Understanding HIV care delays in the US South and the role of the social-level in HIV care engagement/retention: a qualitative study

A qualitative assessment of retention in HIV care among adolescents and young adults (AYA) living with HIV in New York City

Retention in HIV care is a critical precursor to ending the epidemic yet remains suboptimal in the United States. Gaining an understanding of the challenges faced by adolescents and young adults (AYA) living with HIV is essential to improving retention in HIV care. This study explored the barriers and facilitators to retention in care among Black and Hispanic AYA living with HIV. Audio-recorded semi-structured interviews were conducted with 20 AYA living with HIV ages 16-29 years in New York City. Our methods entailed an inductive content analysis to explore key concepts, reconcile codes, and identify a theme, categories, and subcategories. Bronfenbrenner's socioecological model evolved as an organizing framework around barriers and facilitators to retention in care at the individual, interpersonal, healthcare system, and structural level. Data analysis yielded one overarching theme-the influence of psychosocial factors on retention in HIV care. Psychological struggles, powerlessness, clinic-level characteristics, and socioeconomic struggles were barriers reported by participants. Self-responsibility, social support, patient-friendly healthcare services, and socioeconomic resources emerged as facilitators. Retention in HIV care among AYA living with HIV is a multifaceted and complex phenomenon that involves multiple systems. Strengthening patients, healthcare system, and community partnerships can help address some of the HIV-related health disparities.

Understanding the impact of a residential housing program for people living with HIV/AIDS: results from a realist evaluation

BACKGROUND

In Canada, the Public Health Agency surveillance of new HIV cases has demonstrated annual increasing rates since 2020. The rates of new HIV cases are highest in the province of Saskatchewan.

OBJECTIVES

The aim of the project was to conduct a resident-oriented realist evaluation of an innovative supportive housing programme, Sanctum, for people living with HIV/AIDS who also face social care issues, such as homelessness. This project took place in Saskatchewan, a province that is seeking innovative approaches to improve quality of life and HIV/AIDS management for its citizens. Our evaluation addressed how and why participants were successful (or not) within the Sanctum programme.

DESIGN AND SETTING

Sanctum is a housing programme located in an inner-city location within the province of Saskatchewan. A unique component of this evaluation was the inclusion of an individual with lived experience, a resident partner, as a member of the research team.

PARTICIPANTS

11 recent Sanctum graduates, seven men and four women, were recruited for client partner-led in-depth, semistructured interviews.

INTERVENTIONS

Prior to the evaluation, we developed a realist programme theory with potential causal explanations, known as context-mechanism-outcomes (CMO) configurations. Interview data from the evaluation and ongoing discussions with Sanctum board members and our resident partner were used to test, refine and validate the final programme theory and CMO configurations.

RESULTS

CMO configurations at the micro (individual), meso (interpersonal) and macro (community) levels complement the over-arching programme theory. Key findings were the importance of Sanctum's harm reduction philosophy, accompanied by a non-judgmental and patient-oriented approach. Participants were supported to reduce risky behaviour, improve self-care management and develop healthier relationships within a 'safe' home-like setting. Underlying mechanisms that contributed to participants' success in the programme included: intrinsic motivation, self-worth, belongingness, empowerment and self-efficacy. Evidence-informed recommendations are offered to support Sanctum-like programme development for individuals with holistic health needs related to HIV/AIDS diagnoses and lack of access to necessary social determinants of health.

CONCLUSIONS

Stigma associated with HIV/AIDS and living circumstances, such as homelessness, were successfully addressed using harm reduction principles and judgement-free approaches within a family-like environment.

HIV Knowledge among African Americans Living with HIV in the Rural South: Implications for Improving HIV Prevention and Care Outcomes

PURPOSE

This study examines the HIV knowledge of people living with HIV (PLWH) and its implications for improved healthcare outcomes.

METHODS

The study design was a descriptive cross-sectional study, and a total of 41 PLWH were recruited from a larger faith-based anti-stigma study. Data was collected using a semi-structured self-administered questionnaire and analyzed using SAS. In addition, a literature review was conducted using search engines to gauge existing literature from 2013 to 2022 in areas of HIV knowledge and healthcare outcomes among PLWH.

RESULTS

The 41 PLWH enrolled consisted of 51% males and 49% females. Sixteen (39%) were aged ≥ 51 years, 17 (41%) had been living with HIV for > 10 years, 15 (37%) had < high school diploma, and 100% were currently in HIV care. HIV knowledge scores were below average for 20 (49%) of the PLWH. Substantial knowledge deficits were noted in areas of HIV transmission and risk reduction strategies. Lower scores were not significantly associated with the participant's gender, education level, or length of time being HIV-infected. The results of the literature review showed limited research in this area.

CONCLUSIONS

The study and literature review results show that HIV knowledge and health literacy may contribute to racial disparities in retention in care leading to poor health outcomes. Healthcare providers and health facilities in rural areas should be equipped with culturally tailored HIV educational tools to strengthen ongoing care for PLWH, foster patient-provider relationships, and eliminate internalized stigma detrimental to improved healthcare outcomes among PLWH.

Provider Perspectives on Rapid Treatment Initiation Among People Newly Diagnosed With HIV: A New Message of "Urgency"?

BACKGROUND

Early initiation of antiretroviral therapy improves human immunodeficiency virus (HIV) outcomes. However, achieving earlier treatment initiation is challenging for many reasons including provider awareness and clinic barriers; this study sought to understand perceptions of an early initiation program.

METHODS

We interviewed 10 providers from 3 HIV clinics in North Carolina (October-November 2020). We asked providers about overall perceptions of early initiation and the pilot program. We developed narrative summaries to understand individual contexts and conducted thematic analysis using NVivo.

RESULTS

Providers believed earlier initiation would signal an "extra sense of urgency" about the importance of antiretroviral therapy-a message not currently reflected in standard of care. Safety was a consistent concern. Cited implementation barriers included transportation assistance, medication sustainability, and guidance to address increased staff time and appointment availability.

CONCLUSION

Our qualitative findings highlight the need for training on the safety of early initiation and addressing staffing needs to accommodate quicker appointments.

Evaluation of a Linkage to care Quality Improvement Initiative for People with HIV

Adherence to antiretroviral therapy (ART) and engagement in HIV care is critical to decrease HIV transmissions and optimize outcomes in people with HIV (PWH). In 2016, the CDC reported that 63% of incident HIV diagnoses were transmitted by PWH who were aware of their status but not virally suppressed. Adult Special Care Clinic (ASCC) designed and implemented a quality improvement (QI) program to facilitate linkage and increase viral suppression rates in PWH. ASCC utilized identified barriers to create a Linkage to Care (LTC) program with multiple components, including a LTC coordinator, proactive outreach, and standardized protocols. Logistic regression was used to compare 395 PWH enrolled during the post-QI phase (01 January 2019-31 December 2021) to 337 PWH enrolled during the pre-QI phase (01 January 2016-31 December 2018). Newly diagnosed PWH enrolled during the post-QI phase had significantly higher odds of achieving viral suppression compared to those enrolled during the pre-QI phase (aOR 2.22, 95% CI 1.37-3.59, p = .001). There was no significant difference between previously diagnosed but unengaged PWH enrolled during pre- and post-QI phases, although absolute viral suppression increased from 66.1 to 71.5% in this group. Both increasing age and having private insurance increased the likelihood of achieving viral suppression. Results highlight the potential impact on linkage to care and viral suppression rates of a standardized LTC program, addressing barriers to care for PWH. Additional focus should be placed on previously diagnosed but unengaged PWH to determine what parts of the intervention may be modified to increase viral suppression rates.

