Black-White and Country of Birth Disparities in Retention in HIV Care and Viral Suppression among Latinos with HIV in Florida, 2015

Non-Linkage to Care and Non-Viral Suppression among Hispanic/Latino Persons by Birthplace and Social Vulnerability-United States, 2021

BACKGROUND

Assessing individual- and community-level factors may help to explain differences among Hispanic/Latino adults with diagnosed HIV not linked to care and without viral suppression in the United States.

METHODS

We analyzed CDC's National HIV Surveillance System data among Hispanic/Latino persons aged ≥ 18 years with HIV diagnosed during 2021 in 47 states and the District of Columbia and linked cases via census tracts to the CDC/ATSDR's Social Vulnerability Index (SVI). Adjusted prevalence ratios and 95% confidence intervals for non-linkage to care and non-viral suppression were estimated using Poisson regression model.

RESULTS

Among 5,056 Hispanic/Latino adults with HIV diagnosed in 2021, 51.5% were born in the United States, 17.3% in Mexico, 9.2% in Central America, 11.1% in South America, 1.8% in Puerto Rico, 6.8% in Cuba, and 2.4% in the Caribbean. Compared with U.S.-born Hispanic/Latino adults, those born in Mexico and South America had a lower prevalence of non-linkage to care. Hispanic/Latino adults born in Mexico, South America, and the Caribbean (excluding Puerto Rico and Cuba) had a lower prevalence of non-viral suppression, compared with those born in the United States. No significant differences were observed among SVI quartiles for either care outcome.

CONCLUSION

This study aimed to challenge the narrow perspective on HIV care outcomes by examining the impact of birthplace and social vulnerability among Hispanic/Latino adults. To increase HIV care and prevention among Hispanic/Latino persons, research must evaluate health disparities within the group, and efforts are needed to better understand and tailor interventions within the diverse Hispanic/Latino population.

Racial Differences in Social Determinants of Health and Outcomes Among Hispanic/Latino Persons with HIV-United States, 2015-2020

BACKGROUND

Hispanic/Latino people with HIV (PWH) experience disparities in health outcomes compared with other racial and ethnic groups. Disaggregated data based on race for Hispanic/Latino PWH in the United States are rarely reported, potentially masking inequities.

METHODS

The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV. We used weighted interview and medical record data collected from June 2015-May 2021 to examine differences in social determinants of health (SDH) and health outcomes by self-reported race among Hispanic/Latino adults with diagnosed HIV.

RESULTS

Compared with White Hispanic/Latino PWH, Black Hispanic/Latino PWH were more likely to be unemployed (PR, 1.4; CI, 1.2-1.8), have a disability (PR, 1.3; CI, 1.2-1.5), have experienced homelessness (PR, 1.8; CI, 1.2-2.6), and have been incarcerated (PR, 2.6; CI, 1.5-4.5). American Indian/Alaska Native (AI/AN) (PR, 1.8; CI, 1.1-2.7) and multiracial (PR, 2.0; CI, 1.4-2.9) Hispanic/Latino PWH were more likely to have experienced homelessness than White Hispanic/Latino PWH. Black (PR, 1.3; CI, 1.2-1.5) and multiracial (PR, 1.2; CI, 1.1-1.5) Hispanic/Latino PWH were more likely to be virally unsuppressed than White Hispanic/Latino PWH.

CONCLUSION

Black, multiracial, and AI/AN Hispanic/Latino PWH experience disparities in SDH and HIV outcomes. Lumping Hispanic/Latino people into one racial and ethnic category obscures health disparities, which might limit our progress towards reaching national HIV goals. Future studies should consider disaggregating by other factors such as Hispanic origin, place of birth, immigration status, and primary language. Doing so recognizes the diversity of the Hispanic/Latino population.

Examining Global Wellness, Anxiety Severity, and Depression Severity among Black and Latinx Adults: Implications for Counseling

The effectiveness of Global Wellness (combined mental and physical health) among samples of primarily White clients is well-documented in the literature. However, the Global Wellness literature is lacking research among ethnic minority populations who tend to face healthcare inequities. For example, Black and Latinx adults in the U.S. face inequities in the quality and accessibility of mental and physical healthcare services, including unique risks for anxiety and depression. In this study, a national random sample, (N = 4,009) was recruited (stratified by age, gender, and geographic region of the U.S.) of Latinx and Black adults to examine the association between Anxiety Severity and Depression Severity with Global Wellness as well as demographic differences in Global Wellness. Anxiety and depression emerged as significant negative predictors of Global Wellness and results revealed a number of demographic differences in Global Wellness. Implications for counseling practice and how mental health counselors can reduce healthcare disparities are discussed.

