Singular interventions targeting vulnerable populations of people living with HIV (PLWH) are necessary for reducing new infections and optimizing individual-level outcomes, but extant literature for PLWH who experience homelessness and unstable housing (HUH) has not been compiled. To inform implementation of clinic-based programs that improve care outcomes in this population, we present a synthetic review of key studies examining clinic-based interventions, specifically case management, patient navigation, financial incentives, and the use of mobile technology. RECENT FINDINGS Results from unimodal interventions are mixed or descriptive, are limited by inability to address related multi-modal barriers to care, and do not address major challenges to implementation. Multi-component interventions are needed, but gaps in our knowledge base may limit widespread uptake of such interventions before further data are compiled. Future research evaluating interventions for PLWH experiencing HUH should include implementation outcomes in order to facilitate adaptation across diverse clinical settings.
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26
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Park E, Stockman JK, Thrift B, Nicole A, Smith LR. Structural Barriers to Women's Sustained Engagement in HIV Care in Southern California. AIDS Behav 2020; 24:2966-2974. [PMID: 32323105 PMCID: PMC7790164 DOI: 10.1007/s10461-020-02847-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Since the introduction of antiretroviral therapy, the number of women living with HIV (WLHIV) continues to increase. Despite the decrease in HIV diagnosis among women in California, less than half of WLHIV are retained in HIV care. Structural barriers put women at increased risk for delayed HIV diagnosis, delayed entry into HIV care, and poorer treatment outcomes. The objective of this qualitative analysis is to identify how structural barriers negatively impact women's sustained engagement in HIV care in Southern California. WLHIV accessing local HIV support services participated in a qualitative study by completing a semi-structured interview and brief survey between January and April 2015 (n = 30). Poverty, unemployment, housing instability, and needs for transportation emerged as the dominant structural barriers for women when discussing their challenges with sustained engagement in HIV care. System-level interventions that decrease these noted barriers may help improve HIV care continuum for women living in Southern California.
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Affiliation(s)
- Eunhee Park
- Department of Community Health Sciences, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Jamila K Stockman
- Division of Infectious Diseases and Global Public Health, Department of Medicine, School of Medicine, University of California San Diego, 9500 Gilman Drive #0507, La Jolla, CA, 92093-0507, USA
| | - Briana Thrift
- Division of Infectious Diseases and Global Public Health, Department of Medicine, School of Medicine, University of California San Diego, 9500 Gilman Drive #0507, La Jolla, CA, 92093-0507, USA
- Division of Epidemiology, San Diego State University Graduate School of Public Health, San Diego, CA, USA
| | - Ava Nicole
- Division of Infectious Diseases and Global Public Health, Department of Medicine, School of Medicine, University of California San Diego, 9500 Gilman Drive #0507, La Jolla, CA, 92093-0507, USA
| | - Laramie R Smith
- Division of Infectious Diseases and Global Public Health, Department of Medicine, School of Medicine, University of California San Diego, 9500 Gilman Drive #0507, La Jolla, CA, 92093-0507, USA.
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27
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Abstract
PURPOSE OF REVIEW More than half of new HIV diagnoses occur in the Southern United States where the epidemic disproportionately affects persons of color. Although other areas of the country are seeing dramatic declines in the number of new cases, the progress in the South lags behind. This review will examine the reasons for that disparity. Many are unique to the South. RECENT FINDINGS Despite advances in antiretroviral therapy for HIV, many in the South are not benefiting from these medications, at either a personal or public health level. The reasons are complex and include lack of access to healthcare, lower levels of funding than other areas of the country, stigma, structural racism, increased barriers due to social determinants of health, coexisting mental health disorders, substance use disorders and sexually transmitted diseases and insufficient workforce capacity to meet the needs of those living with HIV. SUMMARY These findings should underline the need for investment in the South for a holistic healthcare approach to persons living with HIV including supporting basic needs such as access to food, transportation and housing. Prioritization among politicians for policy and systems changes and approaches to decrease stigma and enhance education about HIV will be key.
