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Hassan R, Saldana CS, Garlow EW, Gutierrez M, Hershow RB, Elimam D, Adame JF, Andía JF, Padilla M, Gonzalez Jimenez N, Freeman D, Johnson EN, Reed K, Holland DP, Orozco H, Pedraza G, Hayes C, Philpott DC, Curran KG, Wortley P, Agnew-Brune C, Gettings JR. Barriers and Facilitators to HIV Service Access among Hispanic/Latino Gay, Bisexual, and Other Men Who Have Sex with Men in Metropolitan Atlanta-a Qualitative Analysis. J Urban Health 2023; 100:1193-1201. [PMID: 38012505 PMCID: PMC10728373 DOI: 10.1007/s11524-023-00809-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 11/29/2023]
Abstract
Hispanic/Latino persons are disproportionately impacted by HIV in the US, and HIV diagnoses among Hispanic/Latino men in Georgia have increased over the past decade, particularly in metropolitan Atlanta. In 2022, the Georgia Department of Public Health detected five clusters of rapid HIV transmission centered among Hispanic/Latino gay, bisexual, and other men who have sex with men (HLMSM) in metropolitan Atlanta. We conducted in-depth interviews with 65 service providers and 29 HLMSM to identify barriers and facilitators to HIV service access for HLMSM. Interviews were audio recorded, transcribed, and translated, if needed. Initial data analyses were conducted rapidly in the field to inform public health actions. We then conducted additional analyses including line-by-line coding of the interview transcripts using a thematic analytic approach. We identified four main themes. First, inequity in language access was a predominant barrier. Second, multiple social and structural barriers existed. Third, HLMSM encountered intersectional stigma. Finally, the HLMSM community is characterized by its diversity, and there is not a one-size-fits-all approach to providing appropriate care to this population. The collection of qualitative data during an HIV cluster investigation allowed us to quickly identity barriers experienced by HLMSM when accessing HIV and other medical care, to optimize public health response and action. Well-designed program evaluation and implementation research may help elucidate specific strategies and tools to reduce health disparities, ensure equitable service access for HLMSM, and reduce HIV transmission in this population.
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Affiliation(s)
- Rashida Hassan
- Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA.
| | - Carlos S Saldana
- Fulton County Board of Health, Atlanta, GA, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | | | - Mariana Gutierrez
- Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA
| | - Rebecca B Hershow
- Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA
- Epidemic Intelligence Service, CDC, Atlanta, GA, USA
| | - Dena Elimam
- Georgia Department of Public Health, Atlanta, GA, USA
| | - Jose F Adame
- Georgia Department of Public Health, Atlanta, GA, USA
| | - Jonny F Andía
- Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA
| | - Mabel Padilla
- Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA
| | | | - Dorian Freeman
- Gwinnett, Newton, and Rockdale County Health Department, Lawrenceville, GA, USA
| | | | - Karrie Reed
- Cobb and Douglas Public Health, Marietta, GA, USA
| | - David P Holland
- Fulton County Board of Health, Atlanta, GA, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Craig Hayes
- Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA
| | - David C Philpott
- Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA
- Epidemic Intelligence Service, CDC, Atlanta, GA, USA
| | - Kathryn G Curran
- Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA
| | | | - Christine Agnew-Brune
- Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA
| | - Jenna R Gettings
- Georgia Department of Public Health, Atlanta, GA, USA
- Epidemic Intelligence Service, CDC, Atlanta, GA, USA
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Naar S, Kimball D, Cain D, Pooler M, Rambo S, Chapman J, MacDonell K, Lin Miller R. Mechanisms of Successful Implementation of Tailored Motivational Interviewing in a Multisite Study of Youth HIV Clinics in the United States. J Acquir Immune Defic Syndr 2023; 94:325-331. [PMID: 37643421 DOI: 10.1097/qai.0000000000003291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND A recent implementation science stepped-wedge trial of motivational interviewing (MI) in adolescent HIV clinics indicated variable degrees of implementation success. The present mixed-methods study analyzed trajectories of postimplementation MI competence scores and compared postimplementation qualitative interviews among the clinics with the highest levels of provider competency and the lowest levels of competency to further understand mechanisms of successful implementation. SETTING Ten