Community-Based Services for Hospitalized Patients With Serious Injection-Related Infections in Alabama: A Brief Report.

Injection-related infections continue to rise, particularly in the South. People who inject drugs are increasingly utilizing hospital services for serious injection-related infections but may be discharged to areas without harm reduction services. We explored the availability and travel time to services for HIV and substance use in Alabama.

A qualitative exploration of health care workers' approaches to relational harm reduction in HIV primary care settings.

BACKGROUND: Structural harm reduction is an approach to care for people who use drugs (PWUD) that incorporates services and resources (e.g., naloxone, sterile syringes). As conceptualized in our previous research, harm reduction is also "relational," encompassing a patient-provider relationship that is non-judgmental and respectful of patients' autonomy. Little is known about health care workers' (HCW) knowledge or attitudes towards harm reduction beyond structural strategies, whose availability and legality vary across geographical settings. To operationalize how relational harm reduction is both characterized and employed in HIV care settings, where nearly half of patients have a diagnosed substance use disorder, we qualitatively explored HCWs' knowledge of and use of harm reduction via individual in-depth interviews. METHODS: Our study sample included three HIV clinics, one in Birmingham, Alabama (AL) and two in Pittsburgh, Pennsylvania (PA). We conducted individual interviews with n = 23 health care workers via Zoom, using a semi-structured interview guide to probe for questions around health care workers' attitudes towards and experiences with providing care to PWH who use drugs and their knowledge of and attitudes towards relational and structural harm reduction. Data was analyzed in Dedoose using thematic analysis. RESULTS: Qualitative analyses revealed two primary themes, Continuum of Relational Harm Reduction in Practice and Limited Harm Reduction Training. Nearly all HCWs (n = 19, 83%) described a patient interaction or expressed a sentiment that corresponded with the principles of relational harm reduction. Yet, over half of participants (n = 14, 61%) used language to describe PWH who use drugs that was stigmatizing or described an interaction that was antithetical to the principles of relational harm reduction. Five HCWs, all from Birmingham, were unaware of the term 'harm reduction.' Few HCWs had any harm reduction training, with most learning about harm reduction from webinars/conferences or on the job. CONCLUSION: Our findings suggest that relational harm reduction in HIV care settings is practiced along a continuum, and that a range of behaviors exist even within individual HCWs (e.g., used stigmatizing terms such as "addict" but also described patient interactions that reflected patients' autonomy). Given that harm reduction is typically described as a structural approach, a broader definition of harm reduction that is not dependent on policy-dependent resources is needed.

A Qualitative Exploration of Providers' Approaches to Relational Harm Reduction in HIV Primary Care Settings.

Background: Structural harm reduction is an approach to care for people who use drugs (PWUD) that incorporates services and resources (e.g., naloxone, sterile syringes). As conceptualized in our previous research, harm reduction is also "relational," encompassing a patient-provider relationship that is non-judgmental and respectful of patients' autonomy. Little is known about providers' knowledge or attitudes towards harm reduction beyond structural strategies, whose availability and legality vary across geographical settings. To operationalize how relational harm reduction is both characterized and employed in HIV care settings, where nearly half of patients have a diagnosed substance use disorder, we qualitatively explored providers' knowledge of and use of harm reduction via individual in-depth interviews. Methods: Our study sample included three HIV clinics, one in Birmingham, Alabama (AL) and two in Pittsburgh, Pennsylvania (PA). We conducted individual interviews with n = 23 providers via Zoom, using a semi-structured interview guide to probe for questions around providers' attitudes towards and experiences with providing care to PWH who use drugs and their knowledge of and attitudes towards relational and structural harm reduction. Data was analyzed in Dedoose using thematic analysis. Results: Qualitative analyses revealed three primary themes, including Relational Harm Reduction in Practice, Not Harm Reduction, No Knowledge of Harm Reduction, and Harm Reduction Training. Nearly all providers (n = 19, 83%) described a patient interaction or expressed a sentiment that corresponded with the principles of relational harm reduction. Yet, over half of participants (n = 14, 61%) used language to describe PWH who use drugs that was stigmatizing or described an interaction that was antithetical to the principles of relational harm reduction. Five providers, all from Birmingham, were unaware of the term 'harm reduction.' Few providers had any harm reduction training. Conclusion: Our findings suggest that relational harm reduction in HIV care settings is practiced along a continuum, and that a range of behaviors exist even within individual providers (e.g., used stigmatizing terms such as "addict" but also described patient interactions that reflected patients' autonomy). Given that harm reduction is typically described as a structural approach, a broader definition of harm reduction that is not dependent on policy-dependent resources is needed.

Identifying Key Factors to PrEP Initiation and Persistence Among YMSM Through Focus Groups and Surveys in Two High-Priority Settings.

