Identifying Implementation Determinants and Strategies for Long-Acting Injectable Cabotegravir-Rilpivirine in People with HIV Who Are Virally Unsuppressed

BACKGROUND

Early evidence suggests long-acting injectable cabotegravir and rilpivirine (LA-CAB/RPV) may be beneficial for people with HIV (PWH) who are unable to attain viral suppression (VS) on oral therapy. Limited guidance exists on implementation strategies for this population.

SETTING

Ward 86, a clinic serving publicly insured PWH in San Francisco.

METHODS

We describe multi-level determinants of and strategies for LA-CAB/RPV implementation for PWH without VS, using the Consolidated Framework for Implementation Research. To assess patient and provider-level determinants, we drew on pre-implementation qualitative data. To assess inner and outer context determinants, we undertook a structured mapping process.

RESULTS

Key patient-level determinants included perceived ability to adhere to injections despite oral adherence difficulties and care engagement challenges posed by unmet subsistence needs; strategies to address these determinants included a direct-to-inject approach, small financial incentives, and designated drop-in days. Provider-level determinants included lack of time to obtain LA-CAB/RPV, assess injection response, and follow-up late injections; strategies included centralizing eligibility review with the clinic pharmacist, a pharmacy technician to handle procurement and monitoring, regular multidisciplinary review of patients, and development of a clinic protocol. Ward 86 did not experience many outer context barriers due to rapid and unconstrained inclusion of LA-CAB/RPV on local formularies and ability of its affiliated hospital pharmacy to stock the medication.

CONCLUSION

Multi-level strategies to support LA-CAB/RPV implementation for PWH without VS are required, which may necessitate additional resources in some settings to implement safely and effectively. Advocacy to eliminate outer-context barriers, including prior authorizations and specialty pharmacy restrictions, is needed.

Addressing Racism's Role in the US HIV Epidemic: Qualitative Findings From Three Ending the HIV Epidemic Prevention Projects

BACKGROUND

Racist socio-political and economic systems in the United States are root causes of HIV disparities among minoritized individuals. However, within HIV implementation science literature, there is scarce empirical research on how to effectively counter racism. This article names racism and White supremacy as key challenges to the success of the Ending the HIV Epidemic (EHE) initiative and delineates opportunities to integrate anti-racism into HIV interventions.

METHODS

Formative data were synthesized from 3 EHE studies in California, North Carolina, and South Carolina. Each study engaged with community stakeholders to inform pre-exposure prophylaxis interventions. Key informant interviews and focus groups were used to query individuals-including Black individuals-about implementation challenges. Although racism was not an a priori focus of included studies, discourse on race and racism emerged as key study findings from all projects.

RESULTS

Across diverse stakeholder groups and EHE locales, participants described racism as a threat to the success of the EHE initiative. Institutional and structural racism, intersectional stigma, and maltreatment of minoritized individuals within healthcare systems were cited as challenges to pre-exposure prophylaxis scale-up. Some recommendations for addressing racism were given-yet these primarily focused on the individual level (eg, enhanced training, outreach).

CONCLUSIONS

EHE implementation scientists should commit to measurable anti-racist actions. To this end, we present a series of recommendations to help investigators evaluate the extent to which they are taking actionable steps to counter racism to improve the adoption, implementation, and real-world impact of EHE interventions for people of color.

The case for prescribing PrEP in community mental health settings

Pre-exposure prophylaxis (PrEP) is a biomedical HIV prevention modality that is up to 99% effective in preventing HIV acquisition through sex if taken as directed. People with serious mental illness (eg, schizophrenia and bipolar disorder) are at high risk of acquiring HIV due to sexual behaviours, injection drug use, social factors, and structural discrimination that limits access to all types of preventive health services. We seek to show the importance of prioritising access to PrEP for people living with serious mental illness treated in community mental health settings. We describe barriers to prescribing PrEP, including provider attitudes and provider knowledge gaps, patient attitudes and knowledge, and systems issues. We also address the concerns that community mental health clinic administrators might have about taking on the responsibility of offering PrEP. In summary, despite the barriers to prescribing PrEP in these settings, we believe that there is a unique opportunity for community mental health settings to help address the HIV epidemic by facilitating the prescribing of PrEP to the at-risk populations they currently serve.

Risk, safety and sex among male PrEP users: time for a new understanding

Recent advances in biomedical HIV prevention have led to optimistic projections of a dramatic worldwide reduction of new infections by 2030. This optimism is counterbalanced by concerns that the protective benefits of one such technology, HIV pre-exposure prophylaxis (PrEP), may be negated by increases in other behaviours that offset these benefits (risk compensation). To contribute to a deeper understanding of concepts of safety and risk in the context of HIV PrEP, we draw on the narrative accounts of 61 male PrEP users who participated in the inaugural PrEP demonstration project: the iPrEx open-label extension study. We conducted in-depth interviews with a purposeful sample of iPrEx participants. Overall, participants did not report significant changes to their sexual practices once they had begun taking PrEP. Rather, participants reported experiencing a sense of relief or reprieve from HIV-related stress. This unburdening of fear did not necessarily lead to condomless sex. Instead, men expressed feeling a sense of security and less free-floating fear of HIV. We contend that no longer living under the threat of HIV is a significant benefit that has not been adequately explored in HIV prevention research.

