Alcohol and drug use severity are independently associated with antiretroviral adherence in the current treatment era

Substance use in people with HIV (PWH) negatively impacts antiretroviral therapy (ART) adherence. However, less is known about this in the current treatment era and the impact of specific substances or severity of substance use. We examined the associations of alcohol, marijuana, and illicit drug use (methamphetamine/crystal, cocaine/crack, illicit opioids/heroin) and their severity of use with adherence using multivariable linear regression in adult PWH in care between 2016 and 2020 at 8 sites across the US. PWH completed assessments of alcohol use severity (AUDIT-C), drug use severity (modified ASSIST), and ART adherence (visual analogue scale). Among 9400 PWH, 16% reported current hazardous alcohol use, 31% current marijuana use, and 15% current use of ≥1 illicit drugs. In multivariable analysis, current methamphetamine/crystal use, particularly common among men who had sex with men, was associated with 10.1% lower mean ART adherence (p < 0.001) and 2.6% lower adherence per 5-point higher severity of use (ASSIST score) (p < 0.001). Current and more severe use of alcohol, marijuana, and other illicit drugs were also associated with lower adherence in a dose-dependent manner. In the current HIV treatment era, individualized substance use treatment, especially for methamphetamine/crystal, and ART adherence should be prioritized.

Reducing no-show visits and disparities in access: The impact of telemedicine

BACKGROUND

No-show visits have serious consequences for patients, providers, and healthcare systems as they lead to delays in care, increased costs, and reduced access to services. Telemedicine has emerged as a promising alternative to in-person visits by reducing travel barriers, but risks exacerbating the digital divide. The aim of this study was to assess the impact of telemedicine (video and phone) at a tertiary care academic center on no-show visits compared to in-person visits.

METHODS

A retrospective cohort analysis of all weekday clinic visits among in-state adult patients at a single tertiary care center in the southeast from January 2020 to April 2023 was performed. Rates of no-show visits for patients who were seen via phone and video were compared with those who were seen in-person. Demographic and clinical characteristics of these groups were also compared, including age, sex, race/ethnicity, socioeconomic status, and visit type. The primary outcome was the rate of no-show visits for each visit type.

RESULTS

Our analysis included 3,105,382 scheduled appointments, of which 81.2% were in-person, 13.4% via video, and 5.4% via phone calls. Compared to in-person visits, phone calls and video visits reduced the odds of no-show visits by 50% (aOR 0.5, CI 0.49-0.51) and 15% (aOR 0.85, CI 0.84-0.86), respectively. Older patients, Black patients, patients furthest from clinic, and patients from counties with the greatest degree of vulnerability and disparities in digital access were more likely to use phone visits. No-shows were more common among non-white, male, and younger patients from counties with lower socioeconomic status.

CONCLUSION

Telemedicine effectively reduced no-show visits. However, limiting telemedicine to video-based visits only exacerbated disparities in access. Phone calls allow historically underserved patients from lower socioeconomic backgrounds to access healthcare and should be included within the definition of telemedicine.

"Just the Stigma Associated with PrEP Makes You Feel Like It's HIV Itself": Exploring PrEP Stigma, Skepticism, and Medical Mistrust Among Black Cisgender Women in Urban and Rural Counties in the U.S. Deep South

Despite its effectiveness in HIV prevention, PrEP use among Black women is suboptimal. Notably in the Deep South, Black women have the lowest PrEP uptake rates among all US regions. To increase PrEP engagement, research suggests the implementation of structural and social interventions particular to the needs of Black women. The state of Alabama is of priority to federal HIV prevention initiatives; therefore, this study conducted focus groups among 47 cis-gender Black women in rural and urban Alabama counties, with the highest statewide HIV incidence rates, to understand perceptions of PrEP and decision-making processes. Deductive coding analysis was conducted and themes were finalized based on consensus among the two coders. Four themes were identified. Findings show stigma undergirds Alabaman Black women's decisions to engage in PrEP care. Moreover, women reported stigma stifled community-level education about PrEP. Despite these experiences, education was regarded as a strategy to decrease stigma and PrEP skepticism, the latter of which emerged as a prominent theme. Medical mistrust and healthcare engagement were the other emergent themes influencing participation in PrEP care. To ensure PrEP efforts meet the needs of Black cisgender women in Alabama counties, interventions must address longstanding stigma, increase educational initiatives, and ensure interventions consider women's experiences with medical mistrust and health care engagement.

Multilevel Resilience and HIV Virologic Suppression Among African American/Black Adults in the Southeastern United States

OBJECTIVE

To assess overall and by neighborhood risk environments whether multilevel resilience resources were associated with HIV virologic suppression among African American/Black adults in the Southeastern United States.

SETTING AND METHODS

This clinical cohort sub-study included 436 African American/Black participants enrolled in two parent HIV clinical cohorts. Resilience was assessed using the Multilevel Resilience Resource Measure (MRM) for African American/Black adults living with HIV, where endorsement of a MRM statement indicated agreement that a resilience resource helped a participant continue HIV care despite challenges or was present in a participant's neighborhood. Modified Poisson regression models estimated adjusted prevalence ratios (aPRs) for virologic suppression as a function of categorical MRM scores, controlling for demographic, clinical, and behavioral characteristics at or prior to sub-study enrollment. We assessed for effect measure modification (EMM) by neighborhood risk environments.

RESULTS

Compared to participants with lesser endorsement of multilevel resilience resources, aPRs for virologic suppression among those with greater or moderate endorsement were 1.03 (95% confidence interval: 0.96-1.11) and 1.03 (0.96-1.11), respectively. Regarding multilevel resilience resource endorsement, there was no strong evidence for EMM by levels of neighborhood risk environments.

CONCLUSIONS

Modest positive associations between higher multilevel resilience resource endorsement and virologic suppression were at times most compatible with the data. However, null findings were also compatible. There was no strong evidence for EMM concerning multilevel resilience resource endorsement, which could have been due to random error. Prospective studies assessing EMM by levels of the neighborhood risk environment with larger sample sizes are needed.

A mixed methods evaluation assessing the feasibility of implementing a PrEP data dashboard in the Southeastern United States

BACKGROUND

Alabama is one of seven priority states for the National Ending the HIV Epidemic Initiative due to a disproportionate burden of rural infections. To reverse growing infection rates, the state must increase its focus on prevention efforts, including novel strategies. One such approach is to utilize dashboards that visualize real-time data on the pre-exposure prophylaxis (PrEP) care continuum to assist in prioritizing evidence-based preventative care for those most vulnerable for HIV infection.

METHODS

We conducted a mixed methods evaluation to ascertain stakeholders' perceptions on the acceptability, feasibility, appropriateness, and usability of a PrEP care continuum dashboard, as well as gain insight on ways to improve the activities necessary to sustain it. Clinicians, administrators, and data personnel from participating sites in Alabama completed surveys (n = 9) and participated in key informant interviews (n = 10) to better understand their experiences with the prototype data dashboard and to share feedback on how it can be modified to best fit their needs.

RESULTS

Surveys and interviews revealed that all participants find the pilot data dashboard to be an acceptable, feasible, and appropriate intervention for clinic use. Overall, stakeholders find the pilot dashboard to be usable and helpful in administrative efforts, such as report and grant writing; however, additional refining is needed in order to reduce burden and optimize usefulness. Participants voiced concerns about their site's abilities to sustain the dashboard, including the lack of systematized PrEP protocols and limited funds and staff time dedicated to PrEP data collection, cleaning, and upload.

CONCLUSION

Study participants from clinics providing HIV prevention services, including PrEP, in Alabama voiced interest in sustaining and refining a data dashboard that tracks clients across the PrEP care continuum. Despite viewing the platform itself as an acceptable, feasible, and appropriate intervention, participants agreed that efforts need to be focused on standardizing PrEP data collection protocols in order to ensure consistent, accurate data capture and that limited funds and staff time are barriers to the sustained implementation of the dashboard in practice.

Vaporized nicotine use among patients in HIV care who smoke tobacco: perceived health effects and effectiveness as a smoking cessation tool

Evidence suggests adverse health effects from vaporized nicotine (VN) use, such as electronic "e" cigarettes, and limited efficacy to aid tobacco cessation. People with HIV (PWH) smoke tobacco at higher rates than the general population, with greater morbidity, highlighting the necessity of effective tobacco cessation tools. PWH may be more vulnerable to adverse effects of VN. Using semi-structured 1:1 interviews, we examined health beliefs regarding VN, patterns of use, and perceived effectiveness for tobacco cessation among PWH in HIV care at three geographically diverse U.S. sites. PWH (n = 24) had limited understanding of VN product content or health effects, presuming VN less harmful than tobacco cigarettes (TC). VN failed to adequately replicate the psychoactive effects or desired ritual of smoking TC. Concurrent TC use, and continuous VN use throughout the day, was common. Satiety using VN was elusive, and consumption quantity was difficult to track. VN had limited desirability and durability as a TC cessation tool among the interviewed PWH.

