Facilitators and Barriers to HIV Screening: A Qualitative Meta-Synthesis

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Community views on active case finding for tuberculosis in low- and middle-income countries: a qualitative evidence synthesis

BACKGROUND

Active case finding (ACF) refers to the systematic identification of people with tuberculosis in communities and amongst populations who do not present to health facilities, through approaches such as door-to-door screening or contact tracing. ACF may improve access to tuberculosis diagnosis and treatment for the poor and for people remote from diagnostic and treatment facilities. As a result, ACF may also reduce onward transmission. However, there is a need to understand how these programmes are experienced by communities in order to design appropriate services.

OBJECTIVES

To synthesize community views on tuberculosis active case finding (ACF) programmes in low- and middle-income countries.

SEARCH METHODS

We searched MEDLINE, Embase, and eight other databases up to 22 June 2023, together with reference checking, citation searching, and contact with study authors to identify additional studies. We did not include grey literature.

SELECTION CRITERIA

This review synthesized qualitative research and mixed-methods studies with separate qualitative data. Eligible studies explored community experiences, perceptions, or attitudes towards ACF programmes for tuberculosis in any endemic low- or middle-income country, with no time restrictions.

DATA COLLECTION AND ANALYSIS

Due to the large volume of studies identified, we chose to sample studies that had 'thick' description and that investigated key subgroups of children and refugees. We followed standard Cochrane methods for study description and appraisal of methodological limitations. We conducted thematic synthesis and developed codes inductively using ATLAS.ti software. We examined codes for underlying ideas, connections, and interpretations and, from this, generated analytical themes. We assessed the confidence in the findings using the GRADE-CERQual approach, and produced a conceptual model to display how the different findings interact.

MAIN RESULTS

We included 45 studies in this synthesis, and sampled 20. The studies covered a broad range of World Health Organization (WHO) regions (Africa, South-East Asia, Eastern Mediterranean, and the Americas) and explored the views and experiences of community members, community health workers, and clinical staff in low- and middle-income countries endemic for tuberculosis. The following five themes emerged. • ACF improves access to diagnosis for many, but does little to help communities on the edge. Tuberculosis ACF and contact tracing improve access to health services for people with worse health and fewer resources (High confidence). ACF helps to find this population, exposed to deprived living conditions, but is not sensitive to additional dimensions of their plight (High confidence) and out-of-pocket costs necessary to continue care (High confidence). Finally, migration and difficult geography further reduce communities' access to ACF (High confidence). • People are afraid of diagnosis and its impact. Some community members find screening frightening. It exposes them to discrimination along distinct pathways (isolation from their families and wider community, lost employment and housing). HIV stigma compounds tuberculosis stigma and heightens vulnerability to discrimination along these same pathways (High confidence). Consequently, community members may refuse to participate in screening, contact tracing, and treatment (High confidence). In addition, people with tuberculosis reported their emotional turmoil upon diagnosis, as they anticipated intense treatment regimens and the prospect of living with a serious illness (High confidence). • Screening is undermined by weak health infrastructure. In many settings, a lack of resources results in weak services in competition with other disease control programmes (Moderate confidence). In this context of low investment, people face repeated tests and clinic visits, wasted time, and fraught social interaction with health providers (Moderate confidence). ACF can create expectations for follow-up health care that it cannot deliver (High confidence). Finally, community education improves awareness of tuberculosis in some settings, but lack of full information impacts community members, parents, and health workers, and sometimes leads to harm for children (High confidence). • Health workers are an undervalued but important part of ACF. ACF can feel difficult for health workers in the context of a poorly resourced health system and with people who may not wish to be identified. In addition, the evidence suggests health workers are poorly protected against tuberculosis and fear they or their families might become infected (Moderate confidence). However, they appear to be central to programme success, as the humanity they offer often acts as a driving force for retaining people with tuberculosis in care (Moderate confidence). • Local leadership is necessary but not sufficient for ensuring appropriate programmes. Local leadership creates an intrinsic motivation for communities to value health services (High confidence). However, local leadership cannot guarantee the success of ACF and contact tracing programmes. It is important to balance professional authority with local knowledge and rapport (High confidence).

AUTHORS' CONCLUSIONS

Tuberculosis active case finding (ACF) and contact tracing bring a diagnostic service to people who may otherwise not receive it, such as those who are well or without symptoms and those who are sick but who have fewer resources and live further from health facilities. However, capturing these 'missing cases' may in itself be insufficient without appropriate health system strengthening to retain people in care. People who receive a tuberculosis diagnosis must contend with a complex and unsustainable cascade of care, and this affects their perception of ACF and their decision to engage with it.

Methodological issues in qualitative research on HIV prevention: an integrative review

In view of the growing concern about the use of qualitative approach in health research, this article aims to analyze how the qualitative theoretical-methodological framework of HIV prevention is presented in empirical research. We conducted an integrative literature review with the following guiding questions: "How is the qualitative theoretical-methodological framework expressed in empirical research on HIV prevention?"; "What are the limits and potentials of the qualitative methodological designs employed?". In the qualitative methodological discussion, five dimensions guided the methodological course and the presentation of findings, from the analysis of the characterization of qualitative studies to the contextualization of the studies and the methodological approaches used, highlighting the use of semi-structured interviews with thematic content analysis. We also examined social categories and analytical references, drawing attention to the plurality of these theoretical-conceptual references and to the authors' polyphony, and identified the limits and potentials of qualitative research. This study focuses on a scientific topic that is related to a wide variety of social groups and analyzes how they are affected by it, examining issues related to social inequality and other analytical possibilities surrounding HIV prevention, and providing resources for a comprehensive methodological discussion. Hence, avoiding the risk of conducting qualitative research based on checklists that limit inventiveness and openness to different designs and forms of execution and analysis is as pivotal as ensuring that the research is consistent and detailed in publications.