Bringing it home: design and implementation of an HIV/STD intervention for women visiting incarcerated men

Incarceration has been identified as a key variable to be addressed in halting the HIV epidemic among African Americans. Our research team has been conducting and evaluating HIV prevention interventions for prisoners and their families since the early 1990s, including interventions specifically tailored to the needs of women with incarcerated partners. This article describes the development and implementation of a multicomponent HIV prevention intervention for women with incarcerated partners, and presents qualitative data from women who participated as peer educators in this intervention. Women with incarcerated partners reported low rates of condom use and HIV testing combined with a lack of information about prison-related HIV risks. We found that peer education is a feasible intervention to reach women with incarcerated partners and that flexibility and inclusiveness are important factors in designing intervention programs for this population.

Predicting HIV transmission risk among HIV-infected patients seen in clinical settings

We assessed risk of transmission among 4,016 HIV-infected patients in primary care, including men who have sex with men (MSM, n = 2,109), women (n = 1,104) and men who had sex with women (MSW, n = 803) in clinics in 15 cities across the U.S. A transmission risk act, assessed by computer assisted interviews, was defined as unprotected vaginal or anal sex with a partner who was HIV-uninfected or of unknown HIV status. MSM were more than twice as likely to report transmission risk acts than MSW (Odds Ratio [OR] = 2.35; 95% Confidence Interval [CI] = 1.84, 3.00; P < or = .001). Women were also more likely to report transmission risk acts than MSW (OR = 1.56; 95% CI = 1.19, 2.05; P < or = .001). Stimulant use was associated with transmission risk in all three groups (P < or = .05). MSM were more likely to use methamphetamines (8% versus 2% and 3% respectively), while MSW (17%) and women (12%, compared to 11% for MSM) were more likely to use cocaine. Clinical settings offer opportunities for preventing HIV transmission, particularly if interventions are tailored to sub-populations of HIV-infected patients.

Increase in Ksp37-positive peripheral blood lymphocytes in mild extrinsic asthma

Killer-specific secretory protein of 37 kDa (Ksp37), identified as a Th1/Tc1 specific secretory protein is expressed preferentially in cytotoxic T lymphocytes (CTL) and natural killer (NK) cells and might be involved in essential processes of CTL-mediated immunity. Although extrinsic asthma is linked currently to a Th2-dominated pathogenesis, there is increasing evidence for Th1/Tc1-mediated processes in the aetiopathology of asthma. CTL from patients with asthma have been shown to express cytokines and effector molecules which were different from healthy controls. We hypothesized that Ksp37 could indicate the involvement of CTL in the pathogenesis of extrinsic asthma. We therefore investigated Ksp37 expression in PBMC from patients with mild extrinsic asthma (n = 7) and healthy controls (n = 7). Flow cytometric analysis was used to quantify Ksp37+ cells and to investigate cellular Ksp37 expression as relative mean fluorescence intensities (MFI). We found a significantly (P = 0.016) higher percentage of Ksp37+ cells within the total lymphocyte population obtained from patients with mild extrinsic asthma compared with healthy controls. Subdifferentiation revealed a significant difference limited exclusively to the CD8+ subset (P = 0.010). In addition, Ksp37 secretion from cultured peripheral blood mononuclear cells (PBMC) and MFI of Ksp37+ lymphocytes were increased in patients with asthma compared with healthy controls. We conclude that mild extrinsic asthma appears to be associated with an increased expression of the Tc1 related protein Ksp37. The functional role of Ksp37 in the pathogenesis of asthma remains to be elucidated.

Synthesis of inducible enzymes in irradiated yeast cells: inhibition by ionizing radiation

The induced activity of the enzyme arginase was measured in diploid wild type Saccharomyces cerevisiae after X-ray and 241Am-alpha-particle exposure. It was found that after doses which are comparable to those necessary to reduce survival, little effect on enzyme activity is seen immediately after irradiation but it is reduced on further incubation. In this case there is an oxygen enhancement ratio of about 2 as for survival. Suppression immediately after exposure requires considerably higher doses, and no oxygen effect is seen. To achieve the same effect with alpha-particles requires even higher doses, the apparent r.b.e. is about 0 . 1. X-ray damage to induced enzyme activity is subject to liquid holding recovery. The results are discussed in relation to current theories of gene inactivation by ionizing radiation.