Routine HIV Screening in an Urban Community Health Center: Results from a Geographically Focused Implementation Science Program

Estimating the potential value of MSM-focused evidence-based implementation interventions in three Ending the HIV Epidemic jurisdictions in the United States: a model-based analysis

INTRODUCTION

Improving the delivery of existing evidence-based interventions to prevent and diagnose HIV is key to Ending the HIV Epidemic in the United States. Structural barriers in the access and delivery of related health services require municipal or state-level policy changes; however, suboptimal implementation can be addressed directly through interventions designed to improve the reach, effectiveness, adoption or maintenance of available interventions. Our objective was to estimate the cost-effectiveness and potential epidemiological impact of six real-world implementation interventions designed to address these barriers and increase the scale of delivery of interventions for HIV testing and pre-exposure prophylaxis (PrEP) in three US metropolitan areas.

METHODS

We used a dynamic HIV transmission model calibrated to replicate HIV microepidemics in Atlanta, Los Angeles (LA) and Miami. We identified six implementation interventions designed to improve HIV testing uptake ("Academic detailing for HIV testing," "CyBER/testing," "All About Me") and PrEP uptake/persistence ("Project SLIP," "PrEPmate," "PrEP patient navigation"). Our comparator scenario reflected a scale-up of interventions with no additional efforts to mitigate implementation and structural barriers. We accounted for potential heterogeneity in population-level effectiveness across jurisdictions. We sustained implementation interventions over a 10-year period and evaluated HIV acquisitions averted, costs, quality-adjusted life years and incremental cost-effectiveness ratios over a 20-year time horizon (2023-2042).

RESULTS

Across jurisdictions, implementation interventions to improve the scale of HIV testing were most cost-effective in Atlanta and LA (CyBER/testing cost-saving and All About Me cost-effective), while interventions for PrEP were most cost-effective in Miami (two of three were cost-saving). We estimated that the most impactful HIV testing intervention, CyBER/testing, was projected to avert 111 (95% credible interval: 110-111), 230 (228-233) and 101 (101-103) acquisitions over 20 years in Atlanta, LA and Miami, respectively. The most impactful implementation intervention to improve PrEP engagement, PrEPmate, averted an estimated 936 (929-943), 860 (853-867) and 2152 (2127-2178) acquisitions over 20 years, in Atlanta, LA and Miami, respectively.

CONCLUSIONS

Our results highlight the potential impact of interventions to enhance the implementation of existing evidence-based interventions for the prevention and diagnosis of HIV.

Going (Anti)Viral: Improving HIV and HCV Screening and HPV Vaccination in Primary Care

BACKGROUND

Human immunodeficiency virus (HIV) and hepatitis C (HCV) screening and human papillomavirus (HPV) vaccine uptake remain suboptimal. To improve HIV and HCV screening and HPV vaccination, the authors implemented a quality improvement project in three southwestern Pennsylvania family medicine residency practices.

METHODS

From June 1 to November 30, 2021, participating practices used universal screening and vaccination guidelines and chose from multiple strategies at the office (for example, standing orders), provider (for example, multiple forms of provider reminders), and patient (for example, incentives) levels derived from published literature and tailored to local context. Age-eligible patients for each recommendation with at least one in-person office visit during the intervention period were included. To assess the interventions' effect, the authors obtained testing and vaccination data from the electronic health record for the intervention period, contrasted it with identical data from June 1 to November 30, 2020, and used logistic regression controlling for patient age, sex, and race to determine differences in screening and vaccination between intervention and baseline periods.

RESULTS

A total of 14,920 and 15,523 patients were eligible in the baseline and intervention periods, respectively. Following the intervention, HIV lifetime screening but not first-time screening for patients 13-64 years old was significantly higher (78.9% vs. 76.1%, p = 0.004, and 39.6% vs. 36.6%, p = 0.152, respectively, adjusted odds ratio [aOR] 1.21, 95% confidence interval [CI] 1.06-1.38). HCV lifetime screening for patients 18-79 years old was significantly higher postintervention (62.5% vs. 53.5%, p < 0.001, aOR 1.51, 95% CI 1.4-1.64). For patients 9-26 years old, no change in HPV initiation was observed, but the percentage of patients who completed their HPV vaccinations in the observed period was significantly higher postintervention (7.0% vs 4.6%, p = 0.006, aOR 1.58, 95% CI 1.14-2.2). During the postintervention period, the researchers identified 0 new HIV diagnoses and 48 HCV diagnoses (19 eligible for treatment).