HIV Treatment and Mental Health Outcomes Among Gay, Bisexual, and Other Men Who Have Sex With Men Living With HIV in a Pilot Multicomponent Intervention in Guatemala City

Globally, gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by HIV, but few interventions address mental health and HIV outcomes among GBMSM living with HIV. The purpose of this study was to pilot a multicomponent intervention, integrating emotional well-being (EW) and health navigation for GBMSM living with HIV in Guatemala City. We implemented a 12-month intervention, including a four-session EW component and a health navigation component among newly diagnosed and reengaged GBMSM with HIV (n = 112). We conducted socio-behavioral surveys at baseline and endline to measure patient characteristics and HIV, and mental health outcomes as well as viral load testing. We documented participation in EW sessions and used a smartphone application to track navigation mode, frequency, and content. Using first-difference estimation modeling, we assessed associations between participation in EW and navigation and mental health (depression and anxiety symptoms) and HIV outcomes (HIV treatment adherence, viral suppression). Acceptability was high for EW (86%) and navigation (99%). During the intervention, viral suppression increased significantly and anxiety and depression decreased significantly. Participation in EW sessions and greater navigation frequency and duration were associated with being suppressed, whereas higher emotional navigator support was associated with being unsuppressed. Participation in EW sessions was associated with reduced anxiety. Findings suggest that multicomponent interventions integrating individual counseling and navigation may promote EW and sustained viral suppression. Future intervention research is needed to confirm whether HIV and mental health outcomes are attributable to the intervention and to assess mechanisms of influence.

Prevalence of delayed antiretroviral therapy initiation among people living with HIV: A systematic review and meta-analysis

OBJECTIVE

HIV continues to be a global challenge. Key recommendations for HIV prevention and treatment are presented on rapid antiretroviral therapy (ART) initiation. However, several studies showed a high prevalence of delayed ART initiation. The aim of this systematic review and meta-analysis was to assess the prevalence of delayed ART initiation among HIV-infected patients globally.

METHODS

This review summarised eligible studies conducted between January 2015 and August 2022 on the prevalence of delayed ART initiation in HIV-infected adults (age ≥ 15). Relevant studies were systematic searched through PubMed/Medline, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, and Chongqing VIP databases. Random-effects models were used to calculate pooled prevalence estimates. The heterogeneity was evaluated using Cochran's Q test and I2 statistics. Moreover, potential sources of heterogeneity were explored using univariate subgroup analysis.

RESULTS

Data on the prevalence of delayed ART initiation was pooled across 29 studies involving 34,937 participants from 15 countries. The overall pooled prevalence of delayed ART initiation was 36.1% [95% confidence interval (CI), 29.7-42.5%]. In subgroup analysis, the estimated pooled prevalence decreased with age. By sex, the prevalence was higher among male patients (39.3%, 95% CI: 32.2-46.4%) than female (36.5%, 95% CI: 26.9-50.7%). Patients with high CD4 cell count were more likely to delay ART initiation than those with low CD4 cell count (>500cells/mm3: 40.3%; 201-500cells/mm3: 33.4%; and ≤200cells/mm3: 25.3%).

CONCLUSIONS

Our systematic review and meta-analysis identified a high prevalence of delayed ART initiation. The prolonged time interval between diagnosis and treatment is a prevalent and unaddressed problem that should spur initiatives from countries globally. Further research is urgently needed to identify effective strategies for promoting the early ART initiation.

Does telehealth affect the adherence to ART among patients with HIV? A systematic review and meta-analysis

BACKGROUND

Several studies have shown different effects of telehealth interventions on adherence to Antiretroviral therapy (ART) among people living with HIV. This study conducted a meta-analysis of Randomized Controlled Trials (RCTs) to estimate the pooled effect of telehealth interventions on the treatment adherence of HIV patients.

METHODS

The researchers conducted literature searches in Scopus, PubMed, Web of Science, Google Scholar, and Cochrane Central Register of Controlled Trials databases. In addition, open grey was systematically searched until January 2022 for RCTs around the effects of telehealth on adherence to treatment ART among patients with HIV. Each study's methodological quality was assessed using the Cochrane Collaboration tool. Pooled Standard Mean Differences (SMD) and Risk Ratio (RR) with 95% CI were calculated using the random effects model.

RESULTS

In total, 12 eligible articles were considered in the present systematic review. A random-effects meta-analysis using 5 RCTs yielded the pooled RR estimate of 1.18 (95% CI: 1.03 to 1.35, p < 0.05); I2 = 0, suggesting the adherence to treatment among patients with HIV who received telehealth intervention was significantly 18% upper than control groups. Moreover, the random effects analysis of SMD showed a positive effect for telehealth with SMR = 0.36 (95% CI: 0.22 to 0.49, p < 0.05); I2 = 91.9%, indicating that telehealth intervention increased ART adherence to the treatment group compared to the control group.

CONCLUSION

Telehealth intervention as a new modality of health care service delivery could be a valuable strategy to improve ART adherence among patients with HIV. It can strengthen the capacity of HIV care services. On a large scale, telehealth can be utilized as a supplementary component for ART delivery and retention toward successful adherence to the therapy.

A Census Tract-Level Examination of HIV Care Outcomes and Social Vulnerability Among Black/African American, Hispanic/Latino, and White Adults in the Southern United States, 2018

We examined the association between social vulnerability and HIV diagnoses, linkage to HIV medical care, and viral suppression among adults in the Southern U.S. Data from CDC's National HIV Surveillance System (NHSS) were used to determine census tract-level HIV diagnosis rates and percentages of persons linked to care within one month and with viral suppression within six months of diagnosis among Black/African American, Hispanic/Latino, and White adults aged ≥ 18 years residing in the Southern U.S. in 2018. Census tract-level social vulnerability data were obtained from the 2018 CDC Social Vulnerability Index (SVI). Rate and proportion ratios were used to determine the difference between the lowest quartile of SVI scores (Q1) and the highest quartile (Q4) by age group, transmission category, and region of residence and stratified by sex assigned at birth. Areas with the highest social vulnerability (Q4) had the highest rates of HIV diagnoses (Black: 56.5, Hispanic/Latino: 27.2, and White: 10.3). Those in Q4 also had the lowest percentages of adults linked to care (Black: 76.1%, Hispanic/Latino: 81.2%, and White: 77.8%), and the lowest percentages of adults with viral suppression (Black: 59.8%, Hispanic/Latino: 68.4%, and White: 65.7%). This ecological study found an association between social vulnerability, HIV diagnoses, and poorer care outcomes among Black/African American, Hispanic/Latino, and White adults. Tailoring interventions and improving access for persons residing in areas with the highest social vulnerability is necessary to reduce HIV transmission and improve health outcomes in the Southern U.S.

Differential Effects of Patient Navigation across Latent Profiles of Barriers to Care among People Living with HIV and Comorbid Conditions

Engaging people living with HIV who report substance use (PLWH-SU) in care is essential to HIV medical management and prevention of new HIV infections. Factors associated with poor engagement in HIV care include a combination of syndemic psychosocial factors, mental and physical comorbidities, and structural barriers to healthcare utilization. Patient navigation (PN) is designed to reduce barriers to care, but its effectiveness among PLWH-SU remains unclear. We analyzed data from NIDA Clinical Trials Network's CTN-0049, a three-arm randomized controlled trial testing the effect of a 6-month PN with and without contingency management (CM), on engagement in HIV care and viral suppression among PLWH-SU (n = 801). Latent profile analysis was used to identify subgroups of individuals' experiences to 23 barriers to care. The effects of PN on engagement in care and viral suppression were compared across latent profiles. Three latent profiles of barriers to care were identified. The results revealed that PN interventions are likely to be most effective for PLWH-SU with fewer, less severe healthcare barriers. Special attention should be given to individuals with a history of abuse, intimate partner violence, and discrimination, as they may be less likely to benefit from PN alone and require additional interventions.

A qualitative inquiry into the patient-related barriers to linkage and retention in HIV care within the community setting

Background

People with the Human Immunodeficiency Virus (PWH) experience barriers to care within the community that impedes their progress from when they discover that they are HIV positive to becoming virally suppressed. For individuals with HIV to achieve sustained viral suppression, they must be linked to care to start receiving anti-retroviral therapy and remain retained in care for continuous treatment. However, HIV surveillance data shows that many PWH are not linked to care and become lost to continuous follow-up care. Although pharmacists, PWH, and social workers interact with one another and are aware of their roles in HIV care, their perspectives on barriers to linkage and retention in care have not been investigated collectively.