Cisgender men are diagnosed with HIV at a rate four times greater than cisgender women, with 71% of infections attributed to male-male sexual contact. Despite expanding accessibility, pre-exposure prophylaxis (PrEP) for HIV prevention is initiated by only 30% of people with PrEP indications. Five focus groups with 42 young men who have sex with men from New York and Alabama were conducted to identify key factors to PrEP initiation and persistence. Thirty focus group participants completed a survey on demographics, PrEP choices and health care attitudes. Findings suggest provider competency significantly influences PrEP use due to stigmatization in medical settings. Participants noted benefits of PrEP including HIV protection and sexual empowerment, yet barriers like cost and side effects were prevalent. Our findings outline barriers and facilitators to PrEP use among young men who have sex with men in two high priority settings that will inform PrEP care updates in participating clinics.

Transactional sex among adults accessing sexual health services in Alabama, 2008-2022: Prevalence, associated risk factors, and associations with HIV, HCV, and STI diagnosis.

BACKGROUND: The U.S. Deep South bears a disproportionate burden of HIV and other STIs. Transactional sex may influence these epidemics, but few studies have estimated its prevalence or correlates in the Deep South. METHODS: We estimated the history of transactional sex among adults accessing an Alabama AIDS Service Organization from 2008-2022, using chi-square tests to examine its sociodemographic and behavioral correlates. We used modified Poisson regression with cluster-robust standard errors to estimate adjusted prevalence ratios (aPR) and 95 % confidence intervals (CI) for the associations between transactional sex and new HIV, hepatitis C (HCV), and STI diagnoses. RESULTS: Transactional sex was reported at 944/20,013 visits (4.7 %) and associated with older age, being a cisgender woman or gender minority, identifying as white, diverse drug use, and sharing of drug equipment. Compared to others, clients reporting transactional sex had increased prevalence of syphilis (apR 3.60, 95 % CI 1.16-11.19) and HCV (aPR 1.53, 95 % CI 1.24-1.88). CONCLUSION: Using 14 years of community-based data, this study is the first to estimate the relationship between transactional sex and HIV, HCV, and STIs in Alabama and highlights the need address STI burden and diverse drug use among people who transact sex in the Deep South.

Workforce outcomes among substance use peer supports and their contextual determinants: A scoping review protocol.

Background: Peer recovery support services are a promising approach for improving harm reduction, treatment, and recovery-related outcomes for people who have substance use disorders. However, unique difficulties associated with the role may put peer recovery support staff (i.e., peers) at high risk for negative workforce outcomes, including burnout, vicarious trauma, and compassion fatigue, which impact one's personal recovery journey. Little is known about the extent to which peers experience such negative outcomes or the influence the service setting context has upon them. This scoping review aims to describe the nature and extent of research evidence on peers' workforce outcomes and how these outcomes might differ across service settings. Methods: A scoping review will be conducted with literature searches conducted in PsycINFO®, (EBSCO), Embase® (EBSCO), CINAHL® (EBSCO), Web of Science™ (Clarivate), and Google Scholar databases for relevant articles discussing US-based research and published in English from 1 January 1999 to 1 August 2023. The study will include peer-reviewed and grey-literature published materials describing the experiences of peers participating in recovery support services and harm reduction efforts across a variety of service settings. Two evaluators will independently review the abstracts and full-text articles. We will perform a narrative synthesis, summarizing and comparing the results across service settings. Conclusions: This review will assess the state of the literature on peer workforce-related outcomes and how outcomes might vary by service setting context. Exploration will include individual characteristics of peers that moderate workforce outcomes, and workforce outcomes that mediate personal recovery outcomes. Results will inform the field regarding future directions for research in this area. Systematic review registration: Submitted to Open Science Framework, August 22nd, 2023.

Opioid misuse among people with HIV: results from the National Survey on Drug Use and Health (NSDUH) 2015-2019.

Aim: Pain is a major challenge in the management of HIV/AIDS. This research analyzed the prevalence of substance use and opioid misuse among people with HIV (PWH) and those without (PWoH) in the USA. Methods: Using data from the 2015-2019 National Survey on Drug Use and Health, the study assessed misuse of pain relievers and opioids in 279,025 individuals. Results: PWH were about 1.88-times more likely to misuse pain relievers and 1.85-times to misuse opioids than PWoH, with a notable rise in hydrocodone and tramadol misuse. Conclusion: The data highlights an imperative for interventions targeting substance misuse among PWH, addressing the complex nexus of HIV, chronic pain and opioid use.

Elucidating Harm Reduction Principles in a Client-Centered Representative Payee Program.

Harm Reduction seeks to mitigate harms associated with health behaviors without the expectation that these behaviors be extinguished completely. Client-Centered Representative Payee (CCRP) is an intervention that modifies the US Social Security Administration's (SSA) Representative Payee policy by incorporating relational harm reduction. We used Human-Centered Design (HCD) methods to elucidate ways that harm reduction principles are present in and integral to CCRP and to create a blueprint for replication. Thirteen individuals familiar with CCRP brainstormed 88 statements, which were parsed, consolidated, and then independently assigned by a subgroup of participants to six principles of harm reduction. After refining the data, 29 statements aligning with harm reduction principles remained. Delineating harm reduction within CCRP, which can empower and establish trust with clients, may help other providers identify how to offer representative payee services that are respectful, compassionate, rooted in harm reduction, and ultimately improve client outcomes.