Associations Between Health Insurance Coverage with HIV Detection and Prevention Behaviors Among Individuals with Undiagnosed HIV or at Increased Risk for HIV Infection in the USA

BACKGROUND

Improving HIV detection and prevention remains a critical public health initiative that requires policy-based solutions. This study sought to compare HIV detection/prevention behaviors before and after healthcare reform in Massachusetts, USA, among heterosexually active persons - the group with the highest reported number of undiagnosed HIV cases. The current study sought to (1) characterize differences in insurance coverage and HIV detection/prevention behaviors between cycles 1 (2006) to 5 (2019); (2) evaluate socio-demographic disparities in insurance coverage accounting for cycle; and (3) evaluate associations between health insurance coverage and HIV detection/prevention behaviors accounting for cycle and socio-demographics.

METHODS

This is a secondary analysis of the National HIV Behavioral Surveillance (NHBS) project: Boston HET cycle (i.e., made up of heterosexually active persons living in the Boston area) data. Descriptive, bivariate (e.g., chi-square), and multiple logistic and negative binomial loglink regression analyses were conducted.

RESULTS

In chi-square analyses with post hoc Bonferroni tests, the proportion of participants with current health insurance significantly increased from cycle 1 (77%) to cycle 2 (95%), p < .001. In the regression models that controlled for NHBS cycle, 1-year change in age (adjusted odds ratio [aOR] = 1.03, 95% confidence interval [CI] = 1.02, 1.05), female gender (aOR = 3.41, 95% CI = 2.48, 4.69), and change in education category (aOR = 1.19, 95% CI = 1.02, 1.39) were associated with a higher likelihood of having health insurance. In regression models that controlled for cycle, age, gender, and education, participants with health insurance were more likely than those without insurance to report seeing a medical provider in the past year (aOR = 3.49, 95% CI = 2.32, 4.66), ever having an HIV test (aOR = 1.52, 95% CI = 0.35, 2.69) and more frequent HIV testing in the past 2 years (incidence rate ratio [IRR] = 1.44, 95% = 1.14, 1.82). Participants with health insurance did not differ from those without insurance in number of vaginal condomless sex partners (IRR = 1.16, 95% CI = 0.95, 1.41) but did report more condomless anal sex partners in the past year (IRR = 1.97, 95% CI = 1.46, 2.65).

CONCLUSIONS

This study demonstrates how health insurance coverage is positively associated with HIV detection and prevention relevant to both US and international efforts to end the HIV epidemic.

Predictors of missed HIV screening opportunities among newly diagnosed individuals at an urban medical center in New York City, 2018-2022

OBJECTIVE

To identify demographic and clinical factors predictive of having a missed opportunity (MO) for HIV screening.

DESIGN

Retrospective cohort study.

METHODS

Electronic medical records were queried for individuals newly diagnosed with HIV in different sites within a large urban academic medical center in New York City between 2018 and 2022. The primary outcome was having one or more MO for HIV screening within the institution, defined as any encounter at which screening was not performed in the 365 days preceding the HIV diagnosis.

RESULTS

Over one third of new diagnoses had at least one MO in the preceding year. Older individuals, cisgender women and those assigned female sex at birth, and heterosexual individuals were more likely to have at least one MO. An initial CD4 < 200 cells/ul was more likely among men who have sex with women specifically. Most MOs occurred in the emergency department and outpatient settings, with minimal HIV prevention discussions documented during each MO.

CONCLUSIONS

These findings suggest that populations perceived to be at lower risk for HIV are more likely to have MOs and possibly late diagnoses, and that universal HIV screening must be implemented into the workflows of emergency department and outpatient settings to facilitate early diagnosis and reduce the incidence of HIV.

Identity management in the face of HIV and intersecting stigmas: A metasynthesis of qualitative reports from sub-Saharan Africa

While stigma experienced by people living with HIV (PLWH) is well documented, intersectional stigma and additional stigmatized identities have not received similar attention. The purpose of this metasynthesis is to identify salient stigmatized intersections and their impact on health outcomes in PLWH in sub-Saharan Africa. Using Sandelowski and Barroso's metasynthesis method, we searched four databases for peer-reviewed qualitative literature. Included studies (1) explored personal experiences with intersecting stigmas, (2) included ≥1 element of infectious disease stigma, and (3) were conducted in sub-Saharan Africa. Our multinational team extracted, aggregated, interpreted, and synthesized the findings. From 454 screened abstracts, the 34 studies included in this metasynthesis reported perspectives of at least 1258 participants (282 men, 557 women, and 109 unspecified gender) and key informants. From these studies, gender and HIV was the most salient stigmatized intersection, with HIV testing avoidance and HIV-status denial seemingly more common among men to preserve traditional masculine identity. HIV did not threaten female identity in the same way with women more willing to test for HIV, but at the risk of abandonment and withdrawal of financial support. To guard against status loss, men and women used performative behaviors to highlight positive qualities or minimize perceived negative attributes. These identity management practices ultimately shaped health behaviors and outcomes. From this metasynthesis, the Stigma Identity Framework was devised for framing identity and stigma management, focusing on role expectation and fulfillment. This framework illustrates how PLWH create, minimize, or emphasize other identity traits to safeguard against status loss and discrimination. Providers must acknowledge how stigmatization disrupts PLWH's ability to fit into social schemas and tailor care to individuals' unique intersecting identities. Economic security and safety should be considered in women's HIV care, while highlighting antiretrovirals' role in preserving strength and virility may improve care engagement among men.