HIV clinics in the Adolescent Trials Network for HIV/AIDS Interventions. METHODS This study used a sequential explanatory mixed-methods design. Continuous MI competency data from the parent study were structured with repeated measurements nested within providers nested within 10 sites. A mixed-effects regression model rank ordered the clinics by competence scores. Key stakeholders (N = 77) at the 10 randomized clinics completed a 1-hour qualitative interview at 12-month follow-up (immediately postimplementation). Using the phases of reflexive thematic analysis, interviews from the 3 highest competence clinics and the 3 lowest competence clinics were pragmatically analyzed. RESULTS Thematic analysis suggested 3 central themes that influenced successful evidence-based practice (EBP) implementation. Organizational culture included the leadership, collective effort, and resources that influenced how the organization at large responded to the implementation intervention. Staff attitudes encapsulated individual providers' mindsets and attitudes about MI and the implementation intervention. EBP integration reflected the perception and use of MI by individuals and the organization as a whole. These themes and their subthemes are interconnected and exerted an influence on each other through the implementation process. CONCLUSIONS Findings suggest additional implementation strategies to improve implementation of EBPs. Such mixed-methods research is critical to understanding the mechanisms of successful implementation of EBP and improving future implementation strategies.
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Affiliation(s)
- Sylvie Naar
- Florida State University, Center for Translational Behavioral Science, Tallahassee, FL
| | - Devon Kimball
- Department of Psychology, Michigan State University, East Lansing, MI
| | - Demetria Cain
- Department of Psychology, Hunter College of the City University of New York (CUNY), New York, NY
| | - Meardith Pooler
- Florida State University, Center for Translational Behavioral Science, Tallahassee, FL
| | - Shane Rambo
- Florida State University, College of Medicine, Tallahassee, FL; and
| | | | - Karen MacDonell
- Florida State University, Center for Translational Behavioral Science, Tallahassee, FL
| | - Robin Lin Miller
- Department of Psychology, Michigan State University, East Lansing, MI
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Baim-Lance A, Addison D, Archer N, Gordon P, Duke S, Shubert V, Nash D, Robertson M. Integrating a Resilience Framework to Assess Implementation of a Novel HIV Care Re-Engagement Model in NYC. J Acquir Immune Defic Syndr 2023; 94:308-316. [PMID: 37851952 PMCID: PMC10609692 DOI: 10.1097/qai.0000000000003285] [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: 01/30/2023] [Accepted: 07/05/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The Bottom Up Project, a collaboration of clinical, community, and academic partners, consists of 7 major steps that leverage a health information exchange, a system for sharing patient health information, with real-time alerts to mobilize peer outreach workers to find and re-engage persons with HIV disconnected from care. Bottom Up faced implementation challenges in its start-up phase and produced effective responses leading to Project maturation, which we explore using a novel implementation science framework incorporating resilience. METHODS We conducted semistructured interviews with implementation staff (N = 6) and meeting minutes and protocols document reviews (N = 35). The Consolidated Framework for Implementation Research and a novel resilience framework guided thematic and process analyses. The resilience framework consisted of the following 3 resilience types: absorptive to cope with adversity, adaptive to adjust as short-term solutions, and transformative to structurally change. RESULTS The Project experienced 20 major challenges, 2-5 challenges per step. Challenges were multilevel and of chronic and crisis intensities. Implementers overcame challenges by leveraging multilevel factors that were absorptive, adaptive (most common), and transformative. DISCUSSION Bottom Up matured by practicing consistency and flexibility. The Project maintained core operations while under crisis-level stress by strategically simplifying or "downshifting" activities. Transformational responses suggest that specific initiatives can catalyze organizational change. CONCLUSIONS Bottom Up implementation demonstrates using diverse tactics to respond to challenges, thereby shaping Project development and in turn organizations. Applying resilience to Consolidated Framework for Implementation Research helps build awareness of active and dynamic processes promoting or impeding the growth and success of intervention-oriented Projects.
