Operational research to improve HIV prevention in the United States

A Longitudinal Mixed-Methods Examination of Positive Health Check: Implementation Results From a Type 1 Effectiveness-Implementation Hybrid Trial

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.

Client-Centered Care Coordination (C4™) for HIV/STI Prevention: a Theoretical, Conceptual, and Methodological Overview-HIV Prevention Trials Network (HPTN) 073

Introduction

There are few culturally informed, theory-driven evidence-based strategies to support PrEP use among Black MSM. This paper describes the theoretical foundation and conceptual development of C4™ to support the prevention of HIV and other STIs.

Methods

C4™ integrates self-determination theory with comprehensive risk counseling and services using an integrative anti-racism lens. C4™ was implemented in a 52-week HIV prevention demonstration project to facilitate PrEP use and adherence among Black MSM (N=225) in three US cities from 2014-2017.

Results

PrEP use was 79%, with 91% of PrEP users starting within 30-days. 12-month retention in C4™ was 92%. Care coordination encounters focused primarily on clients' needs related to PrEP adherence (43%) and sexual health (19%). Over the 12-month period, a substantial proportion of the men made progress towards their PrEP adherence goals at the 8-week (83%), 26-week (75%) and 52-week (81%) study visits.

Conclusions

C4™ is a multi-level, multi-component intervention that dually targets individual-level motivations and capacities of Black MSM and the healthcare facility-level attitudes, behaviors and processes that characterize the climates where Black MSM receive services.

Policy Implications

Public health policy efforts to scale-up PrEP may consider C4™ as a tool to optimize the use of PrEP and PrEP program retention with Black MSM. C4™ is also a tool for healthcare facilities to transform their models of service delivery towards improving the implementation PrEP services, including ensuring racial equity in the prevention impact of novel PrEP formulations such as long-acting injectable and potential future long-acting oral regimens.

A qualitative model of the HIV care continuum in Vancouver, Canada

A team of health care stakeholders and researchers collaboratively developed a qualitative model and graphic representation of the continuum of HIV care in Vancouver to inform delivery of antiretroviral therapy and other HIV health services. The model describes the patient journey through the HIV care continuum, including states of infection, health services, and care decisions. We used a Unified Modelling Language (UML) activity diagram to capture patient and provider activities and to guide the construction of a UML state machine diagram. The state machine diagram captures model agent states in a formalism that facilitates the development of system dynamics or agent-based models. These quantitative models can be applied to optimizing the allocation of resources, and to evaluate potential strategies for improved patient care and system performance. The novel approach of combining UML diagrams we present provides a general method for modelling capacity ---management strategies within complex health systems.

Social Support and Other Factors Associated with HIV Testing by Hispanic/Latino Gay, Bisexual, and Other Men Who Have Sex with Men in the U.S. South

Cognitive-psychosocial and other factors may affect participation in HIV testing, particularly by Hispanic/Latino gay, bisexual, and other men who have sex with men (MSM) in the U.S. South, a region hard-hit by HIV. We used univariate and multivariable logistic regression analyses to examine the association between social support and other cognitive-psychosocial factors; sociodemographic characteristics; risk behaviors; and self-reported HIV testing in a sample of 304 Hispanic/Latino MSM in North Carolina. In the multivariable logistic regression analysis, general and HIV-related social support and HIV-related knowledge were associated with greater odds of testing; speaking only Spanish was associated with reduced odds of testing. Social support and aspects of social connectedness may constitute community-based resources for use in HIV prevention efforts with Hispanic/Latino MSM. However, harnessing these resources for HIV prevention will require a better understanding of how social support relationships and processes shape HIV risks and protective actions by these vulnerable MSM.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

The contributions and future direction of Program Science in HIV/STI prevention

Background

Program Science is an iterative, multi-phase research and program framework where programs drive the scientific inquiry, and both program and science are aligned towards a collective goal of improving population health.

