Perspectives from the Field: HIV Testing and Linkage to Care in North Carolina

Digital Intervention Services to Promote HIV Self-Testing and Linkage to Care Services: A Bibliometric and Content Analysis-Global Trends and Future Directions

Objective: The global burden of HIV remains a critical public health challenge, particularly in sub-Saharan Africa, home to over two-thirds of individuals living with HIV. HIV self-testing (HIVST) has emerged as a promising strategy endorsed by the World Health Organization to achieve UNAIDS targets. Despite its potential, challenges persist in linking self-testers to care post a positive result. Digital health interventions, including chatbots and mobile applications, offer innovative solutions to address this gap. However, a comprehensive bibliometric analysis of the collaboration and growth in the literature at the intersection of HIVST and digital interventions is lacking. Methods: The study employs a bibliometric approach, leveraging data from the Web of Science, to analyze the characteristics, citation pattern and content of 289 articles spanning 1992-2023. The analysis involves performance assessment, scientific collaboration analysis, science mapping, and content analysis. Key bibliometric indicators, such as annual growth rate, citation impact, and authorship patterns, are explored. Collaboration patterns among countries, institutions, and authors are elucidated, and thematic mapping provides insight into the key research themes. Results: The analysis reveals a dynamic and expanding field, with an annual scientific growth rate of 12.25%. Notable contributions come from diverse sources, including North America, Europe, and Africa. High-impact journals such as JMIR mHealth and uHealth play a crucial role in disseminating research findings. African authors, including Lebelonyane R, Ford N, and Lockman S, feature prominently, reflecting a positive trend in diverse authorship. Co-citation analysis highlights influential manuscripts, with systematic reviews dominating the top-cited articles. Collaboration analysis underscores strategic partnerships globally, particularly involving the United States, Australia, South Africa, and the United Kingdom. Conclusion: This bibliometrics analysis provides a comprehensive overview of the digital health landscape in HIVST and linkage to care. It identifies key contributors, high-impact journals, and collaborative networks. The thematic map reveals nuanced research domains, including alcohol dependence, men's health, outcomes, and user acceptance. The findings offer insights for researchers, policymakers, and practitioners, guiding future directions in the evolving intersection of HIVST and digital health interventions.

Health Care Provider Discussions Regarding HIV/Sexually Transmitted Infection Risk Factors and Associations with HIV/Sexually Transmitted Infection Screening Among Men

Little is known regarding the specific discussions health care providers (HCP) have with their patients and how these discussions may increase rates of HIV/STI screening. The main objective of this study was to examine the content of HCP-patient discussions and associations with HIV/STI screening while adjusting for patient characteristics. Using the 2017-2019 National Survey of Family Growth data, seven survey-weighted multivariable multinomial/binary logistic regression models were analyzed in men ages 15-49 years old (N = 4260). Patients had significantly higher odds of a lifetime HIV test when their HCP asked about number of sexual partners (adjusted odds ratio [aOR] = 2.325; 95% CI 1.379-3.919) and discussed HIV/AIDS (aOR = 4.149; 95% CI 2.877-5.983). Odds of a recent STI screening were higher among patients with HCP that asked about: sexual orientation (aOR = 1.534; 95% CI 1.027-2.291), number of sexual partners (aOR = 2.123; 95% CI 1.314-3.430), use of condoms (aOR = 2.295 95% CI 1.484-3.548), type of sexual intercourse (aOR = 1.900; 95% CI 1.234-2.925), and discussed HIV/AIDS (aOR = 1.549; 95% CI 1.167-2.056). Results may provide insight on how HCPs may potentially promote HIV/AIDS and STI screening among men and which patient groups are more likely to receive a discussion of risks factors from their HCPs.

The lived experiences of rural HIV social workers

HIV service providers are the primary implementers of HIV care services, but rural HIV service providers are under researched. We used an interpretative phenomenological analysis to explore rural HIV service providers' lived experiences of working in HIV care, who work in a rural region of a Midwestern state in the United States. From July to August 2019, 15 HIV service providers participated in a one-hour semi-structured telephone interview that elicited their experiences working in the rural HIV care continuum. Participants were tired of constantly educating and working to reduce HIV stigma; however, they received support from family and friends once they educated them about HIV. Participants felt they lacked control over systems and they developed emotional-based coping to address constant occupational stressors. Findings highlight the importance of resiliency and advocacy research and practice across ecological levels.