Partnership status and retention in care among cisgender heterosexual newly diagnosed people with HIV: a cohort study

This study examined the role of partnership status (married, unmarried-partnered, and unpartnered) on retention in care among newly diagnosed (2013-2017), cisgender heterosexual people with HIV in Birmingham, Alabama (n = 152). This study evaluated all scheduled HIV primary care provider visits for two years following diagnosis date. A kept-visit measure was calculated such that, if an individual attended ≥1 visit in each of the four 6-month intervals, they were considered to have high visit constancy. A missed-visit measure was categorized as ≥1 no-show vs. 0 no-show for first and second year after diagnosis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression models. Models were adjusted for confounding sociodemographic and clinical characteristics. The study population was 76% Black, 57% male, median age of 37 years. Overall, 65% had high visit consistency and 34.5% had ≥1 no-show in both years. Compared to unpartnered, married individuals had higher visit constancy [AOR (95% CI): 2.88 (1.02, 8.16)]; no differences were observed among unmarried-partnered individuals. No differences in having ≥1 no-show among partnership status groups were observed for either year. These findings suggest potential success of interventions involving a social confidant in optimizing retention in care among newly diagnosed, heterosexual PWH.

Measuring continuity of care for diabetes: which visits to include?

OBJECTIVES

Continuity of care measures are widely used to evaluate the quality of health care delivery, but which visits are included vary across studies. Our objective was to determine how the provider specialties included affect continuity values, year-to-year stability, and association with emergency department (ED) visits.

STUDY DESIGN

Retrospective study of Alabama Medicaid administrative data.

METHODS

We included beneficiaries with diabetes who had at least 3 outpatient visits in each of 2018 and 2019 (N = 9578). We defined 3 provider groupings: all providers, diabetes-broad (primary care, cardiology, neurology, endocrinology, ophthalmology, nephrology, and psychiatry), and diabetes-narrow (primary care and endocrinology). Continuity of care was calculated using the Continuity of Care Index (COCI) for each provider grouping. We compared correlation between measures and from year to year using Spearman correlations, and we used multivariable logistic regression to determine association with ED visits.

RESULTS

The mean COCI was 0.54 using visits with all providers, 0.64 with diabetes-broad providers, and 0.83 with diabetes-narrow providers. COCI with diabetes-narrow providers was moderately correlated with the broader sets of providers (Spearman ρ, 0.52-0.65). Comparing each participant's COCI in 2018 with that in 2019, the mean intraperson difference was similar (0.16-0.22), and correlation was moderate (Spearman ρ, 0.41-0.47) for each measure. COCI had similar weak association with ED visits using each provider grouping (odds ratio, 0.99; 95% CI, 0.98-0.99 for each 0.1-unit difference in COCI).

CONCLUSIONS

Continuity values differed substantially depending on which provider specialties were included. The importance of this variation is uncertain, as continuity was weakly associated with ED visits using each of the measures.

The Brief Human Immunodeficiency Virus (HIV) Index: A Rapid 3-Item Scale to Measure Engagement in HIV Care

We created a brief version of The Index, a validated patient-reported measure that has potential to quickly identify patients at risk for poor retention. We analyzed Index scores from 2406 patients from 2016 to 2017 in a national cohort of patients in human immunodeficiency virus (HIV) care. Index scores predicted poor retention 12 months after administered.

Relationships Between Patient Race and Residential Race Context With Missed Human Immunodeficiency Virus Care Visits in the United States, 2010-2015

BACKGROUND

Racial inequities exist in retention in human immunodeficiency virus (HIV) care and multilevel analyses are needed to contextualize and address these differences. Leveraging data from a multisite clinical cohort of people with HIV (PWH), we assessed the relationships between patient race and residential characteristics with missed HIV care visits.

METHODS

Medical record and patient-reported outcome (PRO; including mental health and substance-use measures) data were drawn from 7 participating Center for AIDS Research Network of Integrated Clinical Systems (CNICS) sites including N = 20 807 PWH from January 2010 through December 2015. Generalized estimating equations were used to account for nesting within individuals and within census tracts in multivariable models assessing the relationship between race and missed HIV care visits, controlling for individual demographic and health characteristics and census tract characteristics.

RESULTS

Black PWH resided in more disadvantaged census tracts, on average. Black PWH residing in census tracts with higher proportion of Black residents were more likely to miss an HIV care visit. Non-Black PWH were less likely to miss a visit regardless of where they lived. These relationships were attenuated when PRO data were included.

CONCLUSIONS

Residential racial segregation and disadvantage may create inequities between Black PWH and non-Black PWH in retention in HIV care. Multilevel approaches are needed to retain PWH in HIV care, accounting for community, healthcare setting, and individual needs and resources.

Using Principles of an Adaptation Framework to Adapt a Transdiagnostic Psychotherapy for People With HIV to Improve Mental Health and HIV Treatment Engagement: Focus Groups and Formative Research Study

BACKGROUND

HIV treatment engagement is critical for people with HIV; however, behavioral health comorbidities and HIV-related stigma are key barriers to engagement. Treatments that address these barriers and can be readily implemented in HIV care settings are needed.

OBJECTIVE

We presented the process for adapting transdiagnostic cognitive behavioral psychotherapy, the Common Elements Treatment Approach (CETA), for people with HIV receiving HIV treatment at a Southern US HIV clinic. Behavioral health targets included posttraumatic stress, depression, anxiety, substance use, and safety concerns (eg, suicidality). The adaptation also included ways to address HIV-related stigma and a component based on Life-Steps, a brief cognitive behavioral intervention to support patient HIV treatment engagement.

METHODS

We applied principles of the Assessment, Decision, Administration, Production, Topical Experts, Integration, Training, Testing model, a framework for adapting evidence-based HIV interventions, and described our adaptation process, which included adapting the CETA manual based on expert input; conducting 3 focus groups, one with clinic social workers (n=3) and 2 with male (n=3) and female (n=4) patients to obtain stakeholder input for the adapted therapy; revising the manual according to this input; and training 2 counselors on the adapted protocol, including a workshop held over the internet followed by implementing the therapy with 3 clinic patients and receiving case-based consultation for them. For the focus groups, all clinic social workers were invited to participate, and patients were referred by clinic social workers if they were adults receiving services at the clinic and willing to provide written informed consent. Social worker focus group questions elicited reactions to the adapted therapy manual and content. Patient focus group questions elicited experiences with behavioral health conditions and HIV-related stigma and their impacts on HIV treatment engagement. Transcripts were reviewed by 3 team members to catalog participant commentary according to themes relevant to adapting CETA for people with HIV. Coauthors independently identified themes and met to discuss and reach a consensus on them.

RESULTS

We successfully used principles of the Assessment, Decision, Administration, Production, Topical Experts, Integration, Training, Testing framework to adapt CETA for people with HIV. The focus group with social workers indicated that the adapted therapy made conceptual sense and addressed common behavioral health concerns and practical and cognitive behavioral barriers to HIV treatment engagement. Key considerations for CETA for people with HIV obtained from social worker and patient focus groups were related to stigma, socioeconomic stress, and instability experienced by the clinic population and some patients' substance use, which can thwart the stability needed to engage in care.

CONCLUSIONS

The resulting brief, manualized therapy is designed to help patients build skills that promote HIV treatment engagement and reduce symptoms of common behavioral health conditions that are known to thwart HIV treatment engagement.

Development and implementation of a distributed data network between an academic institution and state health departments to investigate variation in time to HIV viral suppression in the Deep South

BACKGROUND

Achieving early and sustained viral suppression (VS) following diagnosis of HIV infection is critical to improving outcomes for persons with HIV (PWH). The Deep South of the United States (US) is a region that is disproportionately impacted by the domestic HIV epidemic. Time to VS, defined as time from diagnosis to initial VS, is substantially longer in the South than other regions of the US. We describe the development and implementation of a distributed data network between an academic institution and state health departments to investigate variation in time to VS in the Deep South.

METHODS

Representatives of state health departments, the Centers for Disease Control and Prevention (CDC), and the academic partner met to establish core objectives and procedures at the beginning of the project. Importantly, this project used the CDC-developed Enhanced HIV/AIDS Reporting System (eHARS) through a distributed data network model that maintained the confidentiality and integrity of the data. Software programs to build datasets and calculate time to VS were written by the academic partner and shared with each public health partner. To develop spatial elements of the eHARS data, health departments geocoded residential addresses of each newly diagnosed individual in eHARS between 2012-2019, supported by the academic partner. Health departments conducted all analyses within their own systems. Aggregate results were combined across states using meta-analysis techniques. Additionally, we created a synthetic eHARS data set for code development and testing.