Objectives

Explore the perspectives of PWH, pharmacists, and social workers on barriers to linkage and retention of HIV care within the community setting.

Methods

Convenience sampling was used to recruit 15 stakeholders (five PWH, five community pharmacists, and five social workers) who participated in 1-h, semi-structured interviews based on three domains of the Patient-centered Medical Home Model including (1) experiences (individual and system-level barriers to care experienced by PWH), (2) activities (social workers and pharmacists initiatives that impact adherence to care)and (3) interventions (critical issues pharmacists can address in the community to engage PWH in their HIV care). We conducted a directed content analysis based on deductive coding. To establish rigor, we focused on Lincoln and Guba's criteria of rigorous qualitative methodology: credibility, dependability, confirmability, and transferability. Similarities and divergences of themes were discussed during data analysis and agreement was reached before interpretation.

Results

Emergent themes uncovered barriers to linkage and retention in HIV care as HIV-related stigma, having mental health illnesses including a history of substance abuse and social determinants of health such as homelessness, food insecurity, and insurance issues.

Conclusion

The perspectives of pharmacists, social workers, and PWH can provide insight into barriers that should be identified and addressed in people living with HIV to enhance their linkage and retention in care.

HIV Health literacy beyond the biomedical model: an innovative visual learning tool to highlight the psychosocial complexities of care

The HIV care continuum represents a linear clinical pathway from testing to viral suppression; however, it does not capture the psychosocial complexities of contemporary HIV care. We developed an innovative and appealing visual learning resource to extend the scope of HIV health literacy beyond biomedical constructs. Based on the lived experiences of recently diagnosed people living with HIV in Queensland, the "Journeys through the HIV Care Continuum" Map presents the continuum as a complex journey incorporating challenges such as poor health literacy, health service access and stigma alongside facilitators to care, including emotional and peer support. Designed for audiences who may not access academic literature, the Map can be used to facilitate conversations between recently diagnosed people living with HIV and peer navigators, and as a learning tool for health professionals, carers and students. The Map highlights opportunities to support PLHIV in meaningful ways that will reduce stigma and promote care access.

What Matters Most? The Power of Kafka's Metamorphosis to Advance Understandings of HIV Stigma and Inform Empathy in Medical Health Education

HIV stigma, a social-medical problem, continues to confound researchers and health professionals, while undermining outcomes. Empathy may reduce stigma; its absence may predict stigma. This research investigates: How does Kafka's Metamorphosis advance understandings of HIV stigma in medical health education? Metamorphosis amplifies the sociological-relational mechanisms fostering HIV stigma. It offers a multi-disciplinary, responsive space for ethical, humanistic and clinical inquiry to meet: enabling students to consider how social structures shape health inequities, moral, social experience, and their professional identity within. Metamorphosis may ultimately promote medical health humanities' social mission-allowing literature to unfold such revelations towards greater equity in health.

The Boundary of HIV Care: Barriers and Facilitators to Care Engagement Among People with HIV in the United States

Treating people with HIV (PWH) quickly and effectively to achieve viral suppression is a key strategy for Ending the HIV Epidemic. Understanding barriers and facilitators to HIV care engagement could improve outcomes among PWH and reduce HIV infections. We sampled PWH who participated in the Medical Monitoring Project from June 2018 to May 2019 and were not engaged in HIV care to participate in 60-min semistructured telephone interviews on barriers and facilitators to HIV care engagement. We used applied thematic analysis and placed codes into themes based on their frequency and salience. Participants reported various intrapersonal, health system, and structural barriers to care. We conceptualize the boundary of care as the space between the stages of the HIV care continuum, where PWH may find themselves when they lack intrapersonal, health system, and structural support. Research and interventions tackling these barriers are needed to improve outcomes among PWH and reduce HIV infections.

Factors Influencing Rapid Antiretroviral Therapy Initiation at Four eThekwini Clinics, KwaZulu-Natal, South Africa

Timely uptake of Antiretroviral therapy considerably improves the health of people living with the Human Immunodeficiency virus. We conducted a cross-sectional study of newly HIV diagnosed individuals in four clinics in eThekwini municipality, KwaZulu-Natal. Data was collected between June 2020 and December 2020. Participants completed an interviewer-administered questionnaire after HIV testing, on the day of HIV diagnosis. We evaluated factors influencing uptake of same-day ART initiation in eThekwini clinics, KwaZulu Natal, South Africa. Demographic information, health status, sexual behaviour, knowledge of universal test and treat (UTT), ART initiation uptake, and disclosure data was collected. Among the 403 participants, same-day initiation (SDI) was 69.2% (n = 279). We observed the number of sexual partners (aOR 0.35; 95% CI 0.15–0.81), HIV status of the partner (aOR 5.03; 95% CI 2.74–9.26) and knowledge of UTT (aOR 1.97; 95% CI 1.34–2.90) were identified as major factors influencing uptake of same-day ART initiation. More strategies are needed to achieve the SDI uptake within the framework of UTT.

Healthcare and treatment experiences among people diagnosed with HIV before and after a province-wide treatment as prevention initiative in British Columbia, Canada

Introduction

In 2010, the Canadian province of British Columbia (BC) initiated the Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) program to improve HIV testing, linkage to care, and treatment uptake, thereby operationalizing the HIV Treatment as Prevention (TasP) framework at the population-level. In this analysis, we evaluated self-reported HIV care experiences and therapeutic outcomes among people diagnosed with HIV prior to and after implementation of this provincial program.

Methods

A cross-sectional analysis was performed on the baseline data of a cohort of people living with HIV (PLWH) (19 years and older) in the province of BC sampled from July 2016 to September 2018. All participants consented to linking their survey data to the provincial HIV treatment registry. Individuals diagnosed with HIV from January 1 2000—December 31 2009 were classified as pre-intervention and those diagnosed January 1 2010—December 31 2018 as post-intervention cohorts. Bivariate analyses were run using Chi-square and Wilcoxon Rank Sum tests. Cox proportional hazards regression model demonstrates time to antiretroviral therapy (ART) initiation (from HIV baseline) and virological suppression (2 consecutive plasma viral load measurements < 200 copies/ml).

Results

Of the 325 participants included in this analysis, 198 (61%) were diagnosed with HIV in the pre-intervention era and 127 (39%) in the post-intervention era. A higher proportion of participants in post-intervention era were diagnosed at walk-in clinics (45% vs. 39%) and hospitals (21% vs. 11%) (vs pre-intervention) (p = 0.042). Post-intervention participants had initiated ART with less advanced HIV disease (CD4 count 410 vs. 270 cells/ul; p = 0.001) and were less likely to experience treatment interruptions at any point in the 5 years after HIV diagnosis (17% vs. 48%; p < 0.001). The post-intervention cohort had significantly more timely ART initiation (aHR: 5.97, 95%CI 4.47, 7.97) and virologic suppression (aHR: 2.03, 95%CI 1.58, 2.60) following diagnosis, after controlling for confounders.

Conclusions

We found favourable treatment experiences and more timely ART initiation and virologic suppression after a targeted TasP provincial program. Our results illustrate the importance of accessible low-barrier HIV testing and treatment in tackling the HIV epidemic.