Cisnormativity as a structural barrier to STI testing for trans masculine, two-spirit, and non-binary people who are gay, bisexual, or have sex with men

Trans masculine, two-spirit, and non-binary people who are gay, bisexual or otherwise have sex with men (TGBM) are under-tested for sexually transmitted infections (STI) and may face complex, intersectional barriers that prevent them from accessing STI testing. As part of a study on gay, bisexual and other men who have sex with men's (GBM) experiences of current STI testing systems in Ontario, Canada, this paper reports on the findings from TGBM participants' experiences with in-person STI testing in a range of venues (i.e. Family doctors, walk-in clinics, and community-based organizations) to explore testing barriers specific to TGBM. Using a community-based research approach, between June 2020 and December 2021 peer researchers who identified as GBM conducted focus groups and interviews with 38 cis and trans GBM, 13 of whom identified as TGBM. Data were analyzed following grounded theory. When questioned about past experiences with testing, TGBM participants reported several barriers to STI testing within current testing models in Ontario due to cisnormativity and heteronormativity. Cisnormativity is the assumption that everyone identifies as the gender they were assigned at birth, and those who do not are considered "abnormal", while heteronormativity is when it is assumed that everyone is heterosexual. From our research we identified three overarching themes concerning testing barriers among TGBM participants: (1) non-inclusive clinic environments, (2) lack of provider knowledge and competency, and (3) legal documentation. Inherent cis and heteronormativity in healthcare institutions appear to be factors shaping the historical under-testing for STI in the TGBM population. These findings suggest the relevance of implementing trans-specific clinical practices that reduce the stigma and barriers faced by TGBM in STI testing contexts, including: hosting all-gender testing hours, opening more LGBTQ+ clinics, offering training in transgender health to testing providers, and conducting a review of how gender markers on health documents can be more inclusive of trans, two-spirit, and non-binary communities.

HIV awareness, pre-exposure prophylaxis perceptions and experiences among people who exchange sex: qualitative and community based participatory study

Background

People who exchange sex for money, favors, goods or services, combat higher risk of acquiring sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). Understanding barriers to STD and HIV related healthcare from the perspective of this stigmatized and marginalized community may improve access to sexual health services including pre-exposure prophylaxis (PrEP). 

Methods

We used community-partnered participatory and qualitative methods to conduct anonymous one-on-one interviews with people who exchange sex to understand their perspectives and experiences related to pre-exposure prophylaxis (PrEP) to prevent HIV acquisition. We conducted twenty-two interviews and coded them to perform thematic analysis. 

Results

We identified five themes: (1) Appreciation of HIV risk and prevention strategies grew from information accumulated over time. (2) PrEP information came from a variety of sources with mixed messages and uncertain credibility. (3) Decision-making about use of PrEP was relative to other behavioral decisions regarding exchange sex. (4) The multi-step process of obtaining PrEP presented multiple potential barriers. (5) Healthcare providers were seen as powerful facilitators to PrEP utilization.

Conclusions

Our findings suggest that PrEP education and care needs to be made more relevant and accessible to individuals who exchange sex.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14235-0.

Barriers and Facilitators to Participation in Health Screening: an Umbrella Review Across Conditions

Screening is an essential prevention practice for a number of health conditions. However, screening coverage remains generally low. Studies that investigate determinants of screening participation are becoming more common, but oftentimes investigate screening for health conditions in an individualized rather than integrated fashion. In routine clinical practice, however, healthcare professionals are often confronted with situations in which several screening procedures are recommended for the same patient. The consideration of their common determinants may support a more integrated screening approach. The objectives of this umbrella review were therefore to examine: 1) the determinants (barriers and facilitators) that have been identified in relation to recommended health screening procedures; and 2) the modifiable determinants (in primary care) common across health conditions or specific to individual procedures. Results were presented through a narrative synthesis. PubMed, PsycInfo and Cochrane were searched up to January 2022. Systematic reviews reporting determinants of participation in health screening procedures with grade A or B recommendation according to the US Preventive Services Task Force were included. A total of 85 systematic reviews were included, most which contained both qualitative and quantitative studies on determinants that describe individual factors (961 occurrences), social factors (113 occurrences, healthcare professional factors (149 occurrences), health system factors (105 occurrences) and screening procedure factors (99 occurrences). The most studied screening procedures concerned cervical cancer/human papillomavirus (n = 33), breast cancer (n = 28), colorectal cancer (n = 25) and the human immunodeficiency virus (n = 12). Other conditions have been under-studied (e.g. cardiovascular problems, lung cancer, syphilis). The individual domain, including determinants such as knowledge, beliefs and emotions, was the most covered across health conditions. Healthcare professional's recommendations and the quality of patient-provider communication were identified to have a strong influence on screening participation in most conditions. The other three domains included determinants which were more specific to a condition or a population. Various determinants modifiable in primary care were found in the individual domain and in the health system, healthcare professional and screening procedure domains. Quality was assessed as low for most systematic reviews included. The identification of various modifiable determinants common across conditions highlights the potential of an integrated screening participation approach. Interventions may address common determinants in a broader person-centred framework within which tailoring to specific procedures or populations can be considered. This approach needs to be explored in intervention studies. The systematic review registration is PROSPERO CRD42019126709.

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.

Time From HIV Infection to Diagnosis in the U.S., 2014-2018

INTRODUCTION

Understanding the role of sociologic, structural, and biomedical factors that influence the length of time from HIV infection to diagnosis and reducing the time from infection to diagnosis are critical for achieving the goals of the Ending the HIV Epidemic initiative. In a retrospective analysis, the length of time from HIV infection to diagnosis and its association with individual- and facility-level attributes are determined.