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28
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Abstract
PURPOSE OF REVIEW To summarize recent trends in knowledge of HIV status, care and viral suppression, and the status of implementation of relevant contextual requirements for the United States to achieve the 90-90-90 goals. Recently, the US government announced a plan to decrease HIV incidence by over 90% by 2030. Reaching this goal may require higher targets than 90-90-90. RECENT FINDINGS The United States is on course to reach 90-90-90 goals in the near future, with 86% of persons with HIV aware of their infection, 74% of persons with diagnosed infection in care, and 83% of persons in care with viral suppression in 2016. Some high-burden subnational jurisdictions have already achieved these goals. SUMMARY The United States is likely to reach 90-90-90 targets in the near future. However, to reduce HIV incidence by at least 90% by 2030, the United States will need to rapidly meet the new 95-95-95 targets and deploy a comprehensive strategy with novel approaches to testing, retaining persons with HIV on treatment, and preventing new infections with preexposure prophylaxis and comprehensive syringe services programs.
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29
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Abstract
BACKGROUND Building on several decades of innovative HIV prevention and treatment programming in San Francisco, in 2014, a small group of academic, civic, and community leaders launched Getting to Zero San Francisco, a city-wide consortium focused on getting to zero HIV infections, zero HIV-related deaths, and zero HIV stigma and discrimination. SETTING San Francisco city and county. METHODS The consortium operates under the principles of collective impact composed of 5 components: a common agenda, shared measurement, mutually reinforcing activities, continuous communication, and organization backbone. Two flagship initiatives are described: citywide scale-up of pre-exposure prophylaxis and rapid antiretroviral therapy upon diagnosis. RESULTS The number of new HIV diagnoses declined by over 50% from 399 to 197 from 2013 to 2018; the time from diagnosis to viral suppression decreased from 134 to 62 days during that period. However, continued racial/ethnic disparities in new HIV diagnoses and viral suppression rates point to the need for the Getting to Zero San Francisco committees to focus on racial/ethnic equity as a primary focus. Cisgender and transgender women, people who inject drugs, and people who are homeless also have lower viral suppression rates; ongoing initiatives are attempting to address these disparities. CONCLUSION A collective impact implementation strategy that operates by unifying municipal organizations toward a common goal was associated with citywide gains in reducing new HIV diagnosis and time to viral suppression in San Francisco. Formal evaluation of this strategy will help elucidate under which conditions this approach is most likely to succeed.
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30
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Novick TK, Omenyi C, Han D, Zonderman AB, Evans MK, Crews DC. Housing Insecurity and Risk of Adverse Kidney Outcomes. KIDNEY360 2020; 1:241-247. [PMID: 35372916 DOI: 10.34067/kid.0000032019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/05/2020] [Indexed: 11/27/2022]
Abstract
Background Housing insecurity is characterized by high housing costs or unsafe living conditions that prevent self-care and threaten independence. We examined the relationship of housing insecurity and risk of kidney disease. Methods We used longitudinal data from the Healthy Aging in Neighborhoods of Diversity across the Life Span study (Baltimore, MD). We used multivariable regression to quantify associations between housing insecurity and rapid kidney function decline (loss of >5 ml/min per 1.73 m2 of eGFR per year) and, among those without kidney disease at baseline, incident reduced kidney function (eGFR <60 ml/min per 1.73 m2) and incident albuminuria (urine albumin-creatinine ratio [ACR] ≥30 mg/g). Results Among 1262 participants, mean age was 52 years, 40% were male and 57% were black. A total of 405 (32%) reported housing insecurity. After a median of 3.5 years of follow-up, rapid kidney function decline, incident reduced kidney function, and incident albuminuria occurred in 199 (16%), 64 (5%), and 74 (7%) participants, respectively. Housing insecurity was associated with increased odds of incident albuminuria (unadjusted OR, 2.04; 95% CI, 1.29 to 3.29; adjusted OR, 3.23; 95% CI, 1.90 to 5.50) but not rapid kidney function decline or incident reduced kidney function. Conclusions In this urban population, housing insecurity was associated with increased risk of subsequent albuminuria. Increased recognition of housing insecurity as a social determinant of kidney disease is needed, and risk-reduction efforts that specifically target populations experiencing housing insecurity should be considered.