Understanding the Social and Emotional Dimensions of HIV Self-Management: A Qualitative Study of Newly Diagnosed People Living With HIV in Queensland, Australia

ABSTRACT

Understanding of HIV self-management increasingly focuses on treatment adherence and associated health-related behaviors, yet people living with HIV (PLWH) seldom perform these actions in a social vacuum. Thus, delivering comprehensive self-management support programs for PLWH requires an understanding of the social and emotional dimensions of HIV self-management. Through thematic analysis of in-depth interviews with 35 newly diagnosed PLWH, this descriptive qualitative study highlights these dimensions and their effect on experiences of HIV diagnosis and care. HIV self-management involves interpersonal interactions that affect efforts to seek support and reimagine one's personal identity in a changed reality. Managing disclosures and navigating stigma constitute everyday work for many PLWH. Because stigma continues to impede care engagement and well-being for PLWH, health practitioners must extend focus beyond viral suppression and prioritize support for emotional and social self-management. Nurses can create safe, nonstigmatizing spaces for conversations about HIV, uphold the rights of PLWH around disclosure, and ensure that PLWH are connected to peer support services.

Age and Year of HIV Diagnosis are Associated with Perceptions of Discrimination and Internalized Stigma Among Sexual Minority Men Who Use Substances

Discrimination and internalized stigma are barriers to engagement in HIV self-care among men who have sex with men (MSM) living with HIV. However, differences in perceptions of discrimination and internalized stigmas by age, year of HIV-diagnosis, and race are poorly understood. We assessed differences in reported discrimination related to HIV, race, sexual orientation, and substance use and internalized stigmas among 202 MSM living with HIV who use substances. Younger participants reported higher levels of all types of discrimination and internalized stigmas (p-values < 0.001-0.030). Those diagnosed after the advent of antiretrovirals reported higher levels of discrimination related to HIV, sexual orientation, and substance use, as well as internalized stigma related to HIV and substance use (p-values 0.001-0.049). We explored perceived community HIV stigma, which accounted for associations involving age and year of diagnosis. Age, year of diagnosis, and race should be considered when assessing and intervening with stigma.

Substance Use Stigma, Avoidance Coping, and Missed HIV Appointments Among MSM Who Use Substances

Men who have sex with men (MSM) living with HIV who use substances have multiple stigmatized identities. Theory suggests that internalization of stigma may elicit avoidance behaviors associated with these stigmas, potentially resulting in suboptimal engagement in HIV care. We investigated interrelationships between internalized stigmas related to HIV, sexual orientation, and substance use; avoidance coping; and missed HIV appointments among 202 MSM living with HIV who use substances. Neither HIV nor sexual orientation-related internalized stigmas were associated with missed appointments, however, internalized substance use stigma (SUS) was associated (OR 1.47, 95% CI 1.15, 1.87). The relationship between internalized SUS and missed appointments was partially accounted for by avoidance coping (b = 0.12; bootstrap 95% CI 0.02, 0.25). To better understand the role of SUS, we assessed relationships between enacted and anticipated SUS and missed appointments (OR 2.08, 95% CI 1.52, 2.84 and OR 1.44, 95% CI 1.10, 1.88, respectively). Avoidance coping fully accounted for the relationship between anticipated SUS and missed appointments (b = 0.12; 95% CI 0.02, 0.25). Results suggest that avoidance strategies to manage anticipated SUS may result in substance using MSM forgoing HIV care appointments.

Ethics and the treatment as prevention strategy among transgender women living with HIV in Argentina

While numerous ethical concerns have been voiced regarding HIV service scale-up strategies targeting key populations, few studies have examined these from the perspective of affected groups. This study therefore sought to understand transgender women's experiences and perspectives of targeted HIV services scale-up in the context of Argentina's Treatment as Prevention strategy. In 2016, 25 purposively selected transgender women living with HIV were interviewed by a peer research associate. Interviews were audio recorded, transcribed verbatim and analysed using participatory coding techniques. Findings suggest that procedures around informed consent, including the provision of full information in lay language and voluntariness, were lacking both pre- and post-HIV test. Further, many transgender women felt disrespected and disregarded by healthcare workers. While the majority of participants were unaware of Treatment as Prevention, once explained, most felt the approach was ethical overall, and helped improve equity in HIV service access. Study findings offer several community-driven suggestions to support patient rights and the ethical scale-up of HIV services for transgender women in Buenos Aires, including the need for training in and the provision of non-judgemental, gender-affirmative care and the inclusion of peer-navigators.

Understanding the impact of a residential housing programme for people living with HIV/AIDS: a realist evaluation protocol

INTRODUCTION

Housing instability and homelessness are significant barriers to medical treatment for people living with HIV/AIDS. For these individuals, lack of stable housing and stigma is associated with insufficient access to care, poor adherence to medication and higher cost burdens to the healthcare system. This protocol reports on the efforts to evaluate Sanctum V.1.0, a hospice and transitional care home for adults with HIV/AIDS in Saskatoon, Saskatchewan, Canada. The current project was developed out of a need to identify how Sanctum V.1.0 produces varying programme outcomes to assist in endeavours to replicate the programme in other geographic locations.

METHODS AND ANALYSIS

A realist evaluation will be conducted to explore how and why Sanctum V.1.0 is successful or unsuccessful, in which circumstances and for whom. Rather than explore the degree to which a programme is effective, realist evaluations seek to uncover mechanisms that explain processual links between programme inputs and outcomes. The completed first phase of the project involved the development of an initial realist programme theory. Phases 2 and 3 will consist of methods to test, refine and validate the initial theory using various data sources.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the institutional review board at the University of Saskatchewan on 2 July 2020. Results will be disseminated according to stakeholders' desires.

A Concept Mapping Study to Understand Multilevel Resilience Resources Among African American/Black Adults Living with HIV in the Southern United States

Resilience may help people living with HIV (PLWH) overcome adversities to disease management. This study identifies multilevel resilience resources among African American/Black (AA/B) PLWH and examines whether resilience resources differ by demographics and neighborhood risk environments. We recruited participants and conducted concept mapping at two clinics in the southeastern United States. Concept Mapping incorporates qualitative and quantitative methods to represent participant-generated concepts via two-dimensional maps. Eligible participants had to attend ≥ 75% of their scheduled clinic appointments and did not have ≥ 2 consecutive detectable HIV-1 viral load measurements in the past 2 years. Of the 85 AA/B PLWH who were invited, forty-eight participated. Twelve resilience resource clusters emerged-five individual, two interpersonal, two organizational/policy and three neighborhood level clusters. There were strong correlations in cluster ratings for demographic and neighborhood risk environment comparison groups (r ≥ 0.89). These findings could inform development of theories, measures and interventions for AA/B PLWH.

Extragenital Testing for Neisseria gonorrhoeae and Chlamydia trachomatis in a Large HIV Clinic in the US South: Implementation and Epidemiology

BACKGROUND

Rectal and oral Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) infections are common among people with HIV, especially men who have sex with men (MSM); however, GC/CT testing rates remain low in many HIV clinics. We evaluated the real-world implementation and results of extragenital nucleic acid amplification testing for GC/CT in an urban HIV clinic.

METHODS

Electronic health records were reviewed for all patients 18 years or older with ≥1 outpatient visit to an HIV clinic in Dallas, TX, from February 2016 to May 2019. Extragenital nucleic acid amplification testing became available in February 2017, which was followed by active interventions to increase testing.

RESULTS

Overall, 5564 individual patients were included in the preintervention period (February 2016-January 2017), 5067 in the intervention period (February 2017-August 2017), and 7030 in the postintervention period (September 2017-May 2018). Tailored education was provided to patients, and nursing and medical providers, and a self-collection protocol was implemented beginning in spring 2017. A sustained increase in extragenital GC/CT testing among MSM patients, from 70% to 87% (P < 0.01), was observed. Among MSM, overall GC positivity increased from 3.2% to 8.5% and CT positivity increased from 3.9% to 8.3%. N. gonorrhoeae/C. trachomatis infections were highest among young (<35 years) MSM, and approximately 50% of GC/CT infections diagnosed were detected by oral and rectal tests.

CONCLUSIONS

Clinic-wide education and self-collection of extragenital specimens were associated with increased GC/CT testing and detection in a large HIV clinic.