Using the Patient Portal Sexual Health Instrument in Surveys and Patient Questionnaires Among Sexual Minority Men in the United States: Cross-sectional Psychometric Validation Study

Background

Patient portal modules, including electronic personal health records, health education, and prescription refill ordering, may be leveraged to address the sexually transmitted infection (STI) burden, including HIV, among gay, bisexual, and other sexual minority men (SMM). Theoretical frameworks in the implementation sciences highlight examining constructs of innovation attributes and performance expectations as key determinants of behavioral intentions and the use of new web-based health technologies. However, behavioral intentions to use patient portals for HIV and other STI prevention and care among SMM is understudied.

Objective

The aim of this study is to develop a brief instrument for measuring attitudes focused on using patient portals for STI prevention and care among a nationwide sample of SMM.

Methods

A total of 12 items of the American Men’s Internet Survey-Patient Portal Sexual Health Instrument (AMIS-PPSHI) were adapted from a previous study. Psychometric analyses of the AMIS-PPSHI items were conducted among a randomized subset of 2018 AMIS participants reporting web-based access to their health records (N=1375). Parallel analysis and inspection of eigenvalues in a principal component analysis (PCA) informed factor retention in exploratory factor analysis (EFA). After EFA, Cronbach α was used to examine the internal consistency of the scale and its subscales. Confirmatory factor analysis (CFA) was used to assess the goodness of fit of the final factor structure. We calculated the total AMIS-PPSHI scale scores for comparisons within group categories, including age, STI diagnosis history, recency of testing, serious mental illness, and anticipated health care stigma.

Results

The AMIS-PPSHI scale resulting from EFA consisted of 12 items and had good internal consistency (α=.84). The EFA suggested 3 subscales: sexual health engagement and awareness (α=.87), enhancing dyadic communication (α=.87), and managing sexual health care (α=.79). CFA demonstrated good fit in the 3-factor PPSHI structure: root mean square error of approximation=0.061, comparative fit index=0.964, Tucker-Lewis index=0.953, and standardized root mean square residual=0.041. The most notable differences were lower scores on the enhanced dyadic communication subscale among people living with HIV.

Conclusions

PPSHI is a brief instrument with strong psychometric properties that may be adapted for use in large surveys and patient questionnaires in other settings. Scores demonstrate that patient portals are favorable web-based solutions to deliver health services focused on STI prevention and care among SMM in the United States. More attention is needed to address the privacy implications of interpersonal use of patient portals outside of traditional health settings among persons with HIV.

"Meet people where they are": a qualitative study of community barriers and facilitators to HIV testing and HIV self-testing among African Americans in urban and rural areas in North Carolina

BACKGROUND

HIV testing programs in the United States aim to reach ethnic minority populations who experience high incidence of HIV, yet 40% of African Americans have never been tested for HIV. The objective of this study is to identify community-based strategies to increase testing among African Americans in both urban and rural areas.

METHODS

This study conducted focus group discussions (FGDs) informed by community-based participatory research principles to examine African American's concerns and ideas around HIV testing and HIV self-testing. Participants included highly affected (i.e., PLWH, MSM, PWID, low-income, teens and young adults) populations from African American communities in North Carolina, aged 15 years and older. We digitally transcribed and analyzed qualitative data using MAXQDA and axial coding to identify emergent themes.

RESULTS

Fifty-two men and women between 15 to 60 years old living in urban (n=41) and rural (n=11) areas of North Carolina participated in focus group discussions. HIV testing barriers differed by HIV testing setting: facility-based, community-based, and HIV self-testing. In community-based settings, barriers included confidentiality concerns. In facility-based settings (e.g., clinics), barriers included negative treatment by healthcare workers. With HIV self-testing, barriers included improper use of self-testing kits and lack of post-test support. HIV testing facilitators included partnering with community leaders, decentralizing testing beyond facility-based sites, and protecting confidentiality.

CONCLUSIONS

Findings suggest that HIV testing concerns among African Americans vary by HIV testing setting. African Americans may be willing to test for HIV at community events in public locations if client confidentiality is preserved and use HIV self-testing kits in private if post-test social support and services are provided. These community-identified facilitators may improve African American testing rates and uptake of HIV self-testing kits.