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Affiliation(s)
- Tessa K Novick
- Division of Nephrology, Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas
| | | | - Dingfen Han
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Alan B Zonderman
- National Institute on Aging, National Institutes of Health, Baltimore, Maryland; and
| | - Michele K Evans
- National Institute on Aging, National Institutes of Health, Baltimore, Maryland; and
| | - Deidra C Crews
- Johns Hopkins Center for Health Equity and.,Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland.,Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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31
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Spinelli MA, Laborde N, Kinley P, Whitacre R, Scott HM, Walker N, Liu AY, Gandhi M, Buchbinder SP. Missed opportunities to prevent HIV infections among pre-exposure prophylaxis users: a population-based mixed methods study, San Francisco, United States. J Int AIDS Soc 2020; 23:e25472. [PMID: 32294338 PMCID: PMC7159249 DOI: 10.1002/jia2.25472] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/24/2020] [Accepted: 02/14/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Pre-exposure prophylaxis (PrEP) is highly effective, although PrEP adherence and persistence has been variable during real world implementation. Little is known about missed opportunities to enhance PrEP adherence among individuals who later HIV seroconverted after using PrEP. The goal of this analysis was to identify all HIV infections among individuals who had accessed PrEP in an integrated health system in San Francisco, and to identify potentially intervenable factors that could have prevented HIV infection through in-depth interviews with people who HIV seroconverted after using PrEP. METHODS We identified individuals who initiated PrEP in an integrated safety-net public health system and performed in-depth chart review to determine person-time on and after stopping PrEP over six years. We identified all PrEP seroconversions using the Centers for Disease Control and Prevention's Enhanced HIV/AIDS Reporting System and then calculated HIV incidence while using PrEP and during gaps in use. We then performed in-depth interviews with those who seroconverted. RESULTS Overall, 986 initiated PrEP across the San Francisco Department of Public Health from July 2012 to November 2018. Data were gathered from 895 person-years on PrEP and 953 after stopping PrEP. The HIV incidence was 7.5-fold higher after stopping PrEP compared to while on PrEP (95% CI 1 to 336). Of the eight individuals who HIV seroconverted; only one was taking PrEP at the time of seroconversion but was using on-demand PrEP inconsistently. All eight agreed to qualitative interviews. Major barriers to PrEP persistence included substance use, mental health and housing loss; difficulty accessing PrEP due to cost, insurance, and the cost and time of medical visits; difficulty weighing PrEP's benefit versus self-perceived risk; and entering a primary partnership. The individual who developed HIV using on-demand PrEP reported confusion about the dosing regimen and which sexual encounters required accompanying PrEP dosing. CONCLUSIONS HIV incidence during gaps in PrEP use was nearly eight-fold higher than while on PrEP in this large cohort in San Francisco. Many individuals who stop PrEP remain at risk of HIV, and participants reported that proactive outreach could potentially have prevented HIV infections. Individuals using non-daily PrEP may require additional education and support in the United States.
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Affiliation(s)
- Matthew A Spinelli
- University of California, San Francisco, Division of HIV, ID, and Global MedicineSan FranciscoCAUSA
- San Francisco Department of Public HealthSan FranciscoCAUSA
| | - Nicole Laborde
- San Francisco Department of Public HealthSan FranciscoCAUSA
| | - Patrick Kinley
- San Francisco Department of Public HealthSan FranciscoCAUSA
| | - Ryan Whitacre
- Graduate Institute of International and Development StudiesDepartment of Sociology and AnthropologyGeneveSwitzerland
| | - Hyman M Scott
- San Francisco Department of Public HealthSan FranciscoCAUSA
| | - Nicole Walker
- San Francisco Department of Public HealthSan FranciscoCAUSA
| | - Albert Y Liu
- San Francisco Department of Public HealthSan FranciscoCAUSA
| | - Monica Gandhi
- University of California, San Francisco, Division of HIV, ID, and Global MedicineSan FranciscoCAUSA
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32
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Griffin A, Dempsey A, Cousino W, Avery L, Phillips H, Egwim E, Cheever L. Addressing disparities in the health of persons with HIV attributable to unstable housing in the United States: The role of the Ryan White HIV/AIDS Program. PLoS Med 2020; 17:e1003057. [PMID: 32119661 PMCID: PMC7051042 DOI: 10.1371/journal.pmed.1003057] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Amy Griffin and co-authors discuss unstable housing and the response to HIV/AIDS in the United States.