ART Adherence Among Men Who Have Sex with Men Living with HIV: Key Challenges and Opportunities

PURPOSE OF REVIEW

In the USA, gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by HIV. High levels of adherence to antiretroviral therapy (ART) can dramatically improve outcomes for persons living with HIV and reduce the risk of HIV transmission to others. Yet, there are numerous individual, social, and structural barriers to optimal ART adherence. Many of these factors disproportionately impact Black MSM and may contribute to their poorer rates of ART adherence. This review synthesizes the key challenges and intervention opportunities to improve ART adherence among MSM in the USA.

RECENT FINDINGS

Key challenges to ART adherence include stigma, violence, depression, and substance use. Black MSM are significantly disadvantaged by several of these factors. There are several promising interventions to improve ART adherence among MSM, and there remains an opportunity to culturally tailor these to the needs of Black MSM populations to enhance adherence. Despite high rates of HIV among MSM, there continues to be a paucity of research on the various contributors to poor ART adherence among this population. Similarly, few interventions have been tested that lead to increased and sustained ART adherence among Black MSM.

Exploring Current Stereotypes and Norms Impacting Sexual Partner HIV-Status Communication

This study sought to explore HIV-related stereotypes and norms that impact HIV-status communication with potential sexual partners. A series of focus groups and in-depth interviews were conducted (N = 59) with HIV-positive and HIV-negative MSM (75%) and Heterosexuals (25%). Findings indicate that HIV stereotypes and stigma remain as barriers to HIV-status discussion. Differences also emerged across groups: 1) HIV-negative MSM were more likely to report engaging in HIV-status communication, 2) HIV-positive MSM described inconsistent HIV-status communication and reported concealing their status at times, and 3) Heterosexuals reported being least likely to engage in HIV-status communication; often using the blanket question "Are you clean?" to encompass all STIs and avoiding direct HIV-status discussion. Overall, findings indicate that many HIV stereotypes and stigma-related communication norms persist that discourage discussion of sexual partners' HIV-status prior to sexual activity.

An Exploratory Study of Resilience, HIV-Related Stigma, and HIV Care Outcomes Among Men who have Sex with Men (MSM) Living with HIV in Louisiana

The various forms of HIV-related stigma continue to serve as major barriers to HIV care and treatment among men who have sex with men (MSM). The study of resilience within the context of HIV-related stigma among MSM living with HIV represents a promising area of research to inform the development of future HIV interventions for this population. We examined resilience within the context of HIV related stigma among MSM living with HIV in Louisiana with a particular interest in how resilience may be more relevant for Black MSM. We utilized Pearson's correlations and layered chi-square non-parametric tests to examine associations and racial differences in resilience, four HIV-related stigma measures/consequences (i.e., anticipated, internalized, enacted, and consequences of enacted HIV stigma), and HIV care outcomes (i.e., length of time since last HIV care visit, time since last HIV lab result, most recent HIV viral load result) among 110 MSM living with HIV in Louisiana who participated in the Louisiana HIV Stigma Index Project. The majority of MSM participants were Black (75%), lived in New Orleans (52%), and reported limited education (52%) and income (76%). MSM who reported higher levels of enacted HIV stigma, consequences of enacted HIV stigma, and internalized HIV stigma reported poorer HIV care outcomes. Both internalized and anticipated HIV stigma significantly negatively impacted Black MSM perceptions of their overall health compared with White MSM. Compared with White MSM, Black MSM who reported greater consequences of enacted HIV stigma had poorer HIV care outcomes. Resilience was associated with positive HIV care outcomes for both Black and White MSM. However, having higher levels of resilience may have been more protective for Black MSM such that higher levels of resilience were associated with less time since last HIV care visit for Black MSM than for White MSM. The current study provides preliminary information on the potential positive relationship between resilience and HIV care outcomes among MSM, particularly Black MSM. However, these findings need to be confirmed among a more representative sample of Black and White MSM in Louisiana.

Effect of mobile text messages on antiretroviral medication adherence and patient retention in early HIV care: an open-label, randomized, single center study in south Florida

Background

People with HIV (PHIV) with limited access to health services often experience suboptimal antiretroviral therapy (ART) adherence. We investigated whether a daily text messaging intervention improves ART adherence and retention in early HIV care in PHIV in a south Florida hospital-based clinic.

Methods

ART-naïve PHIV receiving care through the clinic’s Ryan White HIV/AIDS Program were enrolled and randomly assigned to the intervention or control groups with a 1:1 ratio. The intervention group received a 1-way text message daily and the control group received standard care without receiving text message reminders for 6 months. HIV RNA and CD4 cell count were measured at baseline and post-intervention. Adherence to ART was defined as a visual analog scale of ≥ 90%. Retention in care was defined as continued engagement at study end.

Results

94 ART-naïve patients were randomized and 83 (85.6%) completed the study, of which 44 were in the intervention group and 39 were in the control group. At the end of the 6-month study period, adherence to ART was 84.4% in the intervention group versus 73.5% in the control group (OR, 1.9; 95% CI 0.7–5.0; p = 0.194). Retention in care significantly improved in the intervention group compared to the control group with the odds of retention increasing by 20% (OR, 1.2; 95% CI 1.1–1.5; p = 0.006). Undetectable HIV RNA (< 50 copies/mL) was 86.7% in the intervention group versus 73.5% in the control group (OR, 2.3; 95% CI 0.8–6.9; p = 0.112). A significant increase in CD4 cell count and a decrease in HIV RNA were found at study end, with no differences between the two groups.

Conclusions

In this pilot study, a one-way daily text messaging intervention did not improve ART adherence over a 6-month study period, but significantly enhanced patient retention in early HIV care. Implementation of interventions to improve adherence in this population is required.

Predictors for Poor Linkage to Care Among Hospitalized Persons Living with HIV and Co-Occurring Substance Use Disorder

Persons living with HIV (PLWH) with substance use disorders (SUD) remain a population difficult to engage in HIV care. Project HOPE (Hospital Visits as an Opportunity for Prevention and Engagement), a randomized controlled trial testing patient navigation with/without contingency management for PLWH with SUD, aimed to address this disparity. PLWH with SUD who were out of care were recruited from 11 hospitals across the United States from 2012 to 2014. Baseline socioeconomic factors, medical mistrust scores, and perceived discrimination surveys were collected at enrollment and evaluated for effects on linkage to care at the 6-month follow-up assessment. Linkage to care (attending an outpatient visit for HIV care), early linkage to care (attending first visit within 30 days of enrollment), and engagement in care (two HIV visits within the 6-month period) were determined by medical record abstraction, supplemented by self-report. Among 801 participants enrolled in the study (mean age 45 years, 33% women, and 73% African American), those who did not complete high school and with severe food insecurity had lower odds of being linked to care at 6 months. Those with high levels of medical mistrust, recent drug use, and who did not complete high school had lower odds of early linkage to care. Early linkage was associated with higher odds of engagement at 6 months and was mitigated by both patient navigator interventions (all p < .05). Addressing social determinants of health is critical to correct the disparity seen in HIV outcomes among PLWH with SUD. Identifying factors that alter the effect of interventions could help identify patients who would benefit most.

Disparities in Retention in Care Among Adults Living with HIV/AIDS: A Systematic Review

As national HIV prevention goals aim to increase the proportion of persons living with HIV, determining existing disparities in retention in care will allow for targeted intervention. The purpose of this systematic review was to identify existing disparities in retention in care. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) 2015 guided this systematic review. Electronic databases, including PubMed/MEDLINE, CINAHL, Sociological Collection, PsychInfo, and Cab Direct/Global Health, were systematically searched and twenty studies were included. This review identified disparities in retention in care that have been documented by race, gender, age, HIV exposure, incarceration history, place of birth, and U.S. geographic location. Research is necessary to further identify existing disparities in retention in care and to better understand determinants of health disparities. Additionally, interventions must be tailored to meet the needs of health disparate populations and should be assessed to determine their effectiveness in reducing health disparities.