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Affiliation(s)
- Abigail Baim-Lance
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Institute for Implementation Science in Population Health, City University of New York, New York, NY
- Geriatric Research Education and Clinical Center, James J Peters VA Medical Center, Bronx VA
| | - Diane Addison
- Institute for Implementation Science in Population Health, City University of New York, New York, NY
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York, New York, NY
| | | | - Peter Gordon
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY; and
| | | | | | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, NY
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York, New York, NY
| | - McKaylee Robertson
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Institute for Implementation Science in Population Health, City University of New York, New York, NY
- Geriatric Research Education and Clinical Center, James J Peters VA Medical Center, Bronx VA
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York, New York, NY
- Housing Works, New York, NY
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY; and
- Alliance for Positive Change, New York, NY
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Garner BR, Burrus O, Ortiz A, Tueller SJ, Peinado S, Hedrick H, Harshbarger C, Galindo C, Courtenay-Quirk C, Lewis MA. A Longitudinal Mixed-Methods Examination of Positive Health Check: Implementation Results From a Type 1 Effectiveness-Implementation Hybrid Trial. J Acquir Immune Defic Syndr 2022; 91:47-57. [PMID: 35583962 PMCID: PMC9377502 DOI: 10.1097/qai.0000000000003018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Positive Health Check is an evidence-based video doctor intervention developed for improving the medication adherence, retention in care, and viral load suppression of people with HIV receiving clinical care. SETTING Four HIV primary care clinics within the United States. METHODS As part of a type 1 hybrid trial, a mixed-methods approach was used to longitudinally assess the following 3 key implementation constructs over a 23-month period: innovation-values fit (ie, the extent to which staff perceive innovation use will foster the fulfillment of their values), organizational readiness for change (ie, the extent to which organizational members are psychologically and behaviorally prepared to implement organizational change), and implementation climate (ie, the extent to which implementation is expected, supported, and rewarded). Quantitative mixed-effects regression analyses were conducted to assess changes over time in these constructs. Qualitative analyses were integrated to help provide validation and understanding. RESULTS Innovation-values fit and organizational readiness for change were found to be high and relatively stable. However, significant curvilinear change over time was found for implementation climate. Based on the qualitative data, implementation climate declined toward the end of implementation because of decreased engagement from clinic champions and differences in priorities between research and clinic staff. CONCLUSIONS The Positive Health Check intervention was found to fit within HIV primary care service settings, but there were some logistical challenges that needed to be addressed. Additionally, even within the context of an effectiveness trial, significant and nonlinear change in implementation climate should be expected over time.
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Affiliation(s)
| | | | - Alexa Ortiz
- RTI International, Research Triangle Park, NC; and
| | | | | | | | - Camilla Harshbarger
- Centers for Disease Control and Prevention, Division of HIV Prevention, Atlanta, GA
| | - Carla Galindo
- Centers for Disease Control and Prevention, Division of HIV Prevention, Atlanta, GA
| | - Cari Courtenay-Quirk
- Centers for Disease Control and Prevention, Division of HIV Prevention, Atlanta, GA
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Geldsetzer P, Chebet JJ, Tarumbiswa T, Phate-Lesihla R, Maponga C, Mandara E, Bärnighausen T, McMahon SA. Knowledge and attitudes about HIV pre-exposure prophylaxis: Evidence from in-depth interviews and focus group discussions with policy makers, healthcare providers, and end-users in Lesotho. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000762. [PMID: 36962565 PMCID: PMC10021845 DOI: 10.1371/journal.pgph.0000762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 08/24/2022] [Indexed: 03/26/2023]
Abstract