CONCLUSION

Family medicine residency office-based multistrategy efforts appear to successfully increase patient uptake of HIV and HCV screenings and maintain HPV vaccination rates.

Access to Federally Qualified Health Centers and HIV Outcomes in the U.S. South

INTRODUCTION

Federally Qualified Health Centers may increase access to HIV prevention, care, and treatment for at-risk populations.

METHODS

A pooled cross section of ZIP Code Tabulation Areas from cites in the U.S. South with high HIV diagnoses were used to examine Federally Qualified Health Center density and indicators of HIV epidemic control. The explanatory variable was Federally Qualified Health Center density-number of Federally Qualified Health Centers in a ZIP Code Tabulation Areas' Primary Care Service Area per low-income population-high versus medium/low (2019). Outcomes were 5-year (2015-2019 or 2014-2018) (1) number of new HIV diagnoses, (2) percentage late diagnosis, (3) percentage linked to care, and (4) percentage virally suppressed, which was assessed over 1 year (2018 or 2019). Multiple linear regression was used to examine the relationship, including ZIP Code Tabulation Area-level sociodemographic and city-level HIV funding variables, with state-fixed effects, and data analysis was completed in 2022-2023. Sensitivity analyses included (1) examining ZIP Code Tabulation Areas with fewer non-Federally Qualified Health Center primary care providers, (2) controlling for county-level primary care provider density, (3) excluding the highest HIV prevalence ZIP Code Tabulation Areas, and (4) excluding Florida ZIP Code Tabulation Areas.

RESULTS

High-density ZIP Code Tabulation Areas had a lower percentage of late diagnosis and virally suppressed, a higher percentage linked to care, and no differences in new HIV diagnoses (p<0.05). In adjusted analysis, high density was associated with a greater number of new diagnoses (number or percentage=5.65; 95% CI=2.81, 8.49), lower percentage of late diagnosis (-3.71%; 95% CI= -5.99, -1.42), higher percentage linked to care (2.13%; 95% CI=0.20, 4.06), and higher percentage virally suppressed (1.87%; 95% CI=0.53, 2.74) than medium/low density.

CONCLUSIONS

Results suggest that access to Federally Qualified Health Centers may benefit community-level HIV epidemic indicators.

Locating the Risk: Using Participatory Mapping to Contextualize Perceived HIV Risk across Geography and Social Networks among Men Who Have Sex with Men in the Deep South

HIV incidence among African American (AA) young men who have sex with men (YMSM) has remained stable even though they made up the largest number of new HIV diagnoses among men who have sex with men (MSM) in 2017. HIV spreads at increased rates in dense sexual networks. Identifying the location of risk behaviors "activity spaces" could inform geographically circumscribed HIV prevention interventions. Utilizing the modified social ecological model we completed five semi-structured focus groups incorporating a modified social mapping technique, based on Singer et al.'s approach. Participants included 27 AA YMSM. Focus groups explored how and where HIV transmission happens in Jackson, Mississippi. Result themes included: 1) location of sexual behaviors, 2) knowledge of geographic hotspots of HIV infection in Jackson, and 3) traveling to meet partners: at home and away. HIV transmission or "activity spaces" may be occurring outside identified HIV hot spots. Mixed geospatial and qualitative methods offered a comprehensive assessment of where HIV transmission occurs, and suggests that geographically circumscribed interventions may need to focus on where individuals living with HIV reside and in specific geographic locations where they engage in behaviors that raise their HIV acquisition risks.