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Affiliation(s)
- Amy Griffin
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Antigone Dempsey
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Wendy Cousino
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Latham Avery
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Harold Phillips
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Emeka Egwim
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
| | - Laura Cheever
- US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, Division of Policy and Data, Rockville, Maryland, United States of America
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33
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Whittle HJ, Leddy AM, Shieh J, Tien PC, Ofotokun I, Adimora AA, Turan JM, Frongillo EA, Turan B, Weiser SD. Precarity and health: Theorizing the intersection of multiple material-need insecurities, stigma, and illness among women in the United States. Soc Sci Med 2020; 245:112683. [PMID: 31760320 PMCID: PMC7111434 DOI: 10.1016/j.socscimed.2019.112683] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 12/31/2022]
Abstract
Material-need insecurities (including insecurities in basic resources such as income, food, housing, and healthcare) are widespread in the United States (US) and may be important predictors of poor health outcomes. How material-need insecurities besides food insecurity are experienced, however, remains under-researched, including how multiple material-need insecurities might intersect and converge on the individual. Here we used qualitative methods to investigate experiences with multiple material-need insecurities among 38 food-insecure women aged over 50 years living with or at risk for HIV in the US. Our aims were: (1) to understand the co-experience of material-need insecurities beyond food insecurity; (2) to elucidate how multiple material-need insecurities might intersect; and (3) to discover how this intersection might be detrimental to health. During November 2017-July 2018, we conducted semi-structured interviews at three sites across the US (Northern California, Georgia, North Carolina) and analyzed the data using an inductive-deductive approach. We identified a common and complex picture of multiple material-need insecurities, stigma, and illness among participants across all three sites. There were five primary themes: (1) insecure income arising from a combination of precarious wage labor and federal disability benefits; (2) resultant experiences of uncertainty, compromised quality, insufficiency, and having to use socially unacceptable coping strategies across finances, food, housing, and healthcare; (3) participants' disempowerment arising from their engagement with social safety net institutions; (4) closely related experiences of intersectional stigma and discrimination; and (5) negative implications for health across a wide range of illnesses. By employing the sociological concept of precarity-a term denoting the contemporary convergence of insecure wage labor and retraction of the welfare state-we combine these themes into a unifying framework of precarity and health. This framework may prove useful for testing how the widespread intersection of multiple material-need insecurities interacts with stigma and discrimination to negatively impact physical and mental health.