Studies on knowledge and attitudes about HIV pre-exposure prophylaxis (PrEP) have mostly focused on key populations in North America and Europe. To inform Lesotho's national rollout of PrEP to the general population, this study aimed to characterize knowledge and attitudes about PrEP among policy makers, implementing partners, healthcare providers, and PrEP end-users in Lesotho. Respondents were purposively selected to participate based on personal experience in the development and implementation of Lesotho's PrEP program, or the personal use of PrEP. We conducted 106 in-depth interviews with policy makers (n = 5), implementing partners (n = 4), and end-users (current PrEP users = 55; former PrEP users = 36; and PrEP "decliners" = 6). In addition, we held 11 focus group discussions (FGDs) with a total of 105 healthcare providers. Interview and FGD transcripts were analyzed following the tenets of Grounded Theory. Respondents expressed positive attitudes toward PrEP, owing to experienced and perceived personal, familial, and societal benefits. PrEP was viewed as i) an opportunity for serodiscordant couples to remain together, ii) a means of conceiving children with minimized risk of HIV infection, iii) providing a sense of agency and control, and iv) an avenue for addressing the HIV epidemic in Lesotho. Respondents demonstrated understanding of PrEP's intended use, eligibility requirements, and modality of use. However, respondents also reported that several important misconceptions of PrEP were common among adults in Lesotho, including a belief that PrEP protects against sexually transmitted infections other than HIV, promotes promiscuity, prevents pregnancy, causes seroconversion, and provides lifelong protection from taking the pill just once. In addition to building on the perceived advantages of PrEP to shape a positive message, Lesotho's national rollout of PrEP will likely benefit from a communication strategy that specifically addresses the common misconceptions of PrEP identified in this study.
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Affiliation(s)
- Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, United States of America
- Chan Zuckerberg Biohub, San Francisco, California, United States of America
| | - Joy J Chebet
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
| | - Tapiwa Tarumbiswa
- Disease Control Department, Lesotho Ministry of Health, Maseru, Lesotho
| | | | - Chivimbiso Maponga
- Clinton Health Access Initiative-Lesotho Country Office, Maseru, Lesotho
| | - Esther Mandara
- Clinton Health Access Initiative-Lesotho Country Office, Maseru, Lesotho
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Africa Health Research Institute (AHRI), Durban, South Africa
| | - Shannon A McMahon
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
- Social and Behavioral Interventions, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Mgbako O, E. Sobieszczyk M, Olender S, Gordon P, Zucker J, Tross S, Castor D, H. Remien R. Immediate Antiretroviral Therapy: The Need for a Health Equity Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17197345. [PMID: 33050039 PMCID: PMC7579579 DOI: 10.3390/ijerph17197345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 12/27/2022]
Abstract
Immediate antiretroviral therapy (iART), defined as same-day initiation of ART or as soon as possible after diagnosis, has recently been recommended by global and national clinical care guidelines for patients newly diagnosed with human immunodeficiency virus (HIV). Based on San Francisco’s Rapid ART Program Initiative for HIV Diagnoses (RAPID) model, most iART programs in the US condense ART initiation, insurance acquisition, housing assessment, and mental health and substance use evaluation into an initial visit. However, the RAPID model does not explicitly address structural racism and homophobia, HIV-related stigma, medical mistrust, and other important factors at the time of diagnosis experienced more poignantly by African American, Latinx, men who have sex with men (MSM), and transgender patient populations. These factors negatively impact initial and subsequent HIV care engagement and exacerbate significant health disparities along the HIV care continuum. While iART has improved time to viral suppression and linkage to care rates, its association with retention in care and viral suppression, particularly in vulnerable populations, remains controversial. Considering that in the US the HIV epidemic is sharply defined by healthcare disparities, we argue that incorporating an explicit health equity approach into the RAPID model is vital to ensure those who disproportionately bear the burden of HIV are not left behind.
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Affiliation(s)
- Ofole Mgbako
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY 10032, USA; (S.T.); (R.H.R.)
- Correspondence:
| | - Magdalena E. Sobieszczyk
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Susan Olender
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Peter Gordon
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Jason Zucker
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Susan Tross
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY 10032, USA; (S.T.); (R.H.R.)
| | - Delivette Castor
- Division of Infectious Disease, Department of Internal Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA; (M.E.S.); (S.O.); (P.G.); (J.Z.); (D.C.)
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NY State Psychiatric Institute and Columbia University, New York, NY 10032, USA; (S.T.); (R.H.R.)
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