Six practical recommendations for improved implementation outcomes reporting

Background

Implementation outcomes research spans an exciting mix of fields, disciplines, and geographical space. Although the number of studies that cite the 2011 taxonomy has expanded considerably, the problem of harmony in describing outcomes persists. This paper revisits that problem by focusing on the clarity of reporting outcomes in studies that examine them. Published recommendations for improved reporting and specification have proven to be an important step in enhancing the rigor of implementation research. We articulate reporting problems in the current implementation outcomes literature and describe six practical recommendations that address them.

Recommendations

Our first recommendation is to clearly state each implementation outcome and provide a definition that the study will consistently use. This includes providing an explanation if using the taxonomy in a new way or merging terms. Our second recommendation is to specify how each implementation outcome will be analyzed relative to other constructs. Our third recommendation is to specify “the thing” that each implementation outcome will be measured in relation to. This is especially important if you are concurrently studying interventions and strategies, or if you are studying interventions and strategies that have multiple components. Our fourth recommendation is to report who will provide data and the level at which data will be collected for each implementation outcome, and to report what kind of data will be collected and used to assess each implementation outcome. Our fifth recommendation is to state the number of time points and frequency at which each outcome will be measured. Our sixth recommendation is to state the unit of observation and the level of analysis for each implementation outcome.

Conclusion

This paper advances implementation outcomes research in two ways. First, we illustrate elements of the 2011 research agenda with concrete examples drawn from a wide swath of current literature. Second, we provide six pragmatic recommendations for improved reporting. These recommendations are accompanied by an audit worksheet and a list of exemplar articles that researchers can use when designing, conducting, and assessing implementation outcomes studies.

Acceptability of HIV testing for adolescents and young adults by delivery model: a systematic review

HIV infections are prevalent among adolescents and young adults, of whom 44% remain unaware of their diagnosis. HIV screening presents numerous challenges including stigma, fear, and concerns about confidentiality, which may influence young people's acceptance of HIV screening and linkage to care differently from individuals in other age groups. It is imperative to understand which care delivery models are most effective in facilitating these services for youth. This systematic review analyzes the rates of HIV test acceptance and linkage to care by care delivery model for adolescents and young adults. Studies were classified into emergency department (ED), primary care/inpatient setting, community-based program, or sexually transmitted infection clinic models of care. From 6395 studies initially identified, 59 met criteria for inclusion in the final analyses. Rate of test acceptance and linkage to care were stratified by model of care delivery, gender, race, age ranges (13-17, 18-24 years) as well as site (North America vs rest of the world). A significant difference in acceptance of HIV testing was found between care models, with high rates of test acceptance in the ED setting in North America and primary care/hospital setting in the rest of the world. Similarly, linkage to care differed by model of care, with EDs having high rates of linkages to HIV care in North America. Future studies are needed to test mechanisms for optimizing outcomes for each care delivery model in addressing the unique challenges faced by adolescents and young adults.

HIV Testing Strategies for Health Departments to End the Epidemic in the U.S

An important goal of the Ending the HIV Epidemic in the U.S. initiative is the timely diagnosis of all people with HIV as early as possible after infection. To end the HIV epidemic, health departments were encouraged to propose new and innovative HIV testing strategies and improve the reach of existing programs. These activities were divided into 3 core strategies: expansion of routine screening in healthcare settings, locally tailored HIV testing initiatives in nonhealthcare settings, and specific efforts to increase the frequency of testing for individuals with increased potential for acquiring HIV. Because HIV testing is such a crucial part of the core activities of the Centers for Disease Control and Prevention's HIV prevention programs, there are many examples of evidence-based programs and best practices for HIV testing in both clinical and nonclinical settings. This article reviews the evidence base for these strategies and some of the activities proposed under the Diagnose pillar to achieve the goal of diagnosing all HIV infections as early as possible. All other Ending the HIV Epidemic in the U.S. activities start with an awareness of HIV status, which is actually the indicator for which most health departments are closest to the proposed targets. There are both proven and emerging approaches to increasing HIV screening and increasing the frequency of HIV screening available. The Ending the HIV Epidemic in the U.S. initiative provides the motivation, the resources, and a coordinated plan to bring them to scale.