Rural Black Pastors: the Influence of Attitudes on the Development of HIV/AIDS Programs

This exploratory research addressed the question, among rural Mississippi African American Baptist pastors, what is the impact of attitudes toward HIV/AIDS on the development of HIV/AIDS programs in the church? It was hypothesized that empathetic attitudes toward HIV make programming more likely. The study used Froman and Owen's AIDS Attitude Scale (AAS) and a demographic questionnaire, which included a measure that assessed potential program development. A sample of more than 300 African American pastors participated. The findings suggested that there is a significant relationship between rural Mississippi African American Baptist pastors' empathetic attitudes toward AIDS and their willingness to develop an HIV/AIDS program.

Long-term retention in pre-exposure prophylaxis care among men who have sex with men and transgender women in the United States

INTRODUCTION

Retention in HIV pre-exposure prophylaxis (PrEP) care in real-world settings, outside of controlled trials or demonstration projects, remains poorly understood.

METHODS

We evaluated retention in PrEP care outcomes among men who have sex with men (MSM) and transgender women prescribed PrEP through March 2017 at three clinical sites in the United States (US): Jackson, Mississippi; Providence, Rhode Island; and St. Louis, Missouri. We determined retention rates by attendance of clinical visits every three months, per US Centers for Disease Control and Prevention (CDC) guidelines, as well as by the timing of patients' actual clinical visits. Multivariable analyses examined demographic and behavioural factors associated with retention.

RESULTS

From 2013 to 2015, 282 MSM and transgender women were prescribed PrEP; 82% attended a follow-up visit. Based on CDC recommendations, 56% of patients were retained in PrEP care at the first follow-up visit, having attended a visit three months after initiation. However, 76% had a follow-up visit within eight months. Thirty-percent were retained at 12 months by CDC criteria, but 62% were retained when using a 16-month endpoint. Self-reported adherence was strongly correlated with retention. In multivariable analyses, younger age was associated with decreased odds of retention at initial follow-up, and completing college was associated with increased odds of retention at 16 months. Eight participants were newly diagnosed with HIV; six were African American, and seven were under 30 years of age.

CONCLUSIONS

Measuring retention in PrEP care using three-month follow-up intervals may underestimate true retention. Nevertheless, retention in PrEP care is suboptimal in real-world settings and should be the focus of future interventions.

Long-term retention in pre-exposure prophylaxis care among men who have sex with men and transgender women in the United States

INTRODUCTION

Retention in HIV pre-exposure prophylaxis (PrEP) care in real-world settings, outside of controlled trials or demonstration projects, remains poorly understood.

METHODS

We evaluated retention in PrEP care outcomes among men who have sex with men (MSM) and transgender women prescribed PrEP through March 2017 at three clinical sites in the United States (US): Jackson, Mississippi; Providence, Rhode Island; and St. Louis, Missouri. We determined retention rates by attendance of clinical visits every three months, per US Centers for Disease Control and Prevention (CDC) guidelines, as well as by the timing of patients' actual clinical visits. Multivariable analyses examined demographic and behavioural factors associated with retention.

RESULTS

From 2013 to 2015, 282 MSM and transgender women were prescribed PrEP; 82% attended a follow-up visit. Based on CDC recommendations, 56% of patients were retained in PrEP care at the first follow-up visit, having attended a visit three months after initiation. However, 76% had a follow-up visit within eight months. Thirty-percent were retained at 12 months by CDC criteria, but 62% were retained when using a 16-month endpoint. Self-reported adherence was strongly correlated with retention. In multivariable analyses, younger age was associated with decreased odds of retention at initial follow-up, and completing college was associated with increased odds of retention at 16 months. Eight participants were newly diagnosed with HIV; six were African American, and seven were under 30 years of age.

CONCLUSIONS

Measuring retention in PrEP care using three-month follow-up intervals may underestimate true retention. Nevertheless, retention in PrEP care is suboptimal in real-world settings and should be the focus of future interventions.

Management of Advanced HIV Disease

Great progress has been made in caring for persons with human immunodeficiency virus. However, a significant proportion of individuals still present to care with advanced disease and a low CD4 count. Careful considerations for selection of antiretroviral therapy as well as close monitoring for opportunistic infections and immune reconstitution inflammatory syndrome are vitally important in providing care for such individuals.

Towards ending the US HIV epidemic by 2030: Understanding social determinants of health and HIV in Mississippi

The disproportionate burden of HIV-related inequities borne by African Americans in the US South amplifies the role of social determinants of health (SDH) in shaping social patterning of illness. Despite some attention, SDH remain overlooked in a biomedically oriented, federal HIV policy. Mississippi is the poorest state with the worst HIV outcomes, nationally. Using qualitative methods, we investigated how primarily African American, HIV-positive Mississippians experienced SDH and health inequities in their daily lives. Employing grounded theory and in-depth interviews (n = 25) in an urban and rural site in 2015 yielded these findings: (1) absence of an enabling structural environment; (a) HIV-stigma constructed via social discourse; (b) lack of psycho-social support and HIV education; (c) insufficient economic and social support resources; and (2) presence of family support for coping. Due to stigma, being HIV-positive seemed to lead to further status loss; diminished social position; reduced life chances; and contractions in particular freedoms. Stigma further compounded existing inequalities - contributing to the moral, social experience of those living with HIV. Trump's plan to end HIV by 2030 creates the opportunity to rethink the biomedical-paradigm and fully engage SDH - using social science theory and methods that address multi-level social determinants in ways that are also policy-responsive.

"I'm Gonna Get Busy Living": Examining the Trajectories of Affect, Behavioral Health, and Psychological Resilience Among Persons Living With HIV in a Southeastern U.S. Health District

Internal psychological states and coping processes are significant determinants of resilience. The primary aim of this qualitative work is to provide further insight into how core affect influences the adaptability of persons living with HIV (PLWH) after diagnosis. In-depth interviews were conducted with a diverse group of PLWH in a health district located in the Southeastern United States. A deductive-inductive approach was taken while coding and analyzing, N = 18 participant narratives concerning the psychological and coping processes surrounding diagnosis and engagement in care. Active behavioral and cognitive coping after diagnosis was exhibited by PLWH expressing salient attributes of positive affect, whereas the salience of negative affect among PLWH was associated with avoidant coping and heightened distress. Our findings illuminate the beneficial role of positive affect and active coping on the health and well-being of PLWH. The study implications extend to the development and enhancement of programs designed to fortify psychological resilience.

Community-Based Organization Adaptations to the Changing HIV Prevention and Care Landscape in the Southern United States

Community-based organizations (CBOs) provide HIV prevention services throughout the United States, including the South where HIV/AIDS burden is high. We assessed Southern CBO response to changes in the HIV prevention landscape, including the National HIV/AIDS Strategy, and the Centers for Disease Control and Prevention's (CDC's) High Impact Prevention. Both strategies aim to improve outcomes for people living with or at high risk for HIV. Inductive qualitative analysis of interviews and consultations with CBOs, capacity building assistance providers, and CDC staff revealed CBOs are building clinical service capacity and cross-agency partnerships to adapt, but face inadequate or reduced funding. A holistic approach to HIV prevention and care in the South is critical, where stigma and other socio-structural factors limit health care options for persons affected by HIV. Health care organizations may benefit by partnering with CBOs because CBOs have the skillsets and community rapport to effectively improve health outcomes of persons living with HIV.

Exploring the Correlates of Linkage to HIV Medical Care Among Persons Living with HIV Infection (PLWH) in the Deep South: Results and Lessons Learned from the Louisiana Positive Charge Initiative

We explored the correlates of linkage to HIV medical care and barriers to HIV care among PLWH in Louisiana. Of the 998 participants enrolled, 85.8% were successfully linked to HIV care within 3 months. The majority of participants were male (66.2%), African American (81.6%), and had limited education (74.4%). Approximately 22% of participants were Black gay and bisexual men. The most common reported barrier to care was lack of transportation (27.1%). Multivariable analysis revealed that compared with Black gay and bisexual men, White gay and bisexual men were significantly more likely to be linked to HIV care (adjusted prevalence ratio, aPR 1.08, 95% CI 1.02-1.13). Additionally, participants reporting moderate to high levels of stigma at intake (p < 0.05) were significantly more likely to be linked to HIV care compared with those reporting low or no stigma at enrollment. Study findings highlight the continued importance of client-centered interventions and multi-sector collaborations to link PLWH to HIV medical care.