METHODS

Data reported by December 2019 to the U.S. National HIV Surveillance System for people with HIV diagnosed during 2014-2018 were analyzed during December 2020. A CD4 depletion model was used to estimate the time from HIV infection to diagnosis.

RESULTS

During 2018, the median time from HIV infection to diagnosis was shorter for those infections diagnosed using the rapid testing algorithm (30.3 months, 95% CI=25.5, 34.5) than those diagnosed using the recommended (41.0 months, 95% CI=39.5, 42.0), traditional (37.0 months, 95% CI=29.5, 43.5), or other (35.5 months, 95% CI=32.5, 38.0) diagnostic testing algorithms. From 2014 to 2018, the time from HIV infection to diagnosis remained stable overall for all testing methods except for the traditional diagnostic testing algorithm. In multivariate analyses, those more likely to have HIV diagnosed closer to the time of infection were younger, were White, had transmission risk factors of injection drug use or heterosexual contact (for female individuals) or male-to-male sexual contact and injection drug use, or had HIV diagnosed at a correctional or screening facility (p<0.01).

CONCLUSIONS

Providing access to expanded testing, including rapid testing in nonclinical settings, is likely to result in a decrease in the length of time a person is unaware of their HIV infection and thus reduce onward transmission of HIV infection.

Increasing Men's Engagement in HIV Testing and Treatment Programs Through Crowdsourcing: A Mixed-Methods Analysis in Eswatini

BACKGROUND

Sub-Saharan African HIV programs have had limited success in engaging men. Crowdsourcing contests may be a useful method to spur men's engagement in HIV services. We evaluated contributions and social media response to a crowdsourcing contest focused on increasing men's engagement in Eswatini HIV services.

METHODS

We conducted a crowdsourcing contest to gain insight from the public on how HIV campaigns can more effectively engage young (20-40 years old) men in HIV services. Eligible submissions included images, songs, videos, and Internet memes. We used standard qualitative methods to examine textual themes from submissions. We examined social media response using Facebook analytics, comparing the number of people reached through crowdsourced HIV messages and the number of people reached through conventional HIV messages.

RESULTS

We received 144 submissions from 83 participants. They represented 55 towns and all 4 regions of Eswatini. The contest page gained 461 followers on Facebook. Emergent themes included appealing to men's roles as protectors by suggesting that they need to take care of their own health to continue safeguarding their families. Crowdsourced messages reached a mean of 88 individuals across 4 posts; conventional messages reached a mean of 75 individuals across 4 posts.

CONCLUSIONS

Crowdsourcing contest submissions provided insight on how to encourage men to engage in Eswatini HIV services. Crowdsourcing contests can be effective in collecting messages from men to create more locally relevant communication materials for HIV programs.

The Lived Experience of a Newly Diagnosed Older Person With HIV in Ukraine

Low- and middle-income countries are home to 80% of older people with HIV (OPWH). Ukrainian OPWH experience higher mortality and decreased antiretroviral therapy (ART) initiation than younger patients, but there is little data examining OPWH's perspectives around new diagnosis and impact on care. In this study, we examined accounts of 30 newly diagnosed OPWH in Ukraine, exploring challenges faced in the peri-diagnosis period. Themes emerged representing the longitudinal coping process: OPWH (1) viewed themselves as low risk before diagnosis; (2) experienced HIV diagnosis as a traumatic event challenging their self-image; (3) used disclosure to seek support among a small circle of family, friends, or health care providers; (4) avoided disclosure to outsiders including primary care providers for fears of stigma and breaches in confidentiality; (5) viewed age as an asset; and (6) used HIV diagnosis as starting point for growth. These findings highlight the need for age-specific programming to increase HIV knowledge and coping, increase screening, and improve long-term planning.

Sexual History Taking: Perspectives on Doctor-Patient Interactions During Routine Consultations in Rural Primary Care in South Africa

Background

Sexual history taking for risk behavior contributes to improving health outcomes in primary care. Giving the high numbers of people living with AIDS, every patient in South Africa should be offered an HIV test, which implies that a comprehensive sexual history must be taken.

Aim

To describe the optimal consultation process, as well as associated factors and skills required to improve disclosure of sexual health issues during a clinical encounter with a doctor in primary health care settings in North West province, South Africa.

Methods

This qualitative study, based on grounded theory, involved the video-recording of 151 consultations of adult patients living primarily with hypertension and diabetes. This article reports on the 5 consultations where some form of sexual history taking was observed. Patient consultations were analyzed thematically, which entailed open coding, followed by focused and verbatim coding using MaxQDA 2018 software. Confirmability was ensured by 2 generalist doctors, a public health specialist and the study supervisors.

Main Outcome Measure

Sexual history was not taken and patients living with sexual dysfunction were missed. If patients understand how disease and medication contribute to their sexual wellbeing, this may change their perceptions of the illness and adherence patterns.

Results

Sexual history was taken in 5 (3%) out of 151 consultations. Three themes emerged from these 5 consultations. In the patient-doctor relationship theme, patients experienced paternalism and a lack of warmth and respect. The consultation context theme included the seating arrangements, ineffective use of time, and privacy challenges due to interruptions and translators. Theme 3, consultation content, dealt with poor coverage of the components of the sexual health history.

Conclusion

Overall, sexual dysfunction in patients was totally overlooked and risk for HIV was not explored, which had a negative effect on patients’ quality of life and long-term health outcomes. The study provided detailed information on the complexity of sexual history taking during a routine consultation and is relevant to primary health care in a rural setting. Pretorius D, Couper I, Mlambo M. Sexual History Taking: Perspectives on Doctor-Patient Interactions During Routine Consultations in Rural Primary Care in South Africa. Sex Med 2021;9:100389.