RESULTS

The collaborative structure and distributed data network have allowed us to refine the study questions and analytic plans to conduct investigations into variation in time to VS for both research and public health practice. Additionally, a synthetic eHARS data set has been created and is publicly available for researchers and public health practitioners.

CONCLUSIONS

These efforts have leveraged the practice expertise and surveillance data within state health departments and the analytic and methodologic expertise of the academic partner. This study could serve as an illustrative example of effective collaboration between academic institutions and public health agencies and provides resources to facilitate future use of the US HIV surveillance system for research and public health practice.

A community health worker and mobile health app intervention to improve adherence to HIV medication among persons with HIV: the CHAMPS study protocol

BACKGROUND

Persons with HIV (PWH) can now achieve a near-normal life expectancy due to antiretroviral therapy (ART). Despite widespread availability of ART in the United States (US), many of the country's approximate 1.1 million PWH are not achieving viral suppression due to poor ART adherence. Viral suppression rates are particularly low in Alabama (AL, 62%) and New York City (NYC, 67%). There is mixed evidence on the efficacy of community health workers (CHW) and mHealth interventions for improving ART adherence and viral suppression in PWH thus, we sought to combine these interventions and test the efficacy for improving health outcomes in PWH.

METHODS

The CHAMPS study is a two-arm randomized controlled trial among 300 PWH with suboptimal primary care appointment adherence (n = 150 in AL and 150 in NYC) over the course of 12 months. Participants are randomly assigned to CHAMPS (intervention) or a standard-of-care (control) arm. Participants in the intervention arm are given a CleverCap pill bottle that syncs to the WiseApp to track medication adherence, reminds users to take their medication at a set time, and enables communication with CHW. All participants complete baseline, 6-month, and 12-month follow-up visits where surveys are administered and, CD4 and HIV-1 viral load are obtained through blood draw.

DISCUSSION

Maintaining ART adherence has significant implications in HIV management and transmission. mHealth technologies have been shown to optimize the provision of health services, produce positive changes in health behavior, and significantly improve health outcomes. CHW interventions also provide personal support to PWH. The combination of these strategies may provide the necessary intensity to increase ART adherence and clinic attendance among PWH at highest risk for low engagement. Delivering care remotely enables CHW to contact, assess, and support numerous participants throughout the day, reducing burden on CHW and potentially improving intervention durability for PWH. The adoption of the WiseApp coupled with community health worker sessions in the CHAMPS study has the potential to improve HIV health outcomes, and will add to the growing knowledge of mHealth and CHW efforts to improve PWH medication adherence and viral suppression.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov (NCT04562649) on 9/24/20.

Using publicly available data to identify priority communities for a SARS-CoV-2 testing intervention in a southern U.S. state

Background

The U.S. Southeast has a high burden of SARS-CoV-2 infections and COVID-19 disease. We used public data sources and community engagement to prioritize county selections for a precision population health intervention to promote a SARS-CoV-2 testing intervention in rural Alabama during October 2020 and March 2021.

Methods

We modeled factors associated with county-level SARS-CoV-2 percent positivity using covariates thought to associate with SARS-CoV-2 acquisition risk, disease severity, and risk mitigation practices. Descriptive epidemiologic data were presented to scientific and community advisory boards to prioritize counties for a testing intervention.

Results

In October 2020, SARS-CoV-2 percent positivity was not associated with any modeled factors. In March 2021, premature death rate (aRR 1.16, 95% CI 1.07, 1.25), percent Black residents (aRR 1.00, 95% CI 1.00, 1.01), preventable hospitalizations (aRR 1.03, 95% CI 1.00, 1.06), and proportion of smokers (aRR 0.231, 95% CI 0.10, 0.55) were associated with average SARS-CoV-2 percent positivity. We then ranked counties based on percent positivity, case fatality, case rates, and number of testing sites using individual variables and factor scores. Top ranking counties identified through factor analysis and univariate associations were provided to community partners who considered ongoing efforts and strength of community partnerships to promote testing to inform intervention.

Conclusions

The dynamic nature of SARS-CoV-2 proved challenging for a modelling approach to inform a precision population health intervention at the county level. Epidemiological data allowed for engagement of community stakeholders implementing testing. As data sources and analytic capacities expand, engaging communities in data interpretation is vital to address diseases locally.

Perspective: Acknowledging a Hierarchy of Social Needs in Diabetes Clinical Care and Prevention

The evidence of suboptimal social determinants of health (SDoH) on poor health outcomes has resulted in widespread calls for research to identify ways to measure and address social needs to improve health outcomes and reduce disparities. While assessing SDoH has become increasingly important in diabetes care and prevention research, little guidance has been offered on how to address suboptimal determinants in diabetes-related clinical care, prevention efforts, medical education and research. Not surprisingly, many patients experience multiple social needs - some that are more urgent (housing) than others (transportation/resources), therefore the order in which these needs are addressed needs to be considered in the context of diabetes care/outcomes. Here we discuss how conceptualizing diabetes related health through the lens of Maslow's hierarchy of needs has potential to help prioritize individual social needs that should be addressed to improve outcomes in the context of population-level determinants in the communities where people live.

Real-world integration of the protocol for responding to and assessing patients' assets, risks, and experiences tool to assess social determinants of health in the electronic medical record at an academic medical center

Objective

To describe the real-world deployment of a tool, the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), to assess social determinants of health (SDoH) in an electronic medical record (EMR).

Methods

We employed the collection of the PRAPARE tool in the EMR of a large academic health system in the ambulatory clinic and emergency department setting. After integration, we evaluated SDoH prevalence, levels of missingness, and data anomalies to inform ongoing collection. We summarized responses using descriptive statistics and hand-reviewed data text fields and patterns in the data. Data on patients who were administered with the PRAPARE from February to December 2020 were extracted from the EMR. Patients missing ≥ 12 PRAPARE questions were excluded. Social risks were screened using the PRAPARE. Information on demographics, admittance status, and health coverage were extracted from the EMR.

Results

Assessments with N = 6531 were completed (mean age 54 years, female (58.6%), 43.8% Black). Missingness ranged from 0.4% (race) to 20.8% (income). Approximately 6% of patients were homeless; 8% reported housing insecurity; 1.4% reported food needs; 14.6% had healthcare needs; 8.4% needed utility assistance; and 5% lacked transportation related to medical care. Emergency department patients reported significantly higher proportions of suboptimal SDoH.

Conclusions

Integrating the PRAPARE assessment in the EMR provides valuable information on SDoH amenable to intervention, and strategies are needed to increase accurate data collection and to improve the use of data in the clinical encounter.

Characterizing the neighborhood risk environment in multisite clinic-based cohort studies: A practical geocoding and data linkages protocol for protected health information

BACKGROUND

Maintaining patient privacy when geocoding and linking residential address information with neighborhood-level data can create challenges during research. Challenges may arise when study staff have limited training in geocoding and linking data, or when non-study staff with appropriate expertise have limited availability, are unfamiliar with a study's population or objectives, or are not affordable for the study team. Opportunities for data breaches may also arise when working with non-study staff who are not on-site. We detail a free, user-friendly protocol for constructing indices of the neighborhood risk environment during multisite, clinic-based cohort studies that rely on participants' protected health information. This protocol can be implemented by study staff who do not have prior training in Geographic Information Systems (GIS) and can help minimize the operational costs of integrating geographic data into public health projects.

METHODS

This protocol demonstrates how to: (1) securely geocode patients' residential addresses in a clinic setting and match geocoded addresses to census tracts using Geographic Information System software (Esri, Redlands, CA); (2) ascertain contextual variables of the risk environment from the American Community Survey and ArcGIS Business Analyst (Esri, Redlands, CA); (3) use geoidentifiers to link neighborhood risk data to census tracts containing geocoded addresses; and (4) assign randomly generated identifiers to census tracts and strip census tracts of their geoidentifiers to maintain patient confidentiality.

RESULTS

Completion of this protocol generates three neighborhood risk indices (i.e., Neighborhood Disadvantage Index, Murder Rate Index, and Assault Rate Index) for patients' coded census tract locations.

CONCLUSIONS

This protocol can be used by research personnel without prior GIS experience to easily create objective indices of the neighborhood risk environment while upholding patient confidentiality. Future studies can adapt this protocol to fit their specific patient populations and analytic objectives.

Adapting an Interdisciplinary Learning Health System Framework for Academic Health Centers: A Scoping Review

PURPOSE

Learning health systems (LHSs), defined as a systematic process for aligning science, informatics, and clinical practice to integrate providers, researchers, and patients as active participants in an evidence-based care continuum, can provide an ideal environment for academic health centers to rapidly adopt evidence-based guidelines and translate research into practice. However, few LHS frameworks are specifically adapted for academic health centers. The authors wanted to identify the definitions, components, and other features of LHSs to develop an interdisciplinary LHS framework for use within academic health centers.