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Affiliation(s)
- Henry J Whittle
- Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | - Anna M Leddy
- Division of Prevention Science, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Jacqueline Shieh
- Institute for Global Health Sciences, UCSF, San Francisco, CA, USA
| | - Phyllis C Tien
- Department of Medicine, UCSF and Medical Service, Department of Veteran Affairs Medical Center, San Francisco, CA, USA
| | - Ighovwerha Ofotokun
- School of Medicine, Emory University and Grady Healthcare System, Atlanta, GA, USA
| | - Adaora A Adimora
- School of Medicine and UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Janet M Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Edward A Frongillo
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Bulent Turan
- Department of Psychology, UAB, Birmingham, AL, USA
| | - Sheri D Weiser
- Division of HIV, ID and Global Medicine, Department of Medicine, UCSF, San Francisco, CA, USA
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Stanic A, Rybin D, Cannata F, Hohl C, Brody J, Gaeta J, Bharel M. The impact of the housing status on clinical outcomes and health care utilization among individuals living with HIV. AIDS Care 2019; 33:1-9. [PMID: 31766866 DOI: 10.1080/09540121.2019.1695728] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The lack of stable housing can impair access and continuity of care for patients living with human immunodeficiency virus (HIV). This study investigated the relationship between housing status assessed at multiple time points and several core HIV-related outcomes within the same group of HIV patients experiencing homelessness. Patients with consistently stable housing (CSH) during the year were compared to patients who lacked CSH (non-CSH group). The study outcomes included HIV viral load (VL), CD4 counts, and health care utilization. Multivariable and propensity weighted analyses were used to assess outcomes adjusting for potential group differences. Of 208 patients, 88 (42%) had CSH and 120 (58%) were non-CSH. Patients with CSH had significantly higher proportion of VL suppression and higher mean CD4 counts. The frequency of nurse visits in the CSH group was less than a half of that in the non-CSH group. Patients with CSH were less likely to be admitted to the medical respite facility, and if admitted, their length of stay was about a half of that for the non-CSH group. Our study findings show that patients with CSH had significantly better HIV virologic control and immune status as well as improved health care utilization.
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Affiliation(s)
- Anela Stanic
- Department of Pharmacy Practice, MCPHS University, Boston, MA, USA.,Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Denis Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Francis Cannata
- Department of Pharmacy Practice, MCPHS University, Boston, MA, USA
| | - Carole Hohl
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Jennifer Brody
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Jessie Gaeta
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Monica Bharel
- Boston Health Care for the Homeless Program, Boston, MA, USA
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35
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Hessol NA, Eng M, Vu A, Pipkin S, Hsu LC, Scheer S. A longitudinal study assessing differences in causes of death among housed and homeless people diagnosed with HIV in San Francisco. BMC Public Health 2019; 19:1440. [PMID: 31675932 PMCID: PMC6825332 DOI: 10.1186/s12889-019-7817-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/21/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND San Francisco has implemented several programs addressing the needs of two large vulnerable populations: people living with HIV and those who are homeless. Assessment of these programs on health outcomes is paramount for reducing preventable deaths. METHODS Individuals diagnosed with HIV/AIDS and reported to the San Francisco Department of Public Health HIV surveillance registry, ages 13 years or older, who resided in San Francisco at the time of diagnosis, and who died between January 1, 2002, and December 31, 2016 were included in this longitudinal study. The primary independent variable was housing status, dichotomized as ever homeless since diagnosed with HIV, and the dependent variables were disease-specific causes of death, as noted on the death certificate. The Cochran-Armitage test measured changes in the mortality rates over time and unadjusted and adjusted Poisson regression models measured prevalence ratios (PR) and 95% confidence intervals (CI) for causes of death. RESULTS A total of 4158 deceased individuals were included in the analyses: the majority were male (87%), ages 40-59 years old at the time of death (64%), non-Hispanic White (60%), men who have sex with men (54%), had an AIDS diagnosis prior to death (87%), and San Francisco residents at the time of death (63%). Compared to those who were housed, those who were homeless were more likely to be younger at time of death, African American, have a history of injecting drugs, female or transgender, and were living below the poverty level (all p values < 0.0001). Among decedents who were SF residents at the time of death, there were declines in the proportion of deaths due to AIDS-defining conditions (p < 0.05) and increases in accidents, cardiomyopathy, heart disease, ischemic disease, non-AIDS cancers, and drug overdoses (p < 0.05). After adjustment, deaths due to mental disorders (aPR = 1.63, 95% CI 1.24, 2.14) were more likely and deaths due to non-AIDS cancers (aPR = 0.63, 95% CI 0.44, 0.89) were less likely among those experiencing homelessness. CONCLUSIONS Additional efforts are needed to improve mental health services to homeless people with HIV and prevent mental-health related mortality.