Identifying factors increasing the risk of acquiring HIV among Egyptians to construct a consensus web-based tool for HIV risk assessment

BACKGROUND

Accurate information on HIV transmission risk is required to construct evidence-based risk reduction practices for individuals and to direct the provision of prevention strategies at the population level. HIV transmission risk assessment will help in identifying individuals at high risk of HIV infection and directing the provision of post exposure prophylaxis (PEP).

OBJECTIVE

To identify the common risk factors for HIV transmission in the Egyptian community in order to construct a web-based HIV risk assessment tool.

METHODS

Following a systematic review and meta-analysis of published literature on HIV transmission and risk factors, we retrieved the key determinants of HIV exposure risk. In parallel, we conducted a case control study to identify the common risk factors for HIV transmission in the Egyptian community. The identified risk factors were incorporated in weighted risk scoring models to allow the quantification of the risk of HIV acquisition.

RESULTS

There were 38 determinants associated with HIV seropositivity [people living with HIV (PLWH)] among Egyptians compared to 34 risk factors identified in our meta-analysis. All the derived scores showed high accuracy for predicting HIV infection status [sensitivity, specificity, PPV and NPV of greater than 90.0%, (AUC = 0.998-1.000; p < .001)].

CONCLUSION

Key drivers of HIV transmissions can be incorporated into a risk scoring model in order to quantify the risks of HIV acquisition. Such tools can facilitate the screening of PLWH and at-risk-individuals and direct interventions to halt HIV transmission.

Stages of Adoption of "Treatment as Prevention" Among HIV-Negative Men Who Have Sex with Men Who Engage in Exchange Sex

Prior research found low acceptability of HIV treatment as prevention (TasP; or Undetectable = Untransmittable) among HIV-negative men who have sex with men (MSM). This study reports on qualitative data regarding TasP adoption in a sample of 170 self-reported HIV-negative MSM who had engaged in exchange sex (received money, drugs, or other things in exchange for sex). We classified participants along five stages of TasP adoption: 1-unaware of TasP (11.2%); 2-aware, but perceived ineffective (17.1%); 3-perceived effective, but unwilling to use (35.3%); 4-willing to rely on TasP, but had never done so (24.1%); and 5-had relied on TasP (12.4%). Obstacles to TasP adoption included the following: not believing that it could completely prevent HIV transmission; deeply ingrained fears of HIV/AIDS; concerns about viral load fluctuation; and reluctance to trust a partner's claimed undetectable status. TasP promotion efforts, which can decrease barriers to HIV testing and HIV stigma, will be more effective if tailored to the obstacles specific to each stage of TasP adoption.

Perceived Facilitators and Barriers to Couples' HIV Testing and Counseling in U.S. Clinical Settings: Perspectives From U.S. Health Providers

We used a qualitative descriptive design to ascertain perceived facilitators and barriers to couples' HIV testing and counseling (CHTC) by U.S. health care providers. We recruited 22 providers from 4 health care facilities in Miami-Dade County, FL, from November 2015 to March 2016. In-depth, semistructured interviews were conducted. Content analysis categorized and contextualized provider narratives. Perceived facilitators of CHTC were provider experiences with couple-centered HIV-related care, existing patient or client demands for joint HIV screening, and a health care practice environment that fosters an interprofessional approach to addressing client needs. Perceived barriers were partner unwillingness to undergo HIV screening, provider role beliefs and preferences regarding couple-based approaches, and provider time constraints in tandem with funding and billing issues. Overall, providers endorsed CHTC and thought that current challenges and successes with couple-based efforts and HIV screening and care could influence CHTC implementation. Provider recommendations are discussed.

Assisted partner notification services for patients receiving HIV care and treatment in an HIV clinic in Nairobi, Kenya: a qualitative assessment of barriers and opportunities for scale-up

INTRODUCTION

Identifying HIV-positive individuals is increasingly recognized as one of the most important and most challenging of the UNAIDS 90-90-90 goals. Assisted partner notification services (aPNS) involves tracing and offering HIV testing to partners of HIV-positive individuals, and is effective and safe when provided to newly diagnosed HIV-positive patients. Voluntary aPNS is now part of the World Health Organization's guidelines for HIV prevention and care. However, uptake of aPNS is significantly lower among adults with established HIV infection already engaged in care compared to newly diagnosed individuals. We sought to describe barriers encountered and potential opportunities to providing aPNS to established patients living with HIV.

METHODS

We conducted focus group discussions and in-depth interviews at Nairobi's largest public HIV clinic in April to May 2016 to elucidate barriers to and opportunities for aPNS among established patients engaged in HIV care. Participants included HIV-positive adults in care, their partners, and healthcare workers (HCWs). Qualitative data analysis took a grounded theory approach.

RESULTS

Barriers to aPNS fell under three main categories. Fear of disclosure to partners included concerns over relationship repercussions, loss of trust, blame and violence. Stigma and discrimination were described in the healthcare setting, at church and in general society. Participants described difficulties approaching communication, including cultural barriers and differences in education. For almost every barrier a potential solution was also identified, and a barrier-opportunity relationship emerged. Opportunities included using couples testing centres to aid in disclosure, focusing on the ambiguous introduction of the infection, and sensitization of HCWs and community leaders.