METHOD

The authors conducted a scoping review of the literature to identify definitions, components, and other features of LHSs that are useful to academic health centers. In January 2021, they searched PubMed, Academic Search Premier, and Scopus databases and identified English-language, peer-reviewed articles pertaining to LHS, LHS frameworks, organization, components, and models. Since the phrase learning health system is relatively new terminology, they conducted a supplemental review with alternative phrases, including embedded research and coordinated or collaborative research network . They used the Knowledge to Action (KTA) Framework to integrate the generation and flow of research into practice.

RESULTS

The primary review retrieved 719 articles and the supplemental review retrieved 209; of these, 49 articles were retained to synthesize common definitions, components, and other features of LHS frameworks. Seven structural components of LHSs were identified: organization and collaborations, performance, ethics and security, scientific approaches, data, information technology, and patient outcomes. An adapted interdisciplinary LHS framework was developed that incorporated research and learning engines derived from the KTA and adaptations of common components and other features within the reviewed articles to fit the interests of providers, researchers, and patients within academic health centers.

CONCLUSIONS

The adapted LHS framework can be used as a dynamic foundation for development and organization of interdisciplinary LHSs within academic health centers.

COVID Community-Engaged Testing in Alabama: Reaching Underserved Rural Populations Through Collaboration

Rural communities are often underserved by public health testing initiatives in Alabama. As part of the National Institutes of Health's Rapid Acceleration of Diagnostics‒Underserved Populations initiative, the University of Alabama at Birmingham, along with community partners, sought to address this inequity in COVID-19 testing. We describe the participatory assessment, selection, and implementation phases of this project, which administered more than 23 000 COVID-19 tests throughout the state, including nearly 4000 tests among incarcerated populations. (Am J Public Health. 2022;112(10):1399-1403. https://doi.org/10.2105/AJPH.2022.306985).

Multicenter Development and Validation of a Model for Predicting Retention in Care Among People with HIV

Predictive analytics can be used to identify people with HIV currently retained in care who are at risk for future disengagement from care, allowing for prioritization of retention interventions. We utilized machine learning methods to develop predictive models of retention in care, defined as no more than a 12 month gap between HIV care appointments in the Center for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort. Data were split longitudinally into derivation and validation cohorts. We created logistic regression (LR), random forest (RF), and gradient boosted machine (XGB) models within a discrete-time survival analysis framework and compared their performance to a baseline model that included only demographics, viral suppression, and retention history. 21,267 Patients with 507,687 visits from 2007 to 2018 were included. The LR model outperformed the baseline model (AUC 0.68 [0.67-0.70] vs. 0.60 [0.59-0.62], P < 0.001). RF and XGB models had similar performance to the LR model. Top features in the LR model included retention history, age, and viral suppression.

Expanding access to substance use services and mental health care for people with HIV in Alabama, a technology readiness assessment using a mixed methods approach

BACKGROUND

Alabama is one of seven priority states for the National Ending the HIV Epidemic Initiative due to a large rural burden of disease. Mental health (MH) and substance use disorders (SUD) represent obstacles to HIV care in rural areas lacking Medicaid expansion and infrastructure. Evidence-informed technologies, such as telehealth, may enhance SUD and MH services but remain understudied in rural regions.

METHODS

We conducted a readiness assessment using a mixed methods approach to explore opportunities for enhanced SUD and MH screening using electronic patient reported outcomes (ePROs) and telehealth at five Ryan White HIV/AIDS Program-funded clinics in AL. Clinic providers and staff from each site (N = 16) completed the Organizational Readiness to Implement Change (ORIC) assessment and interviews regarding existing services and readiness to change. People with HIV from each site (PLH, N = 18) completed surveys on the acceptability and accessibility of technology for healthcare.

RESULTS

Surveys and interviews revealed that all clinics screen for depression annually by use of the Patient Health Questionnaire-9 (PHQ9). SUD screening is less frequent and unstandardized. Telehealth is available at all sites, with three of the five sites beginning services due to the COVID-19 pandemic; however, telehealth for MH and SUD services is not standardized across sites. Results demonstrate an overall readiness to adopt standardized screenings and expand telehealth services beyond HIV services at clinics. There were several concerns including Wi-Fi access, staff capacity, and patients' technological literacy. A sample of 18 people with HIV (PWH), ages 18 to 65 years, participated in surveys; all demonstrated adequate technology literacy. A majority had accessed telehealth and were not concerned about it being too complicated or limiting communication. There were some concerns around lack of in-person interaction and lack of a physical exam and high-quality care with telehealth.

CONCLUSION

This study of PWH and the clinics that serve them reveals opportunities to expand SUD and MH services in rural regions using technology. Areas for improvement include implementing routine SUD screening, expanding telehealth while maintaining opportunities for in-person interaction, and using standardized ePROs that are completed by patients, in order to minimize stigma and bias.

Adapting a Motivational Interviewing Intervention to Improve HIV Prevention Among Young, Black, Sexual Minority Men in Alabama: Protocol for the Development of the Kings Digital Health Intervention

BACKGROUND

African American or Black young men who have sex with men (BYMSM) are at a disproportionate risk for contracting HIV and have high rates of undiagnosed, and therefore untreated, HIV infection. In the southern United States, BYMSM face region-specific hurdles to HIV prevention, such as limited access to care and high levels of racism and intersectional stigma, necessitating HIV testing and pre-exposure prophylaxis interventions that address sociocultural and structural barriers while motivating BYMSM to engage in prevention. Brothers Saving Brothers (BSB) is a motivational interviewing behavioral intervention that successfully and simultaneously increased community-based HIV testing and prevention counseling and education among BYMSM in the midwestern United States.

OBJECTIVE

The aim of this protocol is to detail the process for the adaption of the BSB intervention for midwestern BYMSM to the Kings intervention for southern BYMSM. During the adaptation process, the intervention will be modernized to include rapid HIV testing, as opposed to HIV testing that requires BYMSM to return for test results, pre-exposure prophylaxis, and the provision of structural supports, and for relevance in the southern United States.

METHODS

Aim 1 is to gather qualitative data through focus groups and in-depth interviews with BYMSM aged 18 to 29 years in Alabama and in-depth interviews with prevention and outreach workers who routinely work with BYMSM in Alabama. NVivo qualitative software (QSR International) will be used for the coding and analysis of the transcripts via a thematic analysis approach. For aim 2, intervention mapping will guide the adaptation process, intervention content, components, and design. Both aims 1 and 2 will leverage the Exploration, Preparation, Implementation, Sustainment implementation science framework, with emphasis on the exploration and preparation phases of this model. By applying these frameworks, the original midwestern BSB intervention will be scientifically adapted to the southern BYMSM Kings intervention.

RESULTS

This study is ongoing as of 2022 and is expected to conclude in 2024, with aims 1 and 2 being completed in 2023. Qualitative data will offer insight into the current real-world experiences and preferences of BYMSM in Alabama. Feedback will be collected through the adaptation process to inform intervention refinement. Institutional review board approvals have been received.

CONCLUSIONS

The findings will inform next steps, that is, testing the Kings intervention for feasibility, acceptability, and preliminary effectiveness in a pilot hybrid type 1 effective-implementation randomized controlled trial. The study results will provide insights about important considerations for HIV prevention among BYMSM in the southern United States.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03680729; https://clinicaltrials.gov/ct2/show/NCT03680729.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/36655.

Development of Long and Short Forms of the Multilevel Resilience Resource Measure for African American/Black Adults Living with HIV

Understanding resilience in relation to HIV-related outcomes may help address racial/ethnic disparities, however, significant gaps in its measurement preclude in-depth study. Thus, this research aims to develop and evaluate the psychometric properties of long and short forms of the Multilevel Resilience Resource Measure for African American/Black Adults Living with HIV. To develop the items, we conducted a mixed methods study (N = 48) and reviewed published resilience measures. We completed content validity index analyses to ensure the items reflected the resilience construct. Next, we conducted 20 cognitive interviews and a field survey (N = 400). The long and short forms demonstrated acceptable to excellent psychometric properties based on factorial validity, internal consistency and convergent validity and on measurement invariance (conducted for the short form only). These measures provide a comprehensive framework to examine resilience and HIV-related outcomes and can inform resilience-building interventions to reduce racial and ethnic health disparities.

Brief Report: Insomnia and Risk of Myocardial Infarction Among People With HIV

BACKGROUND

Insomnia is common among people with HIV (PWH) and may be associated with increased risk of myocardial infarction (MI). This study examines the association between insomnia and MI by MI type among PWH.

SETTING

Longitudinal cohort study of PWH at 5 Centers for AIDS Research Network of Integrated Clinical Systems sites.