Discussion

To achieve this, Program Science involves the systematic application of theoretical and empirical knowledge to optimize the scale, quality and impact of public health programs. Program Science tools and approaches developed for strategic planning, program implementation, and program management and evaluation have been incorporated into HIV and sexually transmitted infection prevention programs in Kenya, Nigeria, India, and the United States.

Conclusion

In this paper, we highlight key scientific contributions that emerged from the growing application of Program Science in the field of HIV and STI prevention, and conclude by proposing future directions for Program Science.

Self-Reported HIV and HCV Screening Rates and Serostatus Among Substance Abuse Treatment Patients

Substance users are at increased risk for HIV and HCV infection. Still, many substance use treatment programs (SUTP) fail to offer HIV/HCV testing. The present secondary analysis of screening data from a multi-site randomized trial of rapid HIV testing examines self-reported HIV/HCV testing patterns and serostatus of 2473 SUTP patients in 12 community-based sites that had not previously offered on-site testing. Results indicate that most respondents screened for the randomized trial tested more than a year prior to intake for HIV (52 %) and HCV (38 %). Prevalence rates were 3.6 and 30 % for HIV and HCV, respectively. The majority of participants that were HIV (52.2 %) and HCV-positive (40.5 %) reported having been diagnosed within the last 1-5 years. Multivariable logistic regression showed that members of high-risk groups were more likely to have tested. Bundled HIV/HCV testing and linkage to care issues are recommended for expanding testing in community-based SUTP settings.

Advancing the strategic use of HIV operations research to strengthen local policies and programmes: the Research to Prevention Project

In the field of HIV prevention, there is renewed interest in operations research (OR) within an implementation science framework. The ultimate goal of such studies is to generate new knowledge that can inform local programmes and policies, thus improving access, quality, efficiency and effectiveness. Using four case studies from the USAID-funded Research to Prevention (R2P) project, we highlight the strategic use of OR and the impact it can have on shaping the focus and content of HIV prevention programming across geographic and epidemic settings and populations. These case studies, which include experiences from several sub-Saharan African countries and the Caribbean, emphasize four unique ways that R2P projects utilized OR to stimulate change in a given context, including: (1) translating findings from clinical trials to real-world settings; (2) adapting promising structural interventions to a new context; (3) tailoring effective interventions to underserved populations; and (4) prioritizing key populations within a national response to HIV. Carefully crafted OR can bridge the common gap that exists between research-generated knowledge and field-based practice, lead to substantial, real-world changes in national policies and programmes, and strengthen local organizations and the use of data to be more responsive to a given topic or population, ultimately supporting a locally tailored HIV response.

Adherence to antiretroviral therapy among HIV-infected adults in the United States

National estimates of antiretroviral therapy (ART) adherence and adherence support services utilization are needed to inform efforts to improve the health of HIV-infected persons in the United States. In a nationally representative sample of HIV-infected adults receiving medical care, 86% self-reported taking all ART doses in the past 72 hours. Overall, 20% reported using adherence support services and 2% reported an unmet need for services. If all nonadherent persons not receiving adherence support and all persons with a self-perceived unmet need for adherence support accessed services, resources to support ∼42,673 additional persons would be needed. Factors associated with lower adherence included younger age, female gender, depression, stimulant use, binge alcohol use, greater than once-daily dosing, longer time since HIV diagnosis, and patient beliefs. Predictors of adherence are multifactorial so multiple targeted strategies to improve adherence are warranted. Providing adherence support services to all those in need may require additional resources.

Clinician Perspectives on Delaying Initiation of Antiretroviral Therapy for Clinically Eligible HIV-Infected Patients

Objectives:

Guidelines for antiretroviral therapy (ART) initiation have evolved, but consistently note that adherence problems should be considered and addressed. Little is known regarding the reasons providers delay ART initiation in clinically eligible patients.

Methods:

In 2009, we surveyed a probability sample of HIV care providers in 582 outpatient facilities in the United States and Puerto Rico with an open-ended question about nonclinical reasons for delaying ART initiation in otherwise clinically eligible patients.