CONCLUSIONS

aPNS among established HIV patients is associated with different barriers and opportunities than aPNS among newly diagnosed patients, and HCWs should build their capacity to support aPNS in this population. There is a strong need for increased training and sensitization on the use of aPNS in different circumstances and for different clients, taking into consideration factors such as timing of partner notification, characteristics of the relationship and duration of knowledge discordance. The overall success of this intervention among populations living with HIV may rely on customization of services and key messages to meet the patients' specific needs.

Cancer patients' perceptions of factors influencing their decisions on participation in clinical drug trials: A qualitative meta-synthesis

AIMS AND OBJECTIVES

To examine cancer patients' perceptions of factors that may influence their decisions on participating in phase I-III clinical drug trials.

BACKGROUND

The number of cancer participants in clinical drug trials has increased rapidly in Denmark in recent years. The rights, safety and well-being of patients considering participation are protected by the international, ethical and scientific principles. A meta-synthesis was conducted to enable health professionals to support cancer patients who are considering trial participation in accordance with the above principles.

DESIGN

Meta-synthesis.

METHODS

A qualitative meta-synthesis, as described by Sandelowski and Barroso, was conducted based on a literature search in PubMed, CINAHL, EMBASE and PsycINFO. Nine reports were found eligible and were included. The PRISMA checklist was used.

RESULTS

A framework was developed, and patients' perceptions of the factors influencing their decisions were identified, namely patients' perceptions of their relatives, the physician, the hope of therapeutic benefit, altruism, having other options and living with cancer.

CONCLUSIONS

This study shows that cancer patients' decisions on participation in clinical drug trials are influenced by their perceptions of trust towards the physician, their relatives' attitudes and the consequences participation might have for their families. Patients are motivated to participate due to the hope of therapeutic benefit and for altruistic reasons. The factors influencing their decisions to participate include a cost-benefit consideration, which in turn may be subject to the patient's perception of having other options available besides participation. This may be related to the patient's attitude towards living with cancer, and the decision can be a way of trying to cope with the psychological aspects of living with cancer.

RELEVANCE TO CLINICAL PRACTICE

The results of this meta-synthesis offer insight into patients' perceptions of what may influence their decisions, and they enable health professionals to support patients making such decisions.

Sexual and Social Network Correlates of Willingness to Self-Test for HIV Among Ever-Tested and Never-Tested Men: Implications for the Tanzania STEP Project

We examined factors associated with HIV self-testing (HIVST) willingness among male ever-testers and never-testers who participated in a midpoint survey of a cluster randomized controlled HIV prevention trial in Dar es Salaam. Linear mixed binary logistic regression models were constructed to examine factors (demographic, HIV risk behavior, and sexual/social network) associated with willingness to self-test. Sixtyseven percent of 301 never-testers were willing to self-test for HIV compared to 72% 577 of ever-testers. Among never-testers, having discussed testing for HIV with a sexual partner was the only factor associated with HIVST willingness (2.36, 95% CI: 1.35-4.15). For evertesters, younger men were less willing to self-test than older men while men with higher education were more willing to self-test than less educated men. Having a moderate/great HIV risk perception decreased the odds of HIVST willingness relative to no risk perception (0.40, 95% CI 0.23-0.70) for ever-testers. Discussing HIV testing with a sexual partner and having been encouraged to test for HIV by a friend were associated with higher odds of being willing to self-test (2.22, 2.23; 95% CI 1.34-3.67, 1.14-4.39, respectively) among ever-testers. These findings suggest that HIVST willingness is highly acceptable among both male ever-testers and never-testers.

The Uses of Self and Space: Health Providers' Approaches to Engaging Patients into the HIV Care Continuum

In the context of HIV prevention, the provider-patient relationship has been found to profoundly impact HIV screening, patient initiation into HIV care, and adherence to medication following an HIV diagnosis. Given the importance of the provider-patient relationship, insight into provider approaches to cultivate such relationships is essential. Such insight could highlight considerations for provider engagement with patients that can address the current challenges in HIV prevention and treatment. This qualitative descriptive study sought to describe current health providers' approaches to engage patients into the HIV care continuum (HCC). Findings from the content and thematic analysis indicated that health providers (N = 22) used various approaches to engage patients/clients into HIV screening, and subsequent HIV care. Approaches were represented by an interpersonal process and a thematic analysis revealed the nuances in the approaches that manifested in the following themes: uses of self, normalizing disease, and engaging couples. This study demonstrated the importance for health providers to be aware of the specific context of patient's vulnerability to HIV infection and barriers to care. Self-awareness and the capability to self-reflect on one's personal practice also helped to ensure engagement of those vulnerable to infection or infected with HIV into the HCC.

Strategies to Increase HIV Testing Among MSM: A Synthesis of the Literature

More than 30 years into the HIV epidemic, men who have sex with men (MSM) continue to be disproportionately impacted. It is estimated that worldwide nearly half of MSM infected with HIV are unaware of their status, making HIV testing along with early linkage to care crucial to HIV prevention efforts. However, there remain significant barriers to HIV testing among MSM, due largely to complex issues of layered stigma that deter MSM from accessing traditional, clinic-based testing. We conducted a review and synthesis of the literature on strategies to increase uptake of HIV testing among MSM. We found that social network-based strategies, community-based testing, HIV self-testing, and modifications to the traditional clinic-based model can effectively reach a subset of MSM, but success was often context-specific and there are significant gaps in evidence. We provide recommendations for increasing HIV testing rates and status awareness among MSM.

Acceptability of oral rapid HIV testing at dental clinics in communities with high HIV prevalence in South Florida

Background

Expanding HIV screening for populations at risk necessitates testing in nontraditional settings. We assessed HIV testing in dental clinics in South Florida, an urban area with the highest rates of HIV diagnoses in the United States in 2015.