Post-immigration factors affecting retention in HIV care and viral suppression in Latin American and Caribbean immigrant populations in the United States: a systematic review

OBJECTIVES

To reduce disparities in HIV care outcomes among Latin American and Caribbean (LAC) immigrants living with HIV in the U.S., it is necessary to identify factors influencing HIV care in this population. A systematic review that provides a comprehensive understanding of factors influencing retention in HIV care and viral suppression among LAC immigrants living with HIV in the U.S. is lacking. This systematic review used the Immigrant Health Services Utilization theoretical framework to provide an understanding of these factors.

DESIGN

We searched for peer-reviewed publications in MEDLINE, EMBASE, CINAHL, PsycINFO, and ASSIA, from January 1996 to June 2020.

RESULTS

A total of 17 qualitative (n = 10) and quantitative (n = 7) studies were included in the review. The most commonly reported general and immigrant-specific factors appearing in studies were undocumented immigration status, HIV stigma, homophobia, cultural norms, values and beliefs, family and social support, language barriers, structure, complexity and quality of the U.S. healthcare delivery system, and patient-provider relationship.

CONCLUSION

These findings highlight the importance of considering immigrant-specific factors along with general factors to improve the provision of HIV care services and HIV care outcomes among LAC immigrant populations.

Validation of Scores on The Lifestyle Practices and Health Consciousness Inventory with Black and Latinx Adults in the United States: A Three-Dimensional Model

The author tested the psychometric properties of the Lifestyle Practices and Health Consciousness Inventory (LPHCI), an interdisciplinary healthcare screening tool, with a stratified random sample (N = 4,009) of Black and Latinx adults in all 50 states. Results of EFA, CFA, higher-order CFA, and multiple-group CFA all supported a 3-dimensional LPHCI model.

Development and Validation of Vulnerable and Enabling Indices for HIV Viral Suppression among People with HIV Enrolled in the Ryan White Program

BACKGROUND

Numerous factors impact HIV care, often requiring consideration of indices to prevent collinearity when using statistical modeling. Using the Behavioral Model for Vulnerable Populations, we developed vulnerable and enabling indices for people living with HIV (PLWH).

METHODS

We used Ryan White Program (RWP) data and principal component analysis to develop general and gender- and racial/ethnic-specific indices. We assessed internal reliability (Cronbach's alpha), convergent validity (correlation coefficient), and predictive utility (logistic regression) with non-viral suppression.

RESULTS

Three general factors accounting for 79.2% of indicators' variability surfaced: mental health, drug use, and socioeconomic status (Cronbach's alpha 0.68). Among the overall RWP population, indices showed convergent validity and predictive utility. Using gender- or racial/ethnic-specific indices did not improve psychometric performance.

DISCUSSION

General mental health, drug use, and socioeconomic indices using administrative data showed acceptable reliability, validity, and utility for non-viral suppression in an overall PLWH population and in gender- and racial/ethnic-stratified populations. These general indices may be used with similar validity and utility across gender and racial/ethnic diverse populations.

Measuring Race Among Latinos to Address Racism, Discrimination, and HIV Health Inequities: Comparing Self-Reported Race and Fitzpatrick Skin Phototype

Limited research suggests there are significant disparities in HIV outcomes between Black and White Latinos. However, race among Latinos is largely absent from the scientific literature, and relevant measures of race for Latino populations have not been widely incorporated into ongoing research. Using a sample (N = 24) of young (18–34 years old) Latino men who have sex with men living with HIV, we compared self-reported Fitzpatrick skin phototype and self-reported race. Self-identified White Latinos reported skin phototypes 1 “light, pale white” through 4 “olive, moderate brown.” Multiracial Latinos reported skin phototypes 2 “white, fair” through 5 “brown, dark brown.” One-third of participants did not identify with commonly used racial categories, White or Black. Results suggest a widespread of skin phototypes among Latinos self-identifying as White and Multiracial, which may impact the identification of HIV racial disparities, as well as racism, discrimination, and health inequities HIV research among Latino sexual and gender minorities.