METHODS

Clinical data and patient-reported measures and outcomes from PWH in care between 2005 and 2018 were used in this study. Insomnia, measured at baseline, was defined as having difficulty falling or staying asleep with bothersome symptoms. The Centers for AIDS Research Network of Integrated Clinical Systems centrally adjudicates MIs using expert reviewers, with distinction between type 1 MI (T1MI) and type 2 MI (T2MI). Associations between insomnia and first incident MI by MI type were measured using separate Cox proportional hazard models adjusted for age, sex, race/ethnicity, traditional cardiovascular disease risk factors (hypertension, dyslipidemia, poor kidney function, diabetes, and smoking), HIV markers (antiretroviral therapy, viral suppression, and CD4 cell count), and stimulant use (cocaine/crack and methamphetamine).

RESULTS

Among 12,448 PWH, 48% reported insomnia. Over a median of 4.4 years of follow-up, 158 T1MIs and 109 T2MIs were identified; approximately half of T2MIs were attributed to sepsis or stimulant use. After adjustment for potential confounders, we found no association between insomnia and T1MI (hazard ratio = 1.05, 95% confidence interval: 0.76 to 1.45) and a 65% increased risk of T2MI among PWH reporting insomnia compared with PWH without insomnia (hazard ratio = 1.65, 95% confidence interval: 1.11 to 2.45).

CONCLUSIONS

PWH reporting insomnia are at an increased risk of T2MI, but not T1MI, compared with PWH without insomnia, highlighting the importance of distinguishing MI types among PWH.

PrEP service delivery preferences of black Cis-gender women living in the Southern United States

To assess PrEP service delivery preferences among Black cis-gender women living in urban and rural settings in Alabama, we conducted a cross-sectional discrete choice experiment survey. Discrete choice experiments included five attributes. Hierarchical Bayes (HB) modeling and latent class analyses (LCA) were used to evaluate attribute preferences. Among 795 Black cis-gender HIV-negative women, almost two-thirds lived in urban settings and reported having at least some college; about a third reported a household income less than $25,000 annually; and reported willingness to use PrEP. Respondents placed the greatest importance on PrEP medication formulation and healthcare facility. LCA showed the group with the highest rural proportion preferred for on-line visits. Black women in the Deep South had distinct preferences regarding PrEP service delivery. These findings can inform tailored interventions to improve PrEP uptake among Black cis-gender women across diverse settings in the South.

Partnership status and time to viral suppression and sustained viral suppression among newly diagnosed heterosexual people with HIV

BACKGROUND

Previous studies examining the role of partnership on HIV care outcomes have primarily focused on the men who have sex with men population in the United States, leaving a gap in the literature on this phenomenon among the heterosexual persons with HIV (PWH). This study examined association between partnership around diagnosis (married, unmarried-partnered, and un-partnered) with time to viral suppression (TVS) and sustained viral suppression (SVS) in newly diagnosed heterosexual PWH from a HIV clinic in Birmingham, Alabama.

METHODS

TVS [time to first viral load (VL) <200 copies/ml] was measured using VLs from 12 months following diagnosis using Kaplan-Meier and proportional hazard model for interval censoring (n=153) to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). SVS was measured using VLs for 12 months after first VS using logistic regression model (n=137) to calculate odds ratios (ORs) and 95% CIs. Models were adjusted for confounding demographics and clinical characteristics.

RESULTS

The study population comprised of 77% Black, 57% male, and 46% aged 31-49 years; 24% were married, 35% unmarried-partnered, and 41% un-partnered. The median TVS (days) was 57 for married, 73 for unmarried-partnered, and 75 for un-partnered. Compared to un-partnered individuals, unmarried-partnered had similar, whereas married had 69% higher [HR (95% CI): 1.69 (1.02, 2.78)] hazard of TVS. Compared to un-partnered, unmarried-partnered and married individuals had similar odds of achieving SVS.

CONCLUSION

Married, newly diagnosed, heterosexual PWH had faster TVS than un-partnered individuals suggesting that intimate partners may help achieve HIV care goals.

Decreased Alcohol Consumption in an Implementation Study of Computerized Brief Intervention among HIV Patients in Clinical Care

This prospective, nonrandomized implementation study evaluated a computerized brief intervention (CBI) for persons with HIV (PWH) and heavy/hazardous alcohol use. CBI was integrated into two HIV primary care clinics. Eligible patients were engaged in care, ≥ 18 years old, English speaking, endorsed heavy/hazardous alcohol use on the Alcohol Use Disorders Identification Test-C (AUDIT-C). Two 20-min computerized sessions using cognitive behavioral techniques were delivered by a 3-D avatar on touch screen tablets. Of 816 eligible AUDIT-C scores, 537 (66%) resulted in CBI invitation, 226 (42%) of invited patients enrolled, and 176 (78%) of enrolled patients watched at least one session. CBI enrollment was associated with a significant average reduction of 9.1 drinks/week (95% CI - 14.5, - 3.6) 4-12 months post-enrollment. Among those who participated in one or both sessions, average reduction in drinks/week was 11.7 drinks/week (95% CI - 18.8, - 4.6). There was corresponding improvement in AUDIT-C scores. Overall patients reported high levels of intervention satisfaction, particularly among older and Black patients. These promising results point to a practical intervention for alcohol reduction in this vulnerable patient population with elevated rates of heavy/hazardous drinking. Future research should examine strategies to increase initial engagement, strengthen intervention effects to increase the number of patients who achieve non-hazardous drinking, and examine the duration of therapeutic effects.

Drug and alcohol use among people living with HIV in care in the United States by geographic region

Substance use in the U.S. varies by geographic region. Opioid prescribing practices and marijuana, heroin, and methamphetamine availability are evolving differently across regions. We examined self-reported substance use among people living with HIV (PLWH) in care at seven sites from 2017-2019 to understand current regional substance use patterns. We calculated the percentage and standardized percentage of PLWH reporting current drug use and at-risk and binge alcohol use by U.S. Census Bureau geographic region and examined associations in adjusted logistic regression analyses. Among 7,686 PLWH, marijuana use was the most prevalent drug (30%), followed by methamphetamine/crystal (8%), cocaine/crack (7%), and illicit opioids (3%). One-third reported binge alcohol use (32%). Differences in percent of current use by region were seen for marijuana (24-41%) and methamphetamine/crystal (2-15%), with more use in the West and Northeast, and binge alcohol use (26-40%). In adjusted analyses, PLWH in the Midwest were significantly less likely to use methamphetamine/crystal (aOR: 0.13;0.06-0.25) or illicit opioids (aOR:0.16;0.05-0.53), and PLWH in the Northeast were more likely to use cocaine/crack (aOR:1.59;1.16-2.17), compared to PLWH in the West. Understanding differences in substance use patterns in the current era, as policies continue to evolve, will enable more targeted interventions in clinical settings among PLWH.

The University of Alabama at Birmingham COVID-19 Collaborative Outcomes Research Enterprise: Developing an institutional learning health system in response to the global pandemic

Introduction

As a local response to the COVID‐19 global pandemic, the University of Alabama at Birmingham (UAB) established the UAB COVID‐19 Collaborative Outcomes Research Enterprise (CORE), an institutional learning health system (LHS) to achieve an integrated health services outcomes and research response.

Methods

We developed a network of expertise and capabilities to rapidly develop and deploy an institutional‐level interdisciplinary LHS. Based upon a scoping review of the literature and the Knowledge to Action Framework, we adopted a LHS framework identifying contributors and components necessary to developing a system within and between the university academic and medical centers. We used social network analysis to examine the emergence of informal work patterns and diversified network capabilities based on the LHS framework.

Results

This experience report details three principal characteristics of the UAB COVID‐19 CORE LHS development: (a) identifying network contributors and components; (b) building the institutional network; and (c) diversifying network capabilities. Contributors and committees were identified from seven components of LHS: (a) collaborative and executive leadership committee, (b) research coordinating committee, (c) oversight and ethics committee, (d) thematic scientific working groups, (e) programmatic working groups, (f) informatics capabilities, and (g) patient advisory groups. Evolving from the topical interests of the initial CORE participants, scientific working groups emerged to support the learning system network. Programmatic working groups were charged with developing a comprehensive and mutually accessible COVID‐19 database.

Discussion

Our LHS framework allowed for effective integration of multiple academic and medical centers into a cohesive institutional‐level learning system. Network analysis indicated diversity of institutional disciplines, professional rank, and topical focus pertaining to COVID‐19, with each center leveraging existing institutional responsibilities to minimize gaps in network capabilities.

Conclusion

Incorporating an adapted LHS framework designed for academic medical centers served as a foundational resource supporting further institutional‐level efforts to develop agile and responsive learning networks.