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Affiliation(s)
- Nancy A Hessol
- Department of Clinical Pharmacy, University of California, 3333 California Street, Suite 420, San Francisco, CA, 94118, USA.
| | - Monica Eng
- Department of Clinical Pharmacy, University of California, 3333 California Street, Suite 420, San Francisco, CA, 94118, USA
| | - Annie Vu
- Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA, 94102, USA
| | - Sharon Pipkin
- Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA, 94102, USA
| | - Ling C Hsu
- Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA, 94102, USA
| | - Susan Scheer
- Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA, 94102, USA
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36
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Padilla M, Frazier EL, Carree T, Luke Shouse R, Fagan J. Mental health, substance use and HIV risk behaviors among HIV-positive adults who experienced homelessness in the United States - Medical Monitoring Project, 2009-2015. AIDS Care 2019; 32:594-599. [PMID: 31650855 DOI: 10.1080/09540121.2019.1683808] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Homelessness is a challenge to retention in HIV care and adherence to antiretroviral therapy. We describe the sociodemographic and behavioral characteristics of HIV-positive adults who reported recent homelessness. The Medical Monitoring Project is a complex sample survey of HIV-positive adults receiving medical care in the United States. We used weighted interview and medical record data collected from June 2009 to May 2015 to estimate the prevalence of depression, substance use, and HIV risk behaviors among adults experiencing recent homelessness. From 2009 to 2015, 8.3% of HIV-positive adults experienced recent homelessness. Homeless adults were more likely than housed adults to have major depression, to binge drink, use non-injection drugs, use injection drugs, and smoke. Over 60% of homeless adults were sexually active during the past year, with homeless adults reporting more condomless sex with an HIV-negative or unknown status sex partner than housed adults. Programs attempting to improve the health outcomes of HIV-positive homeless persons and reduce ongoing HIV transmission can focus on providing basic needs, such as housing, and ancillary services, such as mental health counseling or substance abuse treatment and counseling.
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Affiliation(s)
- Mabel Padilla
- Division of HIV/AIDS Prevention, National Centers for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Emma L Frazier
- Division of HIV/AIDS Prevention, National Centers for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tamara Carree
- Division of HIV/AIDS Prevention, National Centers for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.,ICF International, Atlanta, GA, USA
| | - R Luke Shouse
- Division of HIV/AIDS Prevention, National Centers for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jennifer Fagan
- Division of HIV/AIDS Prevention, National Centers for HIV, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Riley ED, Vittinghoff E, Koss CA, Christopoulos KA, Clemenzi-Allen A, Dilworth SE, Carrico AW. Housing First: Unsuppressed Viral Load Among Women Living with HIV in San Francisco. AIDS Behav 2019; 23:2326-2336. [PMID: 31324996 PMCID: PMC7478361 DOI: 10.1007/s10461-019-02601-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
While poverty is an established barrier to achieving success at each step of the HIV care continuum, less is known about specific aspects of poverty and how they overlap with behavior in exceptionally low-income individuals who live in well-resourced areas. We considered unsuppressed viral load over 3 years among women living with HIV in San Francisco who used homeless shelters, low-income hotels and free meal programs. One-hundred twenty study participants were followed; 60% had > 1 unsuppressed viral load and 19% were unsuppressed at every visit. Across six-month intervals, the odds of unsuppressed viral load were 11% higher for every 10 nights spent sleeping on the street [Adjusted Odds Ratio (AOR) 1.11, 95% CI 1.02-1.20]; 16% higher for every 10 nights spent sleeping in a shelter (AOR/10 nights 1.16, 95% CI 1.06-1.27); 4% higher for every 10 nights spent sleeping in a single-room occupancy hotel (AOR/10 nights 1.04, 95% CI 1.02-1.07); and over threefold higher among women who experienced any recent incarceration (AOR 3.56, 95% CI 1.84-6.86). Violence and recent use of outpatient health care did not significantly predict viral suppression in adjusted analysis. While strategies to promote retention in care are important for vulnerable persons living with HIV, they are insufficient to ensure sustained viral suppression in low-income women experiencing homelessness and incarceration. Results presented here in combination with prior research linking incarceration to homelessness among women indicate that tailored interventions, which not only consider but prioritize affordable housing, are critical to achieving sustained viral suppression in low-income women living with HIV.