Interprofessional collaboration associated with frequency of life-saving links to HIV continuum of care services in the urban environment of Newark, New Jersey

BACKGROUND

HIV continuum of care has been used as a strategy to reduce HIV transmission rates, with timely engagement in HIV testing being the first and most critical step. This study examines interprofessional-collaboration (IPC) after controlling for agency/ provider demographics, provider training and self-efficacy as a significant predictor of how frequently HIV service providers link their clients to HIV testing.

METHODS

Multilevel binary logistic regression analysis was conducted to examine the effects of IPC on links to HIV testing while controlling for demographic and agency information, provider training, and standardized measures of providers' feelings, attitudes, and opinions about IPC. Cross-sectional data from 142 providers in 13 agencies offering treatment and prevention services for HIV and substance-use disorders were collected via a survey.

RESULTS

Those who scored higher on the IPC scale reported significantly higher rates of linkages to HIV testing. Compared to the null model (i.e., no predictor model), the final multilevel binary logistic regression model showed a significantly improved likelihood of linkage to HIV testing by 11.4%, p. < .05. The final model correctly classified 90.2% of links to HIV testing. Providers in agencies with smaller budgets and in agencies offering substance use disorder services were more likely to link clients to HIV testing. Younger providers who received HIV training were also more likely to link clients to HIV testing.

CONCLUSIONS

Findings suggest IPC training as a potential strategy to improve linkages to HIV testing for clients at risk for HIV infection. Future research is recommended to identify specific areas of IPC that might have differential effects on links to HIV testing.

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.

Individual and neighborhood predictors of retention in care and viral suppression among Florida youth (aged 13-24) living with HIV in 2015

Youth aged 13‒24 are less likely to be retained in HIV care and be virally suppressed than older age groups. This study aimed to assess predictors of retention in HIV care and viral suppression among a population-based cohort of youth (N = 2872) diagnosed with HIV between 1993 and 2014 in Florida. We used generalized estimating equations to estimate prevalence ratios (PRs). Retention in care was defined as evidence of engagement in care (at least one laboratory test, physician visit, or antiretroviral therapy prescription refill), two or more times, at least three months apart during 2015. Viral suppression was defined as having evidence of a viral load <200 copies/ml among those in care during 2015. Among the 2872 youth, 65.4% were retained in care, and among those in care, 65.0% were virally suppressed. Older youth (18‒24 years old) and non-Hispanic Blacks (NHBs) were less likely to be retained in care, whereas those men who have sex with men, perinatal HIV transmission, living in low socioeconomic neighborhoods, and those diagnosed with AIDS before 2016 were more likely to be retained in care. Those diagnosed with AIDS before 2016 and NHBs were less likely to be virally suppressed, whereas those men who have sex with men and foreign-born persons were more likely to be virally suppressed. Results suggest the need for targeted retention and viral suppression interventions for NHB youth and older youth (18‒24 years-age).

From Theory to Application: A Description of Transnationalism in Culturally-Appropriate HIV Interventions of Outreach, Access, and Retention Among Latino/a Populations

Interventions aiming to improve access to and retention in HIV care are optimized when they are tailored to clients' needs. This paper describes an initiative of interventions implemented by ten demonstration sites using a transnational framework to tailor services for Mexicans and Puerto Ricans living with HIV. Transnationalism describes how immigrants (and their children) exist in their "receiving" place (e.g., continental U.S.) while simultaneously maintaining connections to their country or place of origin (e.g., Mexico). We describe interventions in terms of the strategies used, the theory informing design and the tailoring, and the integration of transnationalism. We argue how applying the transnational framework may improve the quality and effectiveness of services in response to the initiative's overall goal, which is to produce innovative, robust, evidence-informed strategies that go beyond traditional tailoring approaches for HIV interventions with Latino/as populations.

Anal Cancer Prevention Perspectives Among Foreign-Born Latino HIV-Infected Gay and Bisexual Men