Missed Opportunities for Human Immunodeficiency Virus (HIV) Testing During Injection Drug Use-Related Healthcare Encounters Among a Cohort of Persons Who Inject Drugs With HIV Diagnosed During an Outbreak-Cincinnati/Northern Kentucky, 2017-2018

BACKGROUND

Persons who inject drugs (PWID) have frequent healthcare encounters related to their injection drug use (IDU) but are often not tested for human immunodeficiency virus (HIV). We sought to quantify missed opportunities for HIV testing during an HIV outbreak among PWID.

METHODS

PWID with HIV diagnosed in 5 Cincinnati/Northern Kentucky counties during January 2017-September 2018 who had ≥1 encounter 12 months prior to HIV diagnosis in 1 of 2 Cincinnati/Northern Kentucky area healthcare systems were included in the analysis. HIV testing and encounter data were abstracted from electronic health records. A missed opportunity for HIV testing was defined as an encounter for an IDU-related condition where an HIV test was not performed and had not been performed in the prior 12 months.

RESULTS

Among 109 PWID with HIV diagnosed who had ≥1 healthcare encounter, 75 (68.8%) had ≥1 IDU-related encounters in the 12 months before HIV diagnosis. These 75 PWID had 169 IDU-related encounters of which 86 (50.9%) were missed opportunities for HIV testing and occurred among 46 (42.2%) PWID. Most IDU-related encounters occurred in the emergency department (118/169; 69.8%). Using multivariable generalized estimating equations, HIV testing was more likely in inpatient compared with emergency department encounters (adjusted relative risk [RR], 2.72; 95% confidence interval [CI], 1.70-4.33) and at the healthcare system receiving funding for emergency department HIV testing (adjusted RR, 1.76; 95% CI, 1.10-2.82).

CONCLUSIONS

PWID have frequent IDU-related encounters in emergency departments. Enhanced HIV screening of PWID in these settings can facilitate earlier diagnosis and improve outbreak response.

A systematic review of early adoption of implementation science for HIV prevention or treatment in the United States

OBJECTIVE

To provide the first systematic review of the early adoption of implementation science for HIV prevention or treatment in the United States. We identified primary research studies that addressed implementation of HIV prevention or treatment in the United States and qualitatively assessed the reporting of implementation outcomes and intervention descriptions.

METHODS

We searched PubMed, PsycInfo, and CINAHL databases for evaluations of HIV prevention or treatment interventions that at least reported one implementation outcome and were published between 2014 and 2018. We used the 12-item Template for Intervention Description and Replication to assess study interventions.

RESULTS

A total of 2275 articles were identified. Thirty-nine studies met inclusion criteria. Of these, 84.6% used quantitative methods with 5% being hybrid effectiveness-implementation studies and 15% used qualitative methods. No studies cited a formal theoretical framework for implementation science. Acceptability and feasibility were the most frequently reported implementation outcomes. Eligible studies were diverse with regard to demographic categories. Most interventions focused on HIV prevention, particularly risk-reduction strategies. HIV treatment interventions targeted linkage to care and adherence to medications. Key implementation outcome findings indicated that these interventions are feasible and acceptable in the real world.

CONCLUSION

HIV implementation science could support dissemination of HIV prevention or treatment in the United States, although HIV treatment interventions are limited. Theoretical frameworks and key implementation outcomes like fidelity, penetration, and appropriateness could promote the rigor of future HIV treatment implementation research, helping the field deliver the promise of HIV prevention or treatment efforts in the United States.