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Affiliation(s)
- Elise D Riley
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., UCSF Mailbox 0874, San Francisco, CA, 94143-0874, USA.
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Catherine A Koss
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., UCSF Mailbox 0874, San Francisco, CA, 94143-0874, USA
| | - Katerina A Christopoulos
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., UCSF Mailbox 0874, San Francisco, CA, 94143-0874, USA
| | - Angelo Clemenzi-Allen
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, 1001 Potrero Ave., UCSF Mailbox 0874, San Francisco, CA, 94143-0874, USA
| | - Samantha E Dilworth
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Adam W Carrico
- Department of Public Health Sciences, University of Miami, Miami, FL, USA
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Homelessness at diagnosis is associated with death among people with HIV in a population-based study of a US city. AIDS 2019; 33:1789-1794. [PMID: 31259765 DOI: 10.1097/qad.0000000000002287] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE San Francisco, California, has experienced a 44% reduction in new HIV diagnoses since 2013 supported by its 'Getting to Zero' initiative; however, the age-adjusted mortality rate in people with HIV (PWH) has not decreased. We sought to identify factors associated with death among PWH in San Francisco. DESIGN Population-based incidence-density case-control study. METHODS Among PWH in the San Francisco HIV surveillance registry, a random sample of 48 decedents from 1 July 2016 to 31 May 2017 were each matched to two to three controls who were alive at the date of death (108 controls matched on age and time since diagnosis). Covariates included demographics, substance use, housing status, medical conditions, and care indicators from the study population. We used matched-pair conditional logistic regression to examine factors associated with mortality. RESULTS Of the 156 PWH in the study, 14% were African-American, 14% Latino, and 8% female sex. In adjusted analysis, factors associated with higher odds of death included: homelessness at HIV diagnosis [adjusted odds ratio (AOR) = 27.4; 95% confidence interval (CI) = 3.0-552.1], prior-year IDU (AOR = 10.2; 95% CI = 1.7-128.5), prior-year tobacco use (AOR = 7.2; 95% CI = 1.7-46.9), being off antiretroviral therapy at any point in the prior year (AOR = 6.8; 95% CI = 1.1-71.4), and being unpartnered vs. married/partnered (AOR = 4.7; 95% CI = 1.3-22.0). CONCLUSION People homeless at HIV diagnosis had 27-fold higher odds of death compared with those with housing; substance use and retention on antiretroviral therapy in the prior year are other important intervenable factors. New strategies to address these barriers, and continued investment in supportive housing and substance use treatment, are needed.
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Baguso GN, Turner CM, Santos G, Raymond HF, Dawson‐Rose C, Lin J, Wilson EC. Successes and final challenges along the HIV care continuum with transwomen in San Francisco. J Int AIDS Soc 2019; 22:e25270. [PMID: 31037858 PMCID: PMC6488760 DOI: 10.1002/jia2.25270] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 03/07/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION To examine the HIV care continuum for transwomen living in San Francisco and to determine factors associated with poor HIV-related health outcomes. METHODS Data were collected from 2016 to 2017 with transwomen in San Francisco. Respondent-driven sampling (RDS) was used to recruit a population-based sample. Bivariate associations were assessed, and RDS-weighted multivariable logistic regression was used to identify associations between exposures and outcomes along the HIV care continuum. RESULTS Of the 123 self-identified transwomen in this analysis, ages ranged from 23 to 71 years with a majority identifying as Latina (40.8%) and African American (29.2%). An estimate of 14.3% of participants were not engaged in care, 13% were not currently on antiretroviral therapy (ART), 22.2% had a self-reported detectable viral load and 13.5% had unknown viral load. Those using hormones had lower odds of not being on ART compared to those who did not use hormones. Those with unstable housing had a higher relative risk ratio of having a detectable viral load. Those who experienced both anti-trans discrimination and racism had higher odds of not being in HIV care. CONCLUSIONS San Francisco has made substantial progress engaging transwomen in the HIV care continuum, but the final push to ensure viral suppression will require addressing social determinants. Future interventions to increase HIV care engagement, ART use and viral suppression among transwomen must address housing needs and risks related to the overlapping effect of both anti-trans discrimination and racism.