This study explores understanding of primary and secondary prevention of anal cancer among human immunodeficiency virus (HIV)-infected foreign-born Latino gay and bisexual men (GBM). Between August 2015 and December 2016, researchers conducted 33 in-depth, semi-structured interviews with HIV-infected foreign-born Latino GBM. Interview questions sought to determine participants' knowledge and perceived barriers and facilitators to primary and secondary prevention of anal cancer. Researchers analyzed interview transcripts using a qualitative content analysis approach. For primary prevention, men reported a lack of knowledge about the human papillomavirus (HPV) vaccine. However, for secondary prevention, roughly 60% of participants had previously screened for anal dysplasia via anal Papanicolaou (Pap) smear. However, participants reported willingness to screen, and provider recommendation was the most common screening facilitator. Men reported stigma related to their HIV status, sexual orientation, and anal Pap smear procedures as anal cancer screening barriers. Participants reported willingness to use a self-screening anal Pap smear test if it was commercially available. Health providers continue to be the leading source of health information. Therefore, provider recommendation for HPV vaccination and anal cancer screening among age-eligible foreign-born Latino HIV-infected GBM is critical. More work is needed to destigmatize HIV and sexual orientation to influence positive health behaviors among this population. Future intervention research could test the effects of provider-led interventions and also media campaigns aimed at influencing HPV vaccine uptake and anal cancer screening among this population.

HIV cascade of care in Greece: Useful insights from additional stages

Background

Aiming to eliminate HIV infection, UNAIDS has set a global “90-90-90” target by 2020. We sought to construct a 6-stages HIV Cascade of Care (CoC) in Greece, overall and by risk group, to assess risk-group and stage-specific progress in achieving the UNAIDS target.

Patients and methods

Combining data from the HIV/AIDS surveillance system and a population-based HIV cohort study, the CoC included: i) number of people living with HIV (PLHIV) by end of 2013; ii) proportion of PLHIV ever diagnosed; iii) proportion of diagnosed linked-to-care iv) proportion of linked-to-care ever initiating antiretroviral therapy (ART); v) proportion of treated who retained-in-care vi) proportion of those retained-in-care who were virally suppressed (≤200 copies/mL) at their last visit (01/07/2012-31/12/2013).

Results

In 2013, 14147 PLHIV were in Greece. Overall, proportions of each stage in the cascade were: 78.4% diagnosed; 86% linked-to-care; 78.5% initiated ART; 86.4% retained-in-care, and 87.1% virally suppressed. Totally, 42.6% of all PLHIV were virally suppressed. The percentage diagnosed was lower among heterosexual men and women (heterosexuals) than in MSM (men who have sex with men) or PWID (people who inject drugs). Most MSM were linked to care (97.2% of diagnosed) while a substantial proportion of PWID were not (80.8% of diagnosed). Once treated, PWID remained in care in similar proportions to MSM. Unlike PWID, a high proportion of the retained in care MSM and heterosexuals achieved viral suppression.

Conclusions

At the end of 2013, we identified gaps in the HIV CoC in Greece, which differed across risk groups. Targeted interventions are critical in optimizing early diagnosis and timely linkage. A 6-stage CoC, stratified by risk group, can inform strategic public health planning in improving HIV treatment outcomes.

Migrant patients living with HIV/AIDS in Japan: Review of factors associated with high dropout rate in a leading medical institution in Japan

The present study aimed to identify factors associated with retention in HIV/AIDS care among migrant patients who visited the outpatient clinic of the AIDS Clinical Center, National Center for Global Health and Medicine in Tokyo, Japan. We reviewed the records of 551 selected (78 non-Japanese and 473 Japanese) patients who started visiting our clinic between 2011 and 2014. A total of 390 patients (70.8%: 38 non-Japanese and 352 Japanese) continued their visits during the study: from the date of their first visit to the end of 2015. The difference in retention rate was not significant (Incidence Rate Ratio (IRR) = 0.89, p = 0.27), but the loss-to-follow-up cases were considerably high among non-Japanese patients (n = 13, Incidence rate (IR) = 24.6 per 100,000 person-days, IRR = 3.65, p<0.01 after adjusting for time since diagnosis). The results showed, nevertheless, that there was no apparent association between retention and factors peculiar to non-Japanese. Twelve out of thirteen lost-to-follow-up non-Japanese patients held legal status to reside in Japan and were eligible for public health services. Nine had limited fluency in Japanese language, and six used alternative verbal communication. Further studies are needed to identify the factors responsible for the high dropout rate and to improve the care of migrant patients living with HIV/AIDS.

Physical activity and sedentary behavior legislation in Canadian childcare facilities: an update

Background

Within the childcare sector, physical activity and sedentary behaviors are not legislated at a national level in Canada. Efforts have been undertaken to identify factors within childcare facilities which support and deter physical activity and sedentary behaviors. The purpose of this paper was to provide an amended review of the legislative landscape, at the provincial and territorial level, regarding physical activity and sedentary behaviors (via screen-viewing) in Canadian childcare centers.