Results:

Very few providers (2%) reported never delaying ART. Reasons for delaying ART were concerns about patient adherence (68%), patient acceptance (60%), and structural barriers (33%). Provider and practice characteristics were associated with reasons for delaying ART.

Conclusion:

Reasons for delaying ART were consistent with clinical guidelines and were both patient level and structural. Providers may benefit from training and access to referrals for ancillary services to enhance their ability to monitor and address these issues with their patients.

HIV testing implementation in two urban cities: practice, policy, and perceived barriers

BACKGROUND

Although funding has supported the scale up of routine, opt-out HIV testing in the US, variance in implementation mechanisms and barriers in high-burden jurisdictions remains unknown.

METHODS

We conducted a survey of health care organizations in Washington, DC and Houston/Harris County to determine number of HIV tests completed in 2011, policy and practices associated with HIV testing, funding mechanisms, and reported barriers to testing in each jurisdiction and to compare results between jurisdictions.

RESULTS

In 2012, 43 Houston and 35 DC HIV-testing organizations participated in the survey. Participants represented 85% of Department of Health-supported testers in DC and 90% of Department of Health-supported testers in Houston. The median number of tests per organization was 568 in DC and 1045 in Houston. Approximately 50% of organizations in both DC and Houston exclusively used opt-in consent and most conducted both pre- and post-test counseling with HIV testing (80% of organizations in DC, 70% in Houston). While the most frequent source of funding in DC was the Department of Health, Houston organizations primarily billed the patient or third-party payers. Barriers to testing most often reported were lack of funding, followed by patient discomfort/refusal with more barriers reported in DC.

CONCLUSIONS

Given unique policies, resources and programmatic contexts, DC and Houston have taken different approaches to support routine testing. Many organizations in both cities reported opt-in consent approaches and pre-test counseling, suggesting 2006 national HIV testing recommendations are not being followed consistently. Addressing the barriers to testing identified in each jurisdiction may improve expansion of testing.

Challenges of infectious diseases in the USA

In the USA, infectious diseases continue to exact a substantial toll on health and health-care resources. Endemic diseases such as chronic hepatitis, HIV, and other sexually transmitted infections affect millions of individuals and widen health disparities. Additional concerns include health-care-associated and foodborne infections--both of which have been targets of broad prevention efforts, with success in some areas, yet major challenges remain. Although substantial progress in reduction of the burden of vaccine-preventable diseases has been made, continued cases and outbreaks of these diseases persist, driven by various contributing factors. Worldwide, emerging and reemerging infections continue to challenge prevention and control strategies while the growing problem of antimicrobial resistance needs urgent action. An important priority for control of infectious disease is to ensure that scientific and technological advances in molecular diagnostics and bioinformatics are well integrated into public health. Broad and diverse partnerships across governments, health care, academia, and industry, and with the public, are essential to effectively reduce the burden of infectious diseases.

HIV behavioural interventions targeted towards older adults: a systematic review

Background

The increasing number of people living with HIV aged 50 years and older has been recognised around the world yet non-pharmacologic HIV behavioural and cognitive interventions specifically targeted to older adults are limited. Evidence is needed to guide the response to this affected group.

Methods

We conducted a systematic review of the available published literature in MEDLINE, Embase and the Education Resources Information Center. A search strategy was defined with high sensitivity but low specificity to identify behavioural interventions with outcomes in the areas of treatment adherence, HIV testing uptake, increased HIV knowledge and uptake of prevention measures. Data from relevant articles were extracted into excel.

Results

Twelve articles were identified all of which originated from the Americas. Eight of the interventions were conducted among older adults living with HIV and four for HIV-negative older adults. Five studies included control groups. Of the included studies, four focused on general knowledge of HIV, three emphasised mental health and coping, two focused on reduced sexual risk behaviour, two on physical status and one on referral for care. Only four of the studies were randomised controlled trials and seven – including all of the studies among HIV-negative older adults – did not include controls at all. A few of the studies conducted statistical testing on small samples of 16 or 11 older adults making inference based on the results difficult. The most relevant study demonstrated that using telephone-based interventions can reduce risky sexual behaviour among older adults with control reporting 3.24 times (95% CI 1.79-5.85) as many occasions of unprotected sex at follow-up as participants. Overall however, few of the articles are sufficiently rigorous to suggest broad replication or to be considered representative and applicable in other settings.