HIV-Related Training and Correlates of Knowledge, HIV Screening and Prescribing of nPEP and PrEP Among Primary Care Providers in Southeast United States, 2017

The Southeast accounted for most HIV diagnoses (52%) in the United States in 2015. Primary care providers (PCPs) play a vital role in HIV prevention for at-risk persons and treatment of persons living with HIV. We studied HIV-related training, knowledge, and clinical practices among PCPs in the Southeast to address knowledge gaps to inform HIV prevention strategies. Between April and August 2017, we conducted an on-line survey of a representative sample of PCPs in six Southeast jurisdictions with high rates of HIV diagnoses (Atlanta; Baltimore; Baton Rouge; District of Columbia; Miami; New Orleans). We defined HIV-related training as self-reported completion of any certified HIV/STD course or continuing education in past 24 months (prior to survey completion). We assessed associations between training and HIV testing practices, familiarity with nonoccupational post-exposure prophylaxis (nPEP) and pre-exposure prophylaxis (PrEP), and ever prescribing nPEP or PrEP. There were 820 participants after fielding 4595 surveys (29.6% adjusted response rate). In weighted analyses, 36.3% reported HIV-related training. Using adjusted prevalence ratio (aPR) and confidence intervals (CI), we found that PCPs with HIV-related training (compared to those with no training) were more likely to be familiar with nPEP (aPR = 1.32, 95% CI 1.05, 1.67) and PrEP (aPR = 1.67, 95% CI 1.19, 2.38); and to have ever prescribed PrEP to patients (aPR = 1.75, 95% CI 1.10, 2.78). Increased HIV-related trainings among PCPs in high HIV prevalence Southeast jurisdictions may be warranted. Strengthening nPEP and PrEP familiarity among PCPs in Southeast may advance national HIV prevention goals.

Past Care Predicts Future Care in Out-of-Care People Living with HIV: Results of a Clinic-Based Retention-in-Care Intervention in North Carolina

Poor retention in care is associated with higher viral load (VL) results and decreased rates of viral load suppression (VS) in people living with HIV (PLWH). Therefore, improving retention in HIV care is a priority of national significance. The NC-LINK Retention Project utilized a systematic approach to identify, locate, and attempt to return to care patients who did not attend a clinic appointment for 6-9 months. Clinical and surveillance data were used to evaluate associations between patient characteristics and VL outcomes. Between January 1, 2013 and December 31, 2014, 1118 patients at participating clinics were identified as out-of-care and referred to retention staff. Of these, 712 (64%) were located in North Carolina. Patients with recent prior medical care (aPR 1.43, 95% CI 1.25, 1.66) and recent VS (aPR 1.28, 95% CI 1.16, 1.41) were more likely to be located. Of located patients, 58% re-engaged in care within 90 days of retention referral. Patients who achieved VS within 180 days were more likely to be 40-49 years (aPR 1.19 95% CI 1.01-1.40; compared with 18-29 age group), had insurance at their last visit (aPR 1.19 95% CI 1.01-1.77), had a care visit in the prior year (aPR 1.37 95% CI 1.05-1.77), and had VS at the prior care visit (aPR 2.54 95% CI 1.98-3.25). Clinic-based retention efforts may be effective at helping PLWH decrease out-of-care periods, but prior patterns of care usage persist.

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.

The North Carolina HIV Bridge Counselor Program: Outcomes From a Statewide Level Intervention to Link and Reengage HIV-Infected Persons in Care in the South

BACKGROUND

To improve the HIV continuum of care, a team of field service interventionists (State Bridge Counselors, SBC) was developed through a state public health system and provided brief (1-2) contacts for linkage of newly diagnosed persons with HIV and reengagement of persons living with HIV (PLWH) who were not in care.

SETTING

North Carolina, United States.

METHODS

Service data from January 2013 to June 2015 were analyzed to determine characteristics of clients referred to SBCs, proportions linked or reengaged in care, and/or achieved viral load suppression (VLs). We evaluated associations between client characteristics and outcomes using multivariable analyses and estimated odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

SBCs provided linkage services to 299 newly diagnosed individuals and reengagement services to 606 PLWH throughout North Carolina. Among persons who received linkage services, 189 (63%) had evidence of care within 90 days of referral and 205 (69%) had VLs within a year. Among PLWH who received reengagement services, 278 (46%) had care within 90 days and 308 (51%) had VLs within a year. Persons aged 30-39 years (OR, 2.1; 95% CI, 1.1 to 3.9) and 40-49 years had an increased likelihood (OR, 2.4; 95% CI, 1.1 to 5.2) of linkage within 90 days compared with persons aged 18-29 years. Non-white PLWH had an increased OR of 1.7; (95% CI, 1.2 to 2.5) of reengagement compared with whites.

CONCLUSIONS

Our SBC program successfully implemented a "low-touch" approach to provision of linkage and reengagement services, demonstrating that public health resources can be used to address the HIV care continuum on a statewide level.