Methods

Individual childcare acts and regulations for each province and territory were collected; documents were reviewed with a focus on sections devoted to child health, physical activity, screen time, play, and outdoor time. An extraction table was used to facilitate systematic data retrieval and comparisons across provinces and territories.

Results

Of the 13 provinces and territories, 8 (62%) have updated their childcare regulations in the past 5 years. All provinces provide general recommendations to afford gross motor movement; but the majority give no specific requirements for how much or at what intensity. Only 3 provinces (Northwest Territories, Nunavut, and Nova Scotia) explicitly mentioned daily physical activity while all provinces’ and territories’ required daily outdoor play. Only 1 province (New Brunswick) made mention of screen-viewing.

Conclusions

The variability in childcare regulations results in different physical activity requirements across the country. By providing high-level targets for physical activity recommendations, by way of provincial/territorial legislation, staff would have a baseline from which to begin supporting more active behaviors among the children in their care. Future research is needed to support translating physical activity policies into improved activity levels among young children in childcare and the role of screen-viewing in these venues.

Role of Country of Birth, Testing Site, and Neighborhood Characteristics on Nonlinkage to HIV Care Among Latinos

The objective of this study was to estimate disparities in linkage to human immunodeficiency virus (HIV) care among Latinos by country/region of birth, HIV testing site, and neighborhood characteristics. A retrospective study was conducted using Florida HIV surveillance records of Latinos/Hispanics aged ≥13 diagnosed during 2014-2015. Linkage to HIV care was defined as a laboratory test (HIV viral load or CD4) within 3 months of HIV diagnosis. Multi-level Poisson regression models were used to estimate adjusted prevalence ratios (aPR) for nonlinkage to care. Of 2659 Latinos, 18.8% were not linked to care within 3 months. Compared with Latinos born in mainland United States, those born in Cuba [aPR 0.60, 95% confidence interval (CI) 0.47-0.76] and Puerto Rico (aPR 0.61, 95% CI 0.41-0.90) had a decreased prevalence of nonlinkage. Latinos diagnosed at blood banks (aPR 2.34, 95% CI 1.75-3.12), HIV case management and screening facilities (aPR 1.76, 95% CI 1.46-2.14), and hospitals (aPR 1.42, 95% CI 1.03-1.96) had an increased prevalence of nonlinkage compared with outpatient general, infectious disease, and tuberculosis/sexually transmitted diseases/family planning clinics. Latinos who resided in the lowest (aPR 1.57, 95% CI 1.19-2.07) and third lowest (aPR 1.33, 95% CI 1.01-1.76) quartiles of neighborhood socioeconomic status compared with the highest quartile were at increased prevalence. Latinos who resided in neighborhoods with <25% Latinos also had increased prevalence of nonlinkage (aPR 1.23, 95% CI 1.01-1.51). Testing site at diagnosis may be an important determinant of HIV care linkage among Latinos due to neighborhood or individual-level resources that determine location of HIV testing.

Factors That Influence Linkages to HIV Continuum of Care Services: Implications for Multi-Level Interventions

Worldwide, the human immunodeficiency virus (HIV) continuum of care involves health promotion providers (e.g., social workers and health educators) linking patients to medical personnel who provide HIV testing, primary care, and antiretroviral treatments. Regrettably, these life-saving linkages are not always made consistently and many patients are not retained in care. To design, test and implement effective interventions, we need to first identify key factors that may improve linkage-making. To help close this gap, we used in-depth interviews with 20 providers selected from a sample of 250 participants in a mixed-method longitudinal study conducted in New York City (2012–2017) in order to examine the implementation of HIV services for at-risk populations. Following a sociomedical framework, we identified provider-, interpersonal- and environmental-level factors that influence how providers engage patients in the care continuum by linking them to HIV testing, HIV care, and other support services. These factors occurred in four domains of reference: Providers’ Professional Knowledge Base; Providers’ Interprofessional Collaboration; Providers’ Work-Related Changes; and Best Practices in a Competitive Environment. Of particular importance, our findings show that a competitive environment and a fear of losing patients to other agencies may inhibit providers from engaging in linkage-making. Our results suggest relationships between factors within and across all four domains; we recommend interventions to modify factors in all domains for maximum effect toward improving care continuum linkage-making. Our findings may be applicable in different areas of the globe with high HIV prevalence.