Missed Opportunities for HIV Testing Among STD Clinic Patients

Current HIV testing guidelines recommend that all adolescents and adults aged 13-64 be routinely screened for HIV in healthcare settings. Sexually transmitted disease (STD) clinic patients represent a population at increased risk for HIV, justifying more frequent risk assessment and testing. This analysis describes missed opportunities for HIV testing among a sample of STD clinic patients to identify areas where HIV testing services may be improved. Secondary analysis was conducted using data from Project AWARE, a randomized trial of 5012 adult patients from 9 STD clinics in the United States, enrolled April-December 2010. HIV testing history, healthcare service utilization, and behavioral risks were obtained through audio computer-assisted self-interview. Missed opportunities for HIV testing, defined as having a healthcare visit but no HIV test in the last 12 months, were characterized by location and frequency. Of 2315 (46.2%) participants not tested for HIV in the last 12 months, 1715 (74.1%) had a missed opportunity for HIV testing. These missed opportunities occurred in both traditional (54.9% at family doctor, 20.3% at other medical doctor visits) and non-traditional (28.5% at dental, 19.0% at eye doctor, 13.9% at correctional facility, and 13.3% at psychology visits) testing settings. Of 53 participants positive for HIV at baseline, 16 (30.2%) had a missed testing opportunity. Missed opportunities for HIV testing were common in this population of STD clinic patients. There is a need to increase routinized HIV screening and expand testing services to a broader range of healthcare settings.

Acceptance of Opt-Out HIV Screening in Outpatient Settings in the United States: A Systematic Review and Meta-Analysis

OBJECTIVES

In the United States, about 15% of persons living with HIV infection do not know they are infected. Opt-out HIV screening aims to normalize HIV testing by performing an HIV test during routine medical care unless the patient declines. The primary objective of this systematic review and meta-analysis was to assess the acceptance of opt-out HIV screening in outpatient settings in the United States.

METHODS

We searched in PubMed and CINAHL (Cumulative Index to Nursing and Allied Health Literature) for studies published from January 1, 2006, through December 31, 2018, of opt-out HIV screening in outpatient settings. We collected data from selected studies and calculated for each study (1) the percentage of persons who were offered HIV testing, (2) the percentage of persons who accepted the test, and (3) the percentage of new HIV diagnoses among persons tested. We also collected information on the reasons given by patients for opting out. The meta-analysis used a random-effects model to estimate the average percentages of HIV testing offered, HIV testing accepted, and new HIV diagnoses.

RESULTS

We initially identified 6986 studies; the final analysis comprised 14 studies. Among the 8 studies that reported the size of the study population eligible for HIV screening, 71.4% (95% confidence interval [CI], 53.9%-89.0%) of the population was offered an HIV test on an opt-out basis. The test was accepted by 58.7% (95% CI, 47.2%-70.2%) of persons offered the test. Among 9 studies that reported data on new HIV diagnoses, 0.18% (95% CI, 0.08%-0.26%) of the persons tested had a new HIV diagnosis. Patients' most frequently cited reasons for refusal of HIV screening were that they perceived a low risk of having HIV or had previously been tested.

CONCLUSIONS

The rates of offering and accepting an HIV test on an opt-out basis could be improved by addressing health system and patient-related factors. Setting a working target for these rates would be useful for measuring the success of opt-out HIV screening programs.

HIV Clustering in Mississippi: Spatial Epidemiological Study to Inform Implementation Science in the Deep South

BACKGROUND

In recent years, more than half of new HIV infections in the United States occur among African Americans in the Southeastern United States. Spatial epidemiological analyses can inform public health responses in the Deep South by identifying HIV hotspots and community-level factors associated with clustering.

OBJECTIVE

The goal of this study was to identify and characterize HIV clusters in Mississippi through analysis of state-level HIV surveillance data.

METHODS

We used a combination of spatial epidemiology and statistical modeling to identify and characterize HIV hotspots in Mississippi census tracts (n=658) from 2008 to 2014. We conducted spatial analyses of all HIV infections, infections among men who have sex with men (MSM), and infections among African Americans. Multivariable logistic regression analyses identified community-level sociodemographic factors associated with HIV hotspots considering all cases.

RESULTS

There were HIV hotspots for the entire population, MSM, and African American MSM identified in the Mississippi Delta region, Southern Mississippi, and in greater Jackson, including surrounding rural counties (P<.05). In multivariable models for all HIV cases, HIV hotspots were significantly more likely to include urban census tracts (adjusted odds ratio [AOR] 2.01, 95% CI 1.20-3.37) and census tracts that had a higher proportion of African Americans (AOR 3.85, 95% CI 2.23-6.65). The HIV hotspots were less likely to include census tracts with residents who had less than a high school education (AOR 0.95, 95% CI 0.92-0.98), census tracts with residents belonging to two or more racial/ethnic groups (AOR 0.46, 95% CI 0.30-0.70), and census tracts that had a higher percentage of the population living below the poverty level (AOR 0.51, 95% CI 0.28-0.92).