Correlates of psychological intimate partner violence with HIV care outcomes on patients in HIV care

Background

Among people living with HIV (PLWH), physical intimate partner violence (IPV) is associated with poor virologic, psychiatric, and behavioral outcomes. We examined non-physical, psychological intimate partner violence (psy-IPV) and HIV care outcomes using data from two U.S. consortia.

Methods

We conducted multivariable analyses with robust standard errors to compare patients indicating/not indicating psy-IPV.

Results

Among PLWH (n = 5950), 9.5% indicated psy-IPV; these individuals were younger (− 3; 95% CI [− 2,-4], p-value < 0.001), less likely to be on antiretroviral treatment (ART) (0.73 [0.55,0.97], p = 0.03), less adherent to ART (− 4.2 [− 5.9,-2.4], p < 0.001), had higher odds of detectable viral load (1.43 [1.15,1.78], p = 0.001) and depression (2.63 [2.18,3.18], p < 0.001), and greater use of methamphetamines/crystal [2.98 (2.30,3.87),p < 0.001], cocaine/crack [1.57 (1.24,1.99),p < 0.001], illicit opioids [1.56 (1.13,2.16),p = 0.007], and marijuana [1.40 (1.15,1.70), p < 0.001].

Conclusion

Psychological IPV, even in the absence of physical or sexual IPV, appears to be associated with HIV care outcomes and should be included in IPV measures integrated into routine HIV care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11854-x.

The Human Immunodeficiency Virus (HIV) Index: Using a Patient-Reported Outcome on Engagement in HIV Care to Explain Suboptimal Retention in Care and Virologic Control

BACKGROUND

We investigated the prospective association between a brief self-report measure of engagement in human immunodeficiency virus (HIV) care (the Index of Engagement in HIV Care; hereafter "Index") and suboptimal retention and viral suppression outcomes.

METHODS

The Centers for AIDS Research Network of Integrated Clinical Systems cohort study combines medical record data with patient-reported outcomes from 8 HIV clinics in the United States, which from April 2016 to March 2017 included the 10-item Index. Multivariable logistic regression was used to estimate the risk and odds ratios of mean Index scores on 2 outcomes in the subsequent year: (1) not keeping ≥75% of scheduled HIV care appointments; and (2) for those with viral suppression at Index assessment, having viral load >200 copies/mL on ≥1 measurement. We also used generalized linear mixed models (GLMMs) to estimate the risk and odds ratios of appointment nonattendance or unsuppressed viral load at any given observation. We generated receiver operating characteristic curves for the full models overlaid with the Index as a sole predictor.

RESULTS

The mean Index score was 4.5 (standard deviation, 0.6). Higher Index scores were associated with lower relative risk of suboptimal retention (n = 2576; logistic regression adjusted risk ratio [aRR], 0.88 [95% confidence interval, .87-.88]; GLMM aRR, 0.85 [.83-.87]) and lack of sustained viral suppression (n = 2499; logistic regression aRR, 0.75 [.68-.83]; GLMM aRR, 0.74 [.68-.80]). The areas under the receiver operating characteristic curve for the full models were 0.69 (95% confidence interval, .67-.71) for suboptimal retention and 0.76 (.72-.79) for lack of sustained viral suppression.

CONCLUSIONS

Index scores are significantly associated with suboptimal retention and viral suppression outcomes.

Practice Transformation in HIV Primary Care: Perspectives of Coaches and Champions in the Southeast United States

INTRODUCTION/OBJECTIVES

Across the United States, and particularly in the South, there is an urgent need to improve health outcomes for people with HIV. In response, the Southeast AIDS Education & Training Center (AETC) conducted a 4-year Practice Transformation (PT) initiative (2015-2018) in 12 mostly primary care clinics across 4 states in the region. Drawing on the leadership of PT facilitators ("coaches") from AETC partner sites throughout the region and specific clinic staff members ("champions"), clinics worked toward self-selected organizational goals to increase their HIV care capacity and improve HIV health outcomes.

METHODS

To explore coaches' and champions' experiences and perspectives of PT, we conducted 2 focus group sessions, 1 tailored for coaches (n = 5) and another for champions (n = 9).

RESULTS

Content analysis of qualitative data revealed 4 major themes around coaches' and champions' experiences and perspectives of PT. These themes include Challenges, Facilitators, Successes, and Suggestions for PT Improvement.

CONCLUSION

Primary care and infectious diseases/HIV clinics can help improve HIV Care Continuum outcomes through increasing their capacity to serve the needs of their clients, as facilitated through coaches and clinic champions. Since no single clinic or clinic patient population is alike, it is important work within organizations to address specific needs and leverage unique skillsets. Future PT initiatives can learn from experiences of this PT program to optimize the effectiveness of their programs.

A critical analysis of COVID-19 research literature: Text mining approach

OBJECTIVE

Among the stakeholders of COVID-19 research, clinicians particularly experience difficulty keeping up with the deluge of SARS-CoV-2 literature while performing their much needed clinical duties. By revealing major topics, this study proposes a text-mining approach as an alternative to navigating large volumes of COVID-19 literature.

MATERIALS AND METHODS

We obtained 85,268 references from the NIH COVID-19 Portfolio as of November 21. After the exclusion based on inadequate abstracts, 65,262 articles remained in the final corpus. We utilized natural language processing to curate and generate the term list. We applied topic modeling analyses and multiple correspondence analyses to reveal the major topics and the associations among topics, journal countries, and publication sources.

RESULTS

In our text mining analyses of NIH's COVID-19 Portfolio, we discovered two sets of eleven major research topics by analyzing abstracts and titles of the articles separately. The eleven major areas of COVID-19 research based on abstracts included the following topics: 1) Public Health, 2) Patient Care & Outcomes, 3) Epidemiologic Modeling, 4) Diagnosis and Complications, 5) Mechanism of Disease, 6) Health System Response, 7) Pandemic Control, 8) Protection/Prevention, 9) Mental/Behavioral Health, 10) Detection/Testing, 11) Treatment Options. Further analyses revealed that five (2,3,4,5, and 9) of the eleven abstract-based topics showed a significant correlation (ranked from moderate to weak) with title-based topics.

CONCLUSION

By offering up the more dynamic, scalable, and responsive categorization of published literature, our study provides valuable insights to the stakeholders of COVID-19 research, particularly clinicians.

Longitudinal Associations of Syndemic Conditions with Antiretroviral Therapy Adherence and HIV Viral Suppression Among HIV-Infected Patients in Primary Care

Psychosocial syndemic conditions have received more attention regarding their deleterious effects on HIV acquisition risk than for their potential impact on HIV treatment and viral suppression. To examine syndemic conditions' impact on the HIV care continuum, we analyzed data collected from people living with HIV (N = 14,261) receiving care through The Centers for AIDS Research Network of Integrated Clinical Systems at seven sites from 2007 to 2017 who provided patient-reported outcomes ∼4-6 months apart. Syndemic condition count (depression, anxiety, substance use, and hazardous drinking), sexual risk group, and time in care were modeled to predict antiretroviral therapy (ART) adherence and viral suppression (HIV RNA <400 copies/mL) using multilevel logistic regression. Comparing patients with each other, odds of ART adherence were 61.6% lower per between-patient syndemic condition [adjusted odds ratio (AOR) = 0.384; 95% confidence interval (CI), 0.362-0.408]; comparing patients with themselves, odds of ART adherence were 36.4% lower per within-patient syndemic condition (AOR = 0.636 95% CI, 0.606-0.667). Odds of viral suppression were 29.3% lower per between-patient syndemic condition (AOR = 0.707; 95% CI, 0.644-0.778) and 27.7% lower per within-patient syndemic condition (AOR = 0.723; 95% CI, 0.671-0.780). Controlling for the effects of adherence (AOR = 5.522; 95% CI, 4.67-6.53), each additional clinic visit was associated with 1.296 times higher odds of viral suppression (AOR = 1.296; 95% CI, 1.22-1.38), but syndemic conditions were not significant. Deploying effective interventions within clinics to identify and treat syndemic conditions and bolster ART adherence and continued engagement in care can help control the HIV epidemic, even within academic medical settings in the era of increasingly potent ART.

Prevalence of and Factors Associated With Genital and Extragenital Chlamydia and Gonorrhea Among Transgender Women in HIV Care in the United States, 2005 to 2016

BACKGROUND

Data on testing rates and prevalence of and factors associated with genital and extragenital chlamydia and gonorrhea among transgender women with HIV in the United States are limited.

METHODS

This retrospective cohort analysis included transgender women living with HIV enrolled in the US Centers for AIDS Research Network of Integrated Clinical Systems cohort between January 2005 and December 2016 with chlamydia or gonorrhea testing performed in HIV clinic. The primary outcome was a positive test result for chlamydia or gonorrhea at urogenital or extragenital (rectal/pharyngeal) sites. Factors associated with infection were examined using logistic regression and generalized estimating equations to account for multiple tests per woman.