Conclusions

More evidence is needed on what interventions work among older adults to support prevention, adherence and testing. More methodological rigourised needed in the studies targeting older adults. Specifically, including control groups in all studies is needed as well as sufficient sample size to allow for statistical testing. Addition of specific bio-marker or validated behavioural or cognitive outcomes would also strengthen the studies.

Preconception care for people living with HIV: recommendations for advancing implementation

Globally, research has documented high fertility desires and intentions among HIV-positive women. Improving implementation of preconception care (PCC) for people living with HIV is critical, given estimates that the majority of HIV-positive women who want future biological children have not received reproductive counseling, largely due to a lack of provider-initiated conversations. This article offers initial recommendations and outlines key considerations for a research agenda to advance PCC implementation efforts in both high-resource and low-resource settings. We consider who should provide PCC; where it can be effectively delivered; when it should be offered; and two potential implementation models depending on available resources. We conclude with a call for PCC-specific implementation science and research translation to help people living with HIV achieve their reproductive goals.

Sisters empowered, sisters aware: three strategies to recruit African American women for HIV testing

African American women account for 66% of new HIV infections among U.S. women, and many are not aware of their status. The authors compared three strategies (targeted outreach, alternate venues, and social networks) to recruit African American women for HIV testing in Houston, New York City, Baltimore, and Dayton. A quasi-experimental design (N = 4,942) was used to compare HIV-positivity rates and to identify risk factors for previously undiagnosed infection. A total of 2.1% of the women were newly diagnosed with HIV. The proportion newly identified as HIV-positive did not differ significantly among the three strategies (2.4% for social networks, 1.7% for both targeted outreach and alternate venues). However, the social networks strategy recruited women with greater risk behaviors and other characteristics associated with newly identified HIV infection and thus may be effective at reaching some high-risk women before they become infected. A combination of recruitment strategies may be warranted to reach various subgroups of African American women at risk for HIV.

A review of self-testing for HIV: research and policy priorities in a new era of HIV prevention

Global progress toward universal human immunodeficiency virus (HIV) testing remains slow. Interest in HIV self-testing is high and may increase knowledge of HIV status; however, empirical research on selftesting is limited, resulting in lack of evidence on which to base policy recommendations.

Inadequate uptake of testing for human immunodeficiency virus (HIV) remains a primary bottleneck toward universal access to treatment and care, and is an obstacle to realizing the potential of new interventions for preventing HIV infection, including treatment for prevention and preexposure prophylaxis. HIV self-testing offers an approach to scaling up testing that could be high impact, low cost, confidential, and empowering for users. Although HIV self-testing was first considered >20 years ago, it has not been widely implemented. We conducted a review of policy and research on HIV self-testing, which indicates that policy is shifting toward a more flexible approach with less emphasis on pretest counseling and that HIV self-testing has been adopted in a number of settings. Empirical research on self-testing is limited, resulting in a lack of an evidence base upon which to base policy recommendations. Relevant research and investment in programs are urgently needed to enable consideration of developing formalized self-testing programs.

Antiretroviral prophylaxis for sexual and injection drug use acquisition of HIV

During the past few years, much has been learned about pre-exposure prophylaxis (PrEP) of HIV from studies conducted in the U.S. and elsewhere. A review and summary was conducted of articles and reports published through August 2012 on the safety and efficacy of PrEP in humans; U.S.-based studies assessing PrEP knowledge, attitudes, and use among at-risk populations and healthcare providers; and models of the cost effectiveness of PrEP. PrEP is generally safe and effective and may be cost effective in a targeted population. Awareness and interest in PrEP are increasing. PrEP is an important new addition to HIV prevention services, but continued study is warranted.