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Affiliation(s)
- Glenda N Baguso
- Department of Community Health SystemsUniversity of California San FranciscoSan FranciscoCAUSA
| | - Caitlin M Turner
- San Francisco Department of Public HealthCenter for Public Health ResearchSan FranciscoUSA
| | - Glenn‐Milo Santos
- San Francisco Department of Public HealthCenter for Public Health ResearchSan FranciscoUSA
| | - H Fisher Raymond
- San Francisco Department of Public HealthCenter for Public Health ResearchSan FranciscoUSA
| | - Carol Dawson‐Rose
- Department of Community Health SystemsUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jess Lin
- San Francisco Department of Public HealthCenter for Public Health ResearchSan FranciscoUSA
| | - Erin C Wilson
- San Francisco Department of Public HealthCenter for Public Health ResearchSan FranciscoUSA
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Clemenzi-Allen A, Neuhaus J, Geng E, Sachdev D, Buchbinder S, Havlir D, Gandhi M, Christopoulos K. Housing Instability Results in Increased Acute Care Utilization in an Urban HIV Clinic Cohort. Open Forum Infect Dis 2019; 6:ofz148. [PMID: 31139668 PMCID: PMC6534280 DOI: 10.1093/ofid/ofz148] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/24/2019] [Indexed: 11/25/2022] Open
Abstract
Background People living with HIV (PLWH) who experience homelessness and unstable housing (HUH) often have fragmented health care. Research that incorporates granular assessments of housing status and primary care visit adherence to understand patterns of acute care utilization can help pinpoint areas for intervention. Methods We collected self-reported living situation, categorized as stable (rent/own, hotel/single room occupancy), unstable (treatment/transitional program, staying with friends), or homeless (homeless shelter, outdoors/in vehicle) at an urban safety-net HIV clinic between February and August 2017 and abstracted demographic and clinical information from the medical record. Regression models evaluated the association of housing status on the frequency of acute care visits—urgent care (UC) visits, emergency department (ED) visits, and hospitalizations—and whether suboptimal primary care visit adherence (<75%) interacted with housing status on acute care visits. Results Among 1198 patients, 25% experienced HUH. In adjusted models, unstable housing resulted in a statistically significant increase in the incidence rate ratio for UC visits (incidence rate ratio [IRR], 1.35; 95% confidence interval [CI], 1.10 to 1.66; P < .001), ED visits (IRR, 2.12; 95% CI, 1.44 to 3.13; P < .001), and hospitalizations (IRR, 1.75; 95% CI, 1.10 to 2.77; P = 0.018). Homelessness led to even greater increases in UC visits (IRR, 1.75; 95% CI, 1.29 to 2.39; P < .001), ED visits (IRR, 4.18; 95% CI, 2.77 to 6.30; P < .001), and hospitalizations (IRR, 3.18; 95% CI, 2.03 to 4.97; P < .001). Suboptimal visit adherence differentially impacted UC and ED visits by housing status, suggesting interaction. Conclusions Increased acute care visit frequency among HUH-PLWH suggests that interventions at these visits may create opportunities to improve care.
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Affiliation(s)
- Angelo Clemenzi-Allen
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital
| | - John Neuhaus
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Elvin Geng
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital
| | - Darpun Sachdev
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital.,San Francisco Department of Public Health, San Francisco, California
| | - Susan Buchbinder
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California.,San Francisco Department of Public Health, San Francisco, California
| | - Diane Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital
| | - Katerina Christopoulos
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital
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Affiliation(s)
- Ingrid Katz
- Harvard Global Health Institute, Cambridge, Massachusetts
- Harvard Medical School, Cambridge, Massachusetts
| | - Ashish K Jha
- Harvard Global Health Institute, Cambridge, Massachusetts
- Harvard School of Public Health, Cambridge, Massachusetts
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