RESULTS

Among 312 transgender women in HIV care, 252 (81%) were tested for chlamydia or gonorrhea at least once. Annual testing rates were low: 23% to 53% at genital sites and 24% to 47% at extragenital sites. A total of 88 infections were detected, and 22% of women (55/252) had at least one positive test result. Most infections occurred at extragenital sites (80% of chlamydia and 82% of gonorrhea positive test results). Factors associated with infection in an adjusted model were as follows: age 18 to 29 years compared with ≥50 years (adjusted odds ratio [aOR], 7.6; 95% confidence interval [CI], 1.8-31.2), CD4 count >350 compared with CD4 <200 (aOR, 5.5; 95% CI, 1.2-25.1), and higher engagement in HIV care (aOR, 2.2; 95% CI, 1.0-4.5).

CONCLUSIONS

Among transgender women living with HIV, testing rates for chlamydia and gonorrhea are inadequate, particularly at extragenital sites where most infections occur.

Missed Prevention Opportunities: Why Young, Black MSM with Recent HIV Diagnosis did not Access HIV Pre-exposure Prophylaxis Services

In the United States, HIV infection rate inequities persist, with new infections highest among young, Black men who have sex with men (YBMSM) in the South. We conducted 23 in-depth interviews with YBMSM newly diagnosed with HIV to explore awareness of and barriers to uptake of HIV pre-exposure prophylaxis (PrEP). Participants were recruited from two university-based HIV Clinics in Alabama and were: (1) 16-29 years of age, (2) diagnosed with HIV within the prior 365 days, (3) Black race, (4) self-identified as a cis-gender male reporting sex with men AND (5) did not report prior PrEP use. Interview guides were grounded in Anderson's Behavioral Healthcare Utilization Model (ABM), with embedded constructs from the situated Information, Motivation and Behavioral Skills theoretical framework. Coding was conducted by three independent coders using thematic analysis methods. Participants (N = 23) median age was 24, more than two-thirds reported annual incomes less than $15,000 and the majority (84%) identified as gay. Major themes that emerged as barriers to accessing PrEP included low prioritization and interests in using PrEP; low perceived HIV risk due to feelings of invincibility and trust in sex partners; lack of information about accessing PrEP; negative beliefs around PrEP; and the suggestion to change PrEP messaging from only targeting YBMSM. These findings indicate that there are important missed opportunities for HIV prevention with PrEP among YBMSM in the South. In these high-risk young men, tailored interventions are needed to better inform and frame perceptions around risk, knowledge, access and prioritization of PrEP.

Internalized HIV Stigma Predicts Suboptimal Retention in Care Among People Living with HIV in the United States

HIV-related stigma is a known barrier to retention in care. However, no large-scale, multi-site studies have prospectively evaluated the effect of internalized stigma on retention in care. The Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort study integrates medical record and survey data from people living with HIV (PLWH) seen in HIV primary care clinics across the United States, and assesses internalized stigma yearly using a validated 4-item Likert scale. We used multivariable logistic regression models to evaluate associations between mean internalized stigma and two prospective retention in care outcomes: keeping the next primary care appointment and keeping all scheduled primary care appointments in the 12 months following stigma assessment. From February 2016 to November 2017, 5968 PLWH completed the stigma assessment and had adequate follow-up time. Mean stigma was 1.9 (standard deviation 1.08). Increased mean stigma scores were associated with decreased odds of attending the next primary care appointment [adjusted odds ratio (aOR) = 0.93, 95% confidence interval (CI) 0.88-0.99, p = 0.02], and all primary care appointments in the subsequent 12 months (aOR = 0.94, 95% CI 0.89-0.99, p = 0.02). In both models, younger age and Black race were also independently associated with suboptimal appointment attendance. There was no support for interactions between internalized stigma and covariates. Internalized HIV stigma had an independent negative effect on the odds of subsequent appointment attendance. This study highlights the importance of identifying even low levels of internalized stigma. Interventions to address internalized HIV stigma are critical to supporting retention in care and improving clinical outcomes.

Intersecting Epidemics: Incident Syphilis and Drug Use in Women Living With Human Immunodeficiency Virus in the United States (2005-2016)

BACKGROUND

Rates of early syphilis in US women are steadily increasing, but predictors of infection in this group are not clearly defined.

METHODS

This retrospective analysis focused on women enrolled in the US CFAR Network of Integrated Clinical Systems cohort between January 2005 and December 2016 with syphilis testing performed. The primary outcome of incident syphilis infection was defined serologically as a newly positive test with positive confirmatory testing after a negative test or a 2-dilution increase in rapid plasma regain titer. Infection rates were calculated for each woman-year in care with testing. Predictors of syphilis were sought among sociodemographics, clinical information, and self-reported behaviors. Multivariable logistic regression models were created; a subgroup analysis assessed predictors in women of reproductive age.

RESULTS

The annual rate of incident syphilis among 4416 women engaged in human immunodeficiency virus (HIV) care and tested during the 12-year study period was 760/100 000 person-years. Independent predictors of infection were injection drug use as a risk factor for HIV acquisition (aOR, 2.2; 95% CI, 1.3-3.9), hepatitis C infection (aOR, 1.9; 95% CI, 1.1-3.4), black race (aOR, 2.2; 95% CI, 1.3-3.7 compared with white race), and more recent entry to care (since 2005 compared with 1994-2004). Predictors were similar in women aged 18-49.

CONCLUSIONS

Syphilis infection is common among US women in HIV care. Syphilis screening and prevention efforts should focus on women reporting drug use and with hepatitis C coinfection. Future studies should identify specific behaviors that mediate syphilis acquisition risk in women who use drugs.

Clinic-Level Factors Associated With Retention in Care Among People Living With Human Immunodeficiency Virus in a Multisite US Cohort, 2010-2016

BACKGROUND

Retention in care (RIC) leads to reduced HIV transmission and mortality. Few studies have investigated clinic services and RIC among people living with HIV (PLWH) in the United States. We conducted a multisite retrospective cohort study to identify clinic services associated with RIC from 2010-2016 in the United States.

METHODS

PLWH with ≥1 HIV primary care visit from 2010-2016 at 7 sites in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) were included. Clinic-level factors evaluated via site survey included patients per provider/trainee, navigation, RIC posters/brochures, laboratory test timing, flexible scheduling, appointment reminder methods, and stigma support services. RIC was defined as ≥2 encounters per year, ≥90 days apart, observed until death, administrative censoring (31 December 2016), or loss to follow-up (censoring at first 12-month interval without a visit with no future visits). Poisson regression with robust error variance, clustered by site adjusting for calendar year, age, sex, race/ethnicity, and HIV transmission risk factor, estimated risk ratios (RRs) and 95% confidence intervals (CIs) for RIC.

RESULTS

Among 21 046 PLWH contributing 103 348 person-years, 67% of person-years were retained. Availability of text appointment reminders (RR, 1.13; 95% CI, 1.03-1.24) and stigma support services (RR, 1.11; 95% CI, 1.04-1.19) were associated with better RIC. Disparities persisted for age, sex, and race.

CONCLUSIONS

Availability of text appointment reminders and stigma support services was associated with higher rates of RIC, indicating that these may be feasible and effective approaches for improving RIC.

Development and Validation of a Multivariable Prediction Model for Missed HIV Health Care Provider Visits in a Large US Clinical Cohort

Background

Identifying individuals at high risk of missing HIV care provider visits could support proactive intervention. Previous prediction models for missed visits have not incorporated data beyond the individual level.

Methods

We developed prediction models for missed visits among people with HIV (PWH) with ≥1 follow-up visit in the Center for AIDS Research Network of Integrated Clinical Systems from 2010 to 2016. Individual-level (medical record data and patient-reported outcomes), community-level (American Community Survey), HIV care site–level (standardized clinic leadership survey), and structural-level (HIV criminalization laws, Medicaid expansion, and state AIDS Drug Assistance Program budget) predictors were included. Models were developed using random forests with 10-fold cross-validation; candidate models with the highest area under the curve (AUC) were identified.

Results

Data from 382 432 visits among 20 807 PWH followed for a median of 3.8 years were included; the median age was 44 years, 81% were male, 37% were Black, 15% reported injection drug use, and 57% reported male-to-male sexual contact. The highest AUC was 0.76, and the strongest predictors were at the individual level (prior visit adherence, age, CD4+ count) and community level (proportion living in poverty, unemployed, and of Black race). A simplified model, including readily accessible variables available in a web-based calculator, had a slightly lower AUC of .700.

Conclusions

Prediction models validated using multilevel data had a similar AUC to previous models developed using only individual-level data. The strongest predictors were individual-level variables, particularly prior visit adherence, though community-level variables were also predictive. Absent additional data, PWH with previous missed visits should be prioritized by interventions to improve visit adherence.