Mental health and retention in HIV care: A systematic review and meta-analysis

OBJECTIVE

Mental health (MH) diagnoses, which are prevalent among persons living with HIV infection, might be linked to failed retention in HIV care. This review synthesized the quantitative evidence regarding associations between MH diagnoses or symptoms and retention in HIV care, as well as determined if MH service utilization (MHSU) is associated with improved retention in HIV care.

METHOD

A comprehensive search of the Centers for Disease Control and Prevention's HIV/AIDS Prevention Research Synthesis database of electronic (e.g., MEDLINE, EMBASE, PsycINFO) and manual searches was conducted to identify relevant studies published during January 2002-August 2017. Effect estimates from individual studies were pooled by using random-effects meta-analysis, and a moderator analysis was conducted.

RESULTS

Forty-five studies, involving approximately 57,334 participants in total, met the inclusion criteria: 39 examined MH diagnoses or symptoms, and 14 examined MHSU. Overall, a significant association existed between MH diagnoses or symptoms, and lower odds of being retained in HIV care (odds ratio, OR = 0.94; 95% confidence interval [CI] [0.90, 0.99]). Health insurance status (β = 0.004; Z = 3.47; p = .001) significantly modified the association between MH diagnoses or symptoms and retention in HIV care. In addition, MHSU was associated with an increased odds of being retained in HIV care (OR = 1.84; 95% CI [1.45, 2.33]).

CONCLUSIONS

Results indicate that MH diagnoses or symptoms are a barrier to retention in HIV care and emphasize the importance of providing MH treatment to HIV patients in need. (PsycINFO Database Record

Unmet Mental Health and Social Service Needs of Formerly Incarcerated Women Living with HIV in the Deep South

Due to the disproportionate burden of HIV among incarcerated women in the United States, jails and prisons have been identified as key sites for health service delivery. Recidivism remains high, potentially reflecting unmet mental health and social service needs of incarcerated women, especially during the postrelease adjustment period. However, little published research has investigated this possibility directly. We conducted semi-structured, in-depth interviews with previously incarcerated women living with HIV, and other key informants, and completed service-availability mapping in two Alabama cities. Key findings were: (a) discharge planning and postrelease support services to manage risky environments were absent, (b) postrelease services were concentrated in a few community-based organizations, (c) mental health and substance abuse treatment during re-entry was essential to prevent relapse, and (d) social support was crucial for postrelease adjustment. We propose a novel conceptual model with key steps to establish continuous care for previously incarcerated women living with HIV.

Predictors of HIV Care Engagement, Antiretroviral Medication Adherence, and Viral Suppression Among People Living with HIV Infection in St. Petersburg, Russia

Over 1 million HIV infections have been diagnosed in Russia, and HIV care uptake and viral suppression are very low. 241 HIV-positive individuals in St. Petersburg were enrolled through social networks, provided blood for viral load testing, and completed measures of medication-taking adherence, readiness, and self-efficacy; psychosocial well-being; and substance use. Outcomes included attending an HIV care appointment in the past 6 months, >90% ART adherence, and undetectable viral load. 26% of participants had no recent care appointment, 18% had suboptimal adherence, and 56% had detectable viral load. Alcohol use consistently predicted all adverse health outcomes. Having no recent care visit was additionally associated with being single and greater past-month drug injection frequency. Poor adherence was additionally predicted by lower medication-taking self-efficacy and lower anxiety. Detectable viral load was additionally related to younger age. Comprehensive interventions to improve HIV care in Russia must address substance abuse, anxiety, and medication-taking self-efficacy.

Racial/Ethnic Disparities in Failure to Initiate HIV Care: Role of HIV Testing Site, Individual Factors, and Neighborhood Factors, Florida, 2014-2015

Delayed initiation of human immunodeficiency virus (HIV) care affects disease progression. To determine the role of HIV testing site and neighborhood- and individual-level factors in racial/ethnic disparities in initiation of care, we examined Florida population-based HIV/AIDS surveillance system records. We performed multilevel Poisson regression to calculate adjusted prevalence ratios (APR) for non-initiation of care by race/ethnicity adjusting for HIV testing site type and individual- and neighborhood-level characteristics. Of 8,913 people diagnosed with HIV during 2014-2015 in the final dataset, 18.3% were not in care within three months of diagnosis. The APR for non-initiation of care for non-Hispanic Blacks relative to non-Hispanic Whites was 1.57 (95% confidence interval [CI] 1.38-1.78) and for those tested in plasma/donation centers relative to outpatient clinics was 2.45 (95% CI 2.19-2.74). Testing site and individual variables contribute to racial/ethnic disparities in non-initiation of HIV care. Linkage procedures, particularly at plasma/blood donation centers, warrant improvement.

The HIV Prison Paradox: Agency and HIV-Positive Women's Experiences in Jail and Prison in Alabama

Incarcerated women face significant barriers to achieve continuous HIV care. We employed a descriptive, exploratory design using qualitative methods and the theoretical construct of agency to investigate participants' self-reported experiences accessing HIV services in jail, in prison, and post-release in two Alabama cities. During January 2014, we conducted in-depth interviews with 25 formerly incarcerated HIV-positive women. Two researchers completed independent coding, producing preliminary codes from transcripts using content analysis. Themes were developed iteratively, verified, and refined. They encompassed (a) special rules for HIV-positive women: isolation, segregation, insults, food rationing, and forced disclosure; (b) absence of counseling following initial HIV diagnosis; and (c) HIV treatment impediments: delays, interruption, and denial. Participants deployed agentic strategies of accommodation, resistance, and care-seeking to navigate the social world of prison and HIV services. Findings illuminate the "HIV prison paradox": the chief opportunities that remain unexploited to engage and re-engage justice-involved women in the HIV care continuum.

Substance Use Disorders, Violence, Mental Health, and HIV: Differentiating a Syndemic Factor by Gender and Sexuality

This paper measures syndemic substance use disorder, violence, and mental health and compares the syndemic among HIV-infected heterosexual men, heterosexual women, and men who have sex with men (MSM). Data were from a sample of high needs substance-using, HIV-infected people in South Florida between 2010 and 2012 (n = 481). We used confirmatory factor analysis to measure a syndemic latent variable and applied measurement invariance models to identify group differences in the data structure of syndemic co-morbidities among heterosexual men, heterosexual women, and MSM. We found that variables used to measure the syndemic fit each sub-group, supporting that substance use disorder, violence, and mental health coincide in HIV-infected individuals. Heterosexual men and MSM demonstrated similar syndemic latent variable factor loadings, but significantly different item intercepts, indicating that heterosexual men had larger mean values on substance use disorder, anxiety, and depression than MSM. Heterosexual men and heterosexual women demonstrated significantly different syndemic variable factor loadings, indicating that anxiety and depression contribute more (and substance use contributes less) to the syndemic in heterosexual men compared to heterosexual women. MSM and heterosexual women demonstrated similar syndemic latent variable factor loadings and intercepts, but had significantly different factor residual variances indicating more variance in violent victimization and depression for MSM and more variance in stress for heterosexual women than what is captured by the observed syndemic indicators. Furthermore, heterosexual women had a larger syndemic factor mean than MSM, indicating that the syndemic burden is greater among heterosexual women than MSM. Our findings support that measurement invariance can elucidate differences in the syndemic to tailor interventions to sub-group needs.

The Metropolitan Atlanta community adolescent rapid testing initiative study: closing the gaps in HIV care among youth in Atlanta, Georgia, USA

Supplemental Digital Content is available in the text

Objective:

To determine the effectiveness of the Metropolitan Atlanta community adolescent rapid testing initiative (MACARTI) intervention relative to standard of care (SOC), in achieving early diagnosis, linkage, and retention among HIV-infected youth ages 18–24 years.