CONCLUSIONS

We used spatial epidemiology and statistical modeling to identify and characterize HIV hotspots for the general population, MSM, and African Americans. HIV clusters concentrated in Jackson and the Mississippi Delta. African American race and urban location were positively associated with clusters, whereas having less than a high school education and having a higher percentage of the population living below the poverty level were negatively associated with clusters. Spatial epidemiological analyses can inform implementation science and public health response strategies, including improved HIV testing, targeted prevention and risk reduction education, and tailored preexposure prophylaxis to address HIV disparities in the South.

Latent class analysis of acceptability and willingness to pay for self-HIV testing in a United States urban neighbourhood with high rates of HIV infection

Introduction: Acceptability and willingness to both take and pay for HIV self-tests (HIVSTs) in US neighbourhoods with high rates of HIV infection are not well understood.

Methods: We surveyed 1,535 individuals about acceptability and willingness to take and pay for an HIVST in a predominately African American neighbourhood with 3% HIV seroprevalence. We recruited individuals presenting for HIV screening services in a community-based programme. Latent class analysis (LCA) grouped individuals with similar patterns of HIV-risk behaviours and determined which groups would be most willing to use and buy HIVSTs.

Results: Nearly 90% of respondents were willing to use an HIVST; 55% were willing to buy HIVSTs, but only 23% were willing to pay the market price of US $40. Four distinct groups emerged and were characterized by risk behaviours: (1) low risk (N = 324); (2) concurrent partnerships (N = 346); (3) incarceration and substance use (N = 293); and (4) condomless sex/multiple partners (N = 538). Individuals in the low-risk class were less willing to self-test compared to concurrent sexual partners (OR = 0.39, p = .003) and incarceration and substance use (OR = 0.46, p = .011) classes. There were no significant differences across classes in the amount individuals were willing to pay for an HIVST.

Conclusions: HIVSTs were overwhelmingly acceptable but cost prohibitive; most participants were unwilling to pay the market rate of US $40. Subsidizing and implementing HIVST programmes in communities with high rates of infection present a public health opportunity, particularly among individuals reporting condomless sex with multiple partners, concurrent sexual partnerships and those with incarceration and substance use histories.

Feasibility of Using HIV Care-Continuum Outcomes to Identify Geographic Areas for Targeted HIV Testing

BACKGROUND

Improved detection and linkage to care of previously undiagnosed HIV infections require innovative approaches to testing. We sought to determine the feasibility of targeted HIV testing in geographic areas, defined by continuum of care parameters, to identify HIV-infected persons needing linkage or engagement in care.

METHODS

Using HIV surveillance data from Washington, DC, we identified census tracts that had an HIV prevalence >1% and were either above (higher risk areas-HRAs) or below (lower risk areas-LRAs) the median for 3 indicators: monitored viral load, proportion of persons out of care (OOC), and never in care. Community-based HIV rapid testing and participant surveys were conducted in the 20 census tracts meeting the criteria. Areas were mapped using ArcGIS, and descriptive and univariate analyses were conducted comparing the areas and participants.

RESULTS

Among 1471 persons tested, 28 (1.9%) tested HIV positive; 2.1% in HRAs vs. 1.7% in LRAs (P = 0.57). Higher proportions of men (63.7% vs. 56.7%, P = 0.007) and fewer blacks (91.0% vs. 94.6%, P = 0.008) were tested in LRAs vs. HRAs; no differences were observed in risk behaviors between the areas. Among HIV-positive participants, 54% were new diagnoses (n = 9) or OOC (n = 6), all were Black, 64% were men with a median age of 51 years.

CONCLUSIONS

Although significant differences in HIV seropositivity were not observed between testing areas, our approach proved feasible and enabled identification of new diagnoses and OOC HIV-infected persons. This testing paradigm could be adapted in other locales to identify areas for targeted HIV testing and other reengagement efforts.