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.

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions

INTRODUCTION

Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.

METHODS

Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.

RESULTS

Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).

CONCLUSIONS

Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.

Impact and correlates of sub-optimal social support among patients in HIV care

Social support (SS) predicts health outcomes among patients living with HIV. We administered a brief, validated measure of SS, the Multifactoral Assessment of Perceived Social Support, within a patient-reported outcomes assessment of health domains in HIV care at 4 U.S. clinics in English and Spanish (n = 708). In univariate analysis, low SS was associated with poorer engagement in care, antiretroviral adherence, and health-related quality of life; current methamphetamine/crystal use, depression, anxiety, and HIV stigma (all p < 0.001); any use of either methamphetamines/crystal, illicit opioids, or cocaine/crack (p = 0.001), current marijuana use (p = 0.012), nicotine use (p = 0.005), and concern for sexually transmitted infection exposure (p = 0.001). High SS was associated with undetectable viral load (p = 0.031). Multivariate analyses found low SS independently associated with depression (risk ratio (RR) 3.72, 95% CI 2.93-4.72), lower adherence (RR 0.76, 95% CI 0.64-0.89), poor engagement in care (RR 2.05, 95% CI 1.44-2.96), and having more symptoms (RR 2.29, 95% CI 1.92-2.75). Medium SS was independently associated with depression (RR 2.59, 95% CI 2.00-3.36), poor engagement in care (RR 1.62, 95% CI 1.15-2.29) and having more symptoms (RR 1.75, 95% CI 1.44-2.13). SS assessment may help identify patients at risk for these outcomes.

Impact of Abstinence and of Reducing Illicit Drug Use Without Abstinence on Human Immunodeficiency Virus Viral Load

BACKGROUND

Substance use is common among people living with human immunodeficiency virus (PLWH) and a barrier to achieving viral suppression. Among PLWH who report illicit drug use, we evaluated associations between HIV viral load (VL) and reduced use of illicit opioids, methamphetamine/crystal, cocaine/crack, and marijuana, regardless of whether or not abstinence was achieved.

METHODS

This was a longitudinal cohort study of PLWH from 7 HIV clinics or 4 clinical studies. We used joint longitudinal and survival models to examine the impact of decreasing drug use and of abstinence for each drug on viral suppression. We repeated analyses using linear mixed models to examine associations between change in frequency of drug use and VL.

RESULTS

The number of PLWH who were using each drug at baseline ranged from n = 568 (illicit opioids) to n = 4272 (marijuana). Abstinence was associated with higher odds of viral suppression (odds ratio [OR], 1.4-2.2) and lower relative VL (ranging from 21% to 42% by drug) for all 4 drug categories. Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with VL suppression (OR, 2.2, 1.6, respectively). Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with lower relative VL (47%, 38%, respectively).

CONCLUSIONS

Abstinence was associated with viral suppression. In addition, reducing use of illicit opioids or methamphetamine/crystal, even without abstinence, was also associated with viral suppression. Our findings highlight the impact of reducing substance use, even when abstinence is not achieved, and the potential benefits of medications, behavioral interventions, and harm-reduction interventions.

965. Partnering with State Health Departments: A Road Map for Collaboration Using Public Health Enhanced HIV/AIDS Reporting System (eHARS)

Background

Academic and public health partnerships are a critical component of the Ending the HIV Epidemic: A Plan for America (EHE). The Enhanced HIV/AIDS Reporting System (eHARS) is a standardized document-based surveillance database used by state health departments to collect and manage case reports, lab reports, and other documentation on persons living with HIV. Innovative analysis of this data can inform targeted, evidence-based interventions to achieve EHE objectives. We describe the development of a distributed data network strategy at an academic institution in partnership with public health departments to identify geographic differences in time to HIV viral suppression after HIV diagnosis using eHARS data.

Figure 1. Distributed Data Network

Methods

This project was an outgrowth of work developed at the University of Alabama at Birmingham Center for AIDS Research (UAB CFAR) and existing relationships with the state health departments of Alabama, Louisiana, and Mississippi. At a project start-up meeting which included study investigators and state epidemiologists, core objectives and outcome measures were established, key eHARS variables were identified, and regulatory and confidentiality procedures were examined. The study methods were approved by the UAB Institutional Review Board (IRB) and all three state health department IRBs.

Results

A common data structure and data dictionary across the three states were developed. Detailed analysis protocols and statistical code were developed by investigators in collaboration with state health departments. Over the course of multiple in-person and virtual meetings, the program code was successfully piloted with one state health department. This generated initial summary statistics, including measures of central tendency, dispersion, and preliminary survival analysis.

Conclusion

We developed a successful academic and public health partnership creating a distributed data network that allows for innovative research using eHARS surveillance data while protecting sensitive health information. Next, state health departments will transmit summary statistics to UAB for combination using meta-analytic techniques. This approach can be adapted to inform delivery of targeted interventions at a regional and national level.

Disclosures

All Authors: No reported disclosures

LB-13. Economic and workload impact of COVID-19 pandemic on physicians in the United States: results of a national survey

Background

The United States (US) healthcare system has experienced enormous economic impact due to the COVID-19 pandemic, driven by both loss of revenue related to shutdowns and increased strain on resources. These factors have impacted the workload and finances of physicians.

Methods

A 31-item anonymous survey evaluating the psychological impact of the COVID-19 pandemic on physicians was developed at the University of Alabama at Birmingham using Qualtrics^XM software and included questions on adverse economic impact (defined as selecting job loss, furlough or reduced income as a stressor), workload, and compensation. It was distributed via physician professional and social networks including email, Facebook groups, and #MedicalTwitter May 14-July 31, 2020.

Results

Among 597 respondents, 295 (49%) reported adverse economic impact, with the highest proportions among emergency medicine (71%), anesthesiologists (63%), and surgeons (60%) and lowest among infectious diseases (ID) (25%). In multivariable analysis (Table), physicians practicing in the Northeastern US saw the lowest economic impact versus the South (OR 3.44, 95% CI: 2.03–5.84), Midwest (2.62, 1.36–5.05) or West (1.98, 1.06–3.71). Physicians practicing in federal or academic settings experienced less economic impact than those in community settings (0.09, 0.03–0.30 and 0.61, 0.41–0.93 respectively). Increased work hours were identified by 185 (31%) of respondents as a stressor, with 169 (92%) reporting additional hours were partially or completely uncompensated. Among 584 respondents, 212 (36%) had new roles and responsibilities (Figure), with the highest proportion among ID physicians (75%).

Table 1: Characteristics and factors associated with reporting adverse economic impact of the COVID-19 pandemic among 597 physicians in the United States

Figure: New roles and responsbilities assumed by 212 physicians during the COVID-19 pandemic

Conclusion

The COVID-19 pandemic has increased physician workload, with approximately one-third of physicians taking on new responsibilities and a similar proportion reporting increased work hours. Much of this additional work is uncompensated due to the economic impact of the pandemic on the healthcare system. Simultaneously, many physicians across the US have suffered adverse economic consequences, especially in the South. ID physicians have experienced higher workload but less economic impact, related to increased need for their expertise and new roles and responsibilities.

Disclosures

Dustin Long, PhD, Nothing to disclose

Changes in Internalized Stigma and HIV Health Outcomes in Individuals New to HIV Care: The Mediating Roles of Depression and Treatment Self-Efficacy

There is limited research on the effects of stigma on health outcomes among new-to-HIV care individuals. We examined the effect of changes in internalized stigma over time on health behaviors and outcomes such as viral suppression, antiretroviral therapy (ART) adherence, and visit adherence among new-to-HIV care individuals. We also analyzed the mediating effects of adherence self-efficacy and depressive symptoms in these associations. Participants were 186 persons living with HIV who initiated care at four HIV clinical sites in the United States and had diverse geographical and ethnic backgrounds. Baseline and 48-week follow-up assessments included measures of internalized stigma, ART adherence, depressive symptoms, and adherence self-efficacy. HIV visit adherence and viral load data were extracted from clinic records. Age, race, gender, insurance status, and site were controlled in all analyses. Logistic regression analyses were used to examine predictors of adherence and viral suppression. Change (decrease) in internalized stigma was calculated by subtracting follow-up internalized stigma scores from baseline scores and served as the main predictor. Mediation analyses included calculation of 95% confidence intervals for the indirect effects using bootstrapping. Decreases in internalized stigma over time were positively associated with viral suppression, ART adherence, and visit adherence. Adherence self-efficacy significantly mediated these effects of decrease in internalized stigma on all outcomes. Depressive symptoms only mediated the association between decrease in internalized stigma and ART adherence. Interventions that address internalized stigma and depressive symptoms, as well as adherence self-efficacy, may significantly improve adherence and viral suppression outcomes for individuals new to HIV care.