Aims

We explored patients’ acceptance of oral HIV rapid tests administered by dental providers and identified reasons for accepting or declining HIV testing.

Methods

During 2014 and 2015, dentists and hygienists at two federally qualified health center (FQHC) dental clinics who serve racial/ethnic minority patient populations in South Florida were trained to administer oral HIV rapid tests as a part of a routine dental visit. Patients presenting for dental services were offered a rapid HIV test and brief survey regarding their demographics, HIV testing history and behaviors.

Results

We enrolled 600 patients (median age = 43 years; IQR: 29–56 years), 45% non-Hispanic black and 35% Hispanic/Latino, 83% graduated high school, and 50% unemployed. Most (85%) accepted oral HIV rapid testing (none tested HIV-positive); 14% had never been tested for HIV. The most common reasons for testing were a desire to know HIV status (56%) and free testing (54%). Among 93 (15%) patients who declined testing, 58% were tested recently and 31% felt confident that they were HIV-negative; however, 74 (80%) who declined testing said they would feel comfortable discussing HIV prevention with their dentist. Additionally, 290 of 600 patients (48%) reported condomless vaginal or anal sex in the past 6 months. Further, among 119 patients who had condomless sex with an HIV-positive partner and/or one whose HIV status was unknown, 98 (82%) accepted the oral HIV test.

Conclusion

Dental clinics may provide expanded opportunities for oral HIV rapid testing and conversations about HIV prevention in high HIV prevalence communities.

Providers' Perceptions of Couples' HIV Testing and Counseling (CHTC): Perspectives From a U.S. HIV Epicenter

Current epidemiology demonstrate the significance of couple-based HIV transmission among vulnerable U.S. populations and its contribution to health disparity in HIV prevalence. Couples HIV testing and counseling (CHTC) can be used to address couple-based HIV risk in the U.S. Though a globally recognized service, the literature lacks U.S.-based healthcare providers' (HCP) perspectives of CHTC. To address this research gap, a qualitative descriptive design was used to ascertain HCPs' perceptions about CHTC. Semi-structured in-depth interviews were conducted with 22 HCPs who were experienced with engaging patients or clients across the HIV care continuum. Overall, HCPs supported CHTC among different U.S.

POPULATIONS

Content and thematic analysis revealed HCPs perceived CHTC to be an evolution from current HIV testing approaches and a mechanism to screen people who may not otherwise. CHTC was perceived to have biomedical and bio-behavioral merit that warranted consideration for implementation within health service settings and among populations with heightened HIV risk. This strategy was perceived to be a mechanism for introducing PrEP and conception health into one's practice. CHTC also signaled patients reorienting perceptions of personal health as being linked to the health of another individual. Providers recognized that couples have evolved to be increasingly non-heteronormative and thought that CHTC should be offered to all couples. However, participants also noted that HCPs in the U.S. need to be comfortable with promoting sexual health among various populations for implementation of CHTC to be successful.

A Systematic Review of Health Care Provider-Perceived Barriers and Facilitators to Routine HIV Testing in Primary Care Settings in the Southeastern United States

Despite efforts to improve HIV screening and testing, many primary care settings do not follow established guidelines. The purpose of our systematic review was to describe health care providers' perceived barriers and facilitators to testing for HIV at poorly used/novel testing sites in the southeastern United States. PubMed, CINAHL, and Embase databases were searched for peer-reviewed studies of providers' perceived barriers and facilitators to routine HIV testing from January 2016 to April 2017 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Of 708 papers retrieved, 12 met inclusion criteria and were analyzed. Barriers to HIV testing in primary care existed at the societal, organizational, and individual levels. Providers need continuing sexual health education, including HIV and federal guideline updates, and students should have clinical experiences to supplement knowledge about sexual health. Clinic protocols should be updated to meet current policy guidelines.

Barriers and facilitators of the HIV care continuum in Southern New England for people with drug or alcohol use and living with HIV/AIDS: perspectives of HIV surveillance experts and service providers

BACKGROUND

Contemporary studies about HIV care continuum (HCC) outcomes within substance using populations primarily focus on individual risk factors rather than provider- or systems-level influences. Over 25% of people living with HIV (PLWH) have substance use disorders that can alter their path through the HCC. As part of a study of HCC outcomes in nine small cities in Southern New England (population 100,000-200,000 and relatively high HIV prevalence particularly among substance users), this qualitative analysis sought to understand public health staff and HIV service providers' perspectives on how substance use may influence HCC outcomes.

METHODS

Interviews with 49 participants, collected between November 2015 and June 2016, were analyzed thematically using a modified social ecological model as the conceptual framework and codes for substance use, HCC barriers and facilitators, successes and failures of initiatives targeting the HCC, and criminal justice issues.

RESULTS

Eight themes were identified concerning the impact of substance use on HCC outcomes. At the individual level, these included coping and satisfying basic needs and could influence all HCC steps (i.e., testing, treatment linkage, adherence, and retention, and viral load suppression). The interpersonal level themes included stigma issues and providers' cultural competence and treatment attitudes and primarily influenced treatment linkage, retention, and viral load suppression. These same HCC steps were influenced at the health care systems level by organizations' physical environment and resources as well as intra-/inter-agency communication. Testing and retention were the most likely steps to affect at the policy/society level, and the themes included opposition within an organization or community, and activities with unintended consequences.

CONCLUSIONS

The most substantial HCC challenges for PLWH with substance use problems included linking and retaining in treatment those with multiple co-morbidities and meeting their basic living needs. Recommendations to improve HCC outcomes for PLWH with substance use problems include increasing easy access to effective drug and mental health treatment, expanding case management and peer navigation services, training staff about harm reduction, de-stigmatizing, and culturally competent approaches to interacting with patients, and increasing information-sharing and service coordination among service providers and the social service and criminal justice systems.