Design:

MACARTI was a pilot single-center, prospective, nonrandomized study.

Methods:

MACARTI combined nontraditional venue HIV testing, motivational interviewing, and case management. We collected demographic, clinical variables and calculated linkage and appointment adherence rates. We obtained SOC data from an adolescent HIV clinic. Longitudinal data were analyzed using inverse propensity treatment-weighted linear growth models; medians, interquartile ranges (IQR), means, and 95% confidence intervals are provided.

Results:

MACARTI screened 435 participants and identified 49 (11.3%) HIV infections. The SOC arm enrolled 49 new HIV-infected individuals. The 98 participants, (49 in each arm) were: 85% men; 91% Black; mean age = 21 years (SD : 1.8). Overall, 63% were linked within 3 months of diagnosis; linkage was higher for MACARTI compared to SOC (96 vs. 57%, P < 0.001). Median linkage time for MACARTI participants compared to SOC was 0.39 (IQR : 0.20–0.72) vs. 1.77 (IQR : 1.12–12.65) months (P < 0.001). MACARTI appointment adherence was higher than SOC (86.1 vs. 77.2%, P = 0.018). In weight-adjusted models, mean CD4⁺ T-cell counts increased and mean HIV-1 RNA levels decreased in both arms over 12 months, but the differences were more pronounced in the MACARTI arm.

Conclusion:

MACARTI successfully identified and linked HIV-infected youth in Atlanta, USA. MACARTI may serve as an effective linkage and care model for clinics serving HIV-infected youth.

An Exploratory Study to Assess Individual and Structural Level Barriers Associated With Poor Retention and Re-engagement in Care Among Persons Living With HIV/AIDS

BACKGROUND

Retention in care is the most challenging step along the HIV care continuum. Many patients who engage in care and achieve viral suppression have care interruptions, characterized by moving in and out of care ("churn"). Poor retention has clinical consequences and contributes to new HIV transmissions, but how to predict or prevent it remains elusive. This study sought to understand the relationship between individual- and structural-level barriers, and poor retention for persons living with HIV/AIDS in Atlanta, GA.

METHODS

We administered a survey, through interviews, with HIV-infected patients continuously retained in care for 6 years ("continuously retained," n = 32) and patients with recent gaps in care ("unretained" n = 27). We assessed individual-level protective factors for successful engagement (self-efficacy, resilience, perceived social support, and disclosure), risk factors for poor engagement (substance use, mental illness, and stigma), and structural/systemic-level barriers (financial and housing instability, transportation, food insecurity, communication barriers, and incarceration history). Chi-square and Mann-Whitney U tests were used to compare the 2 populations.

RESULTS

Both continuously retained and unretained populations had high rates of prior viral suppression but few unretained patients were virologically suppressed upon return to care (11%). Younger age, crack cocaine use, food insecurity, financial instability, housing instability, and phone number changes in the past year were significantly more likely to be present in the unretained population.

CONCLUSIONS

Our findings suggest the need for targeted risk assessment tools to predict the highest-risk patients for poor retention whereby public health interventions can be directed to those individuals.

Transitioning newly diagnosed patients with HIV into care

Fewer than half of the individuals in the United States with HIV are receiving the full benefit of treatment. Primary care providers play a pivotal role in creating a pipeline into HIV care following diagnosis. Using interview data and current literature, this article provides recommendations for promoting care initiation for individuals newly diagnosed with HIV.

Missed Initial Medical Visits: Predictors, Timing, and Implications for Retention in HIV Care

HIV disproportionately affects racial/ethnic minorities and individuals living in the southern United States, and missed clinic visits account for much of this disparity. We sought to evaluate: (1) predictors of missed initial HIV medical visits, (2) time to initial visit, and (3) the association between initial visit attendance and retention in HIV care. Chart reviews were conducted for 200 consecutive HIV-infected patients (100 in Dallas, 100 in San Antonio) completing case management (CM) intake. Of these, 52 (26%) missed their initial visit, with 22 (11%) never presenting for care. Mean age was 40 years, 85% were men, >70% were of minority race/ethnicity, and 28% had a new HIV diagnosis. Unemployment (OR [95% CI] = 2.33 [1.04-5.24], p = 0.04) and lower attendance of CM visits (OR = 3.08 [1.43-6.66], p = 0.004) were associated with missing the initial medical visit. A shorter time to visit completion was associated with CD4 ≤ 200 (HR 1.90 [1.25-2.88], p = 0.003), Dallas study site (HR = 1.48 [1.03-2.14], p = 0.04), and recent hospitalization (HR = 2.18 [1.38-3.43], p < 0.001). Patients who did not complete their initial medical visit within 90 days of intake were unlikely to engage in care. Initial medical visit attendance was associated with higher proportion of visits attended (p = 0.04) and fewer gaps in care (p = 0.01). Missed medical visits were common among HIV patients initiating or reinitiating care in Texas. Employment and CM involvement predicted initial medical visit attendance, which was associated with retention in care. New, early engagement strategies are needed to decrease missed visits and reduce HIV health disparities.

A Longitudinal Analysis of Antiretroviral Adherence Among Young Black Men Who Have Sex With Men

PURPOSE

Young black men who have sex with men (YBMSM) experience poorer antiretroviral therapy (ART) medication adherence relative to their white counterparts. However, few studies have longitudinally examined factors that may correlate with various classifications of ART adherence among this population, which was the primary aim of this study.

METHODS

Project nGage was a randomized controlled trial conducted across five Chicago clinics from 2012 to 2015. Survey and medical records data were collected at baseline and 3- and 12-month periods to assess whether psychological distress, HIV stigma, substance use, family acceptance, social support, and self-efficacy predicted ART medication adherence among 92 YBMSM ages 16-29 years.

RESULTS

Major results controlling for the potential effects of age, education level, employment, and intervention condition indicated that participants with high versus low medication adherence were less likely to report daily/weekly alcohol or marijuana use, had higher family acceptance, and exhibited greater self-efficacy.

CONCLUSIONS

These findings identity important factors that can be targeted in clinical and program interventions to help improve ART medication adherence for YBMSM.

Adaptation and Implementation of an Intervention to Reduce HIV-Related Stigma Among Healthcare Workers in the United States: Piloting of the FRESH Workshop

HIV-related stigma has been shown to have profound effects on people living with HIV (PLWH). When stigma is experienced in a healthcare setting, negative health outcomes are exacerbated. We sought to assess the feasibility and acceptability of a healthcare setting stigma-reduction intervention, the Finding Respect and Ending Stigma around HIV (FRESH) Workshop, in the United States. This intervention, adapted from a similar strategy implemented in Africa, brought together healthcare workers (HW) and PLWH to address HIV-related stigma. Two pilot workshops were conducted in Alabama and included 17 HW and 19 PLWH. Participants completed questionnaire measures pre- and post-workshop, including open-ended feedback items. Analytical methods included assessment of measures reliability, pre-post-test comparisons using paired t-tests, and qualitative content analysis. Overall satisfaction with the workshop experience was high, with 87% PLWH and 89% HW rating the workshop "excellent" and the majority agreeing that others like themselves would be interested in participating. Content analysis of open-ended items revealed that participants considered the workshop informative, interactive, well-organized, understandable, fun, and inclusive, while addressing real and prevalent issues. Most pre- and post-test measures had good-excellent internal consistency reliability (Cronbach's alphas ranging from 0.70 to 0.96) and, although sample sizes were small, positive trends were observed, reaching statistical significance for increased awareness of stigma in the health facility among HW (p = 0.047) and decreased uncertainty about HIV treatment among PLWH (p = 0.017). The FRESH intervention appears to be feasible and highly acceptable to HW and PLWH participants and shows great promise as a healthcare setting stigma-reduction intervention for US contexts.