Perspectives on HIV Testing Among WIC-Enrolled Postpartum Women: Implications for Intervention Development

Low-income minority women are disproportionately represented among those living with HIV in the U.S and also at-risk for substance abuse and intimate partner violence-collectively called the SAVA syndemic-which may impede HIV testing uptake. Views about HIV testing were assessed among women (ages 18-29) enrolled in a federally funded nutrition program for women, infants, and children (WIC) in a large Mid-Atlantic city. A survey (n = 80) and three focus groups were conducted in WIC offices located in neighborhoods with high HIV prevalence. Among this primarily minority sample, most would be interested in getting an HIV test if offered at WIC. Benefits included knowing one's HIV status, convenience, and accessible location, while transportation and peer/partner encouragement were enabling factors. Barriers included privacy concerns and intimate partner violence. Findings will be used to design an intervention to promote HIV testing among women who attend WIC and that proactively addresses reported barriers.

It's Not Just the Pills: A Qualitative Meta-Synthesis of HIV Antiretroviral Adherence Research

Antiretroviral therapy (ART) improves the health and longevity of people living with HIV infection (PLWH) and also prevents transmission of the virus. Yet, lack of adherence to ART regimens has been a persistent problem, even with simpler regimens. Guidelines that deal with ART adherence are based almost solely on quantitative studies; this focus ignores the context and complexity of patients' lives. Guidelines are also focused on the individual. We argue that the solution is to include the broader communities in which patients live, and to deal with systemic disparities that persist worldwide; this can be done in part through demedicalizing HIV care for healthy PLWH. We present findings from a qualitative meta-synthesis of 127 studies conducted around the world on the last two pillars of the HIV treatment cascade: starting and remaining on ART until optimal viral suppression is achieved. We use Maslow's hierarchy of needs to frame our findings.

Asking Numbers to Speak: Verbal Markers and Stages of Change

Through routine screenings for sexually transmitted infections (STIs) and HIV, medical providers are able to motivate behavior change. Although established models rely on quantitative measures, doing so requires time and ability to score each. Listening for verbal cues, however, could simplify the process of suggesting HIV screenings. Using mixed methods to identify verbal indicators for readiness to change, this article conducted two phases of study. First using quantitative means of identifying participant's knowledge of HIV, perceptions of safer sex, and readiness to change safer sex behaviors ( N = 487). Interviews were then conducted exploring the possibility of verbal markers for one's readiness to change ( n = 25). Results confirmed the use of verbal markers when discussing perceptions of risk. Identification of verbal markers, at three stages of change, provides new possibilities for medical providers' such as providing time saving and effective tools when seeking to motivate HIV and STI testing, and other safer sex behaviors.

HIV Stigma and Social Capital in Women Living With HIV

Women living with HIV (WLWH) continue to experience HIV-related stigma. Social capital is one resource that could mitigate HIV stigma. Our cross-sectional study examined associations between social capital and HIV-related stigma in 135 WLWH in the San Francisco Bay Area. The mean age of study participants was 48 years; 60% were African American; 29% had less than a high school education; and 19% were employed. Age was significantly associated with perceived HIV stigma (p = .001), but total social capital was not. Women with lower Value of Life social capital scores had significantly higher total stigma scores (p = .010) and higher Negative Self-image stigma scores (p = .001). Women who felt less valued in their social worlds may have been more likely to perceive HIV stigma, which could have negative health consequences. This work begins to elucidate the possible relationships between social capital and perceived HIV stigma.

Enroling and retaining human immunodeficiency virus (HIV) patients in their care: A metasynthesis of qualitative studies

OBJECTIVES

To report the findings of a metasynthesis review of qualitative studies on patient and provider experiences and perspectives on linkage and retention in HIV care.

DESIGN

The review is an extraction, aggregation, interpretation and synthesis of qualitative findings based on the Sandelowski and Barroso method.

DATA SOURCES

A search of the literature was conducted in the databases Cumulative Index to Nursing and Allied Health, PubMed and PsycInfo for articles published from 2008 to 2013. Inclusion criteria were qualitative research articles published in English from across the world and in peer-reviewed journals. Literature reviews, conference abstracts and grey literature were excluded from this metasynthesis.

REVIEW METHODS

The review consisted of a) comprehensive search, b) study classification, c) abstraction of findings, d) synthesis. Of the 4640 citations screened, 69 articles were included for this metasynthesis.

RESULTS

69 unique articles from 44 countries were included. This metasynthesis takes into account the perspectives of at least 2263 HIV-positive participants (740 men, 1008 women, 78 transgender individuals and 437 unspecified sex) and 994 healthcare providers, family members and community members. The most salient barriers and facilitators to HIV linkage and retention in HIV care affirm ecological factors that are mostly beyond individual patients' control. Triadic streams of influence concurrently affect care engagement that include a person's psychological state upon diagnosis and their informational challenges (intrapersonal stream); one-on-one interactions with providers and their immediate community (social stream); and life demands, overall quality of care experiences and other structural barriers (cultural-attitudinal stream). Each stream's influence on HIV care engagement varies at any given point to reflect an individual's evolving and unique experiences with HIV infection throughout the illness trajectory.

CONCLUSION

There is sufficient evidence that detail how to best link and retain patients in HIV care. Themes identified indicate going beyond individual-level factors and towards shifting attention and resources to systems that patients navigate. Forceful structural-level actions are needed to correct these long-identified barriers and enhance care engagement facilitators.