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.

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.

Role of Visit Modality in the HIV-Related No-Shows During the COVID-19 Pandemic: A Multisite Retrospective Cohort Study.

The emergence of the COVID-19 pandemic necessitated rapid expansion of telehealth as part of healthcare delivery. This study compared HIV-related no-shows by visit type (in-person; video; telephone) during the COVID-19 pandemic (April 2020-September 2021) from the Data for Care Alabama project. Using all primary care provider visits, each visit's outcome was categorized as no-show or arrived. A logistic regression model using generalized estimating equations accounting for repeat measures in individuals and within sites calculated odds ratios (OR) and their accompanying 95% confidence interval (CI) for no-shows by visit modality. The multivariable models adjusted for sociodemographic factors. In-person versus telephone visits [OR (95% CI) 1.64 (1.48-1.82)] and in-person versus video visits [OR (95% CI) 1.53 (1.25-1.85)] had higher odds of being a no-show. In-person versus telephone and video no-shows were significantly higher. This may suggest success of telehealth visits as a method for HIV care delivery even beyond COVID-19.

"If I have to drive 100 miles, I'll drive 100 miles to get it": a qualitative exploration of HIV care travel behavior.

ABSTRACTAlabama depends heavily on Ryan White HIV/AIDS Program (RWHAP) funding, yet patient enrollment at one large, RWHAP-funded, academically-affiliated HIV clinic in Alabama has steadily increased each year, with approximately 20% bypassing more proximal RWHAP clinics. To understand reasons why patients travel long distances and bypass closer clinics to receive care, we conducted eight focus groups over Zoom, each containing between 2-3 participants (n = 18) and applied thematic analysis to code the data. Primary themes included: (1) Reasons for Traveling Long Distances to Receive HIV Medical Care, (2) Experiences with HIV Medical Care during the COVID-19 Pandemic, and (3) Travel Challenges. Some participants were attracted by the clinic's one-stop-shop model, while others eschewed local clinics to avoid status disclosure. An overarching travel challenge was lack of transportation, yet most participants favored in-person appointments over telehealth despite driving long distances. Future research should explore patient attitudes towards telehealth in greater depth.

Assessing the Impact of COVID-19 on Retention in HIV Primary Care: A Longitudinal Multisite Analysis.

We compared retention in care outcomes between a pre-COVID-19 (Apr19-Mar20) and an early-COVID-19 (Apr20-Mar21) period to determine whether the pandemic had a significant impact on these outcomes and assessed the role of patient sociodemographics in both periods in individuals enrolled in the Data for Care Alabama project (n = 6461). Using scheduled HIV primary care provider visits, we calculated a kept-visit measure and a missed-visit measure and compared them among the pre-COVID-19 and early-COVID-19 periods. We used logistic regression models to calculated odds ratios (OR) and accompanying 95% confidence intervals (CI). Overall, individuals had lowers odds of high visit constancy [OR (95% CI): 0.85 (0.79, 0.92)] and higher odds of no-shows [OR (95% CI): 1.27 (1.19, 1.35)] during the early-COVID-19 period. Compared to white patients, Black patients were more likely to miss an appointment and transgender people versus cisgender women had lower visit constancy in the early-COVID-19 period.

Addressing HIV and Homelessness During COVID-19: A Community-Based Demonstration Project.

People experiencing homelessness are at increased risk for HIV, and people with HIV (PWH) experiencing homelessness are more likely to experience suboptimal HIV health outcomes than PWH with stable housing. Within Alabama, a state prioritized in the Ending the HIV Epidemic initiative, Jefferson County consistently has the highest number of new HIV diagnoses as well as a high percentage of the state's homeless population. To address the twin epidemics of both HIV and homelessness within the high-priority setting of Jefferson County, Alabama, this 1-year community-based project, Ending the HIV Epidemic: Addressing HIV Health and Homelessness (AH3), sought to increase HIV testing and linkage to care among this population by placing a full-time case manager trained in HIV testing and case management at a homeless shelter. Results demonstrated that HIV testing was highly acceptable: 733 individuals were offered a test, and only 2.7% (n = 20) declined. Nine previously diagnosed, out of care PWH and one newly diagnosed PWH were identified through AH3 testing efforts. Of these, five (50%) were linked to care at a local HIV clinic. The remaining five PWH left the shelter before they could be linked to care. Just 10 shelter guests expressed interest in taking PrEP (just 1.4% of guests who tested negative for HIV), and only one of these linked to PrEP care. Future health promotion programs are needed to address mental health and other ancillary needs among this population, as well as programs that provide access to PrEP and other HIV prevention services.

Impact of harm reduction care in HIV clinical settings on stigma and health outcomes for people with HIV who use drugs: study protocol for a mixed-methods, multisite, observational study.

INTRODUCTION: Our previous pilot work suggests relational harm reduction strengthens relationships between people with HIV (PWH) who use drugs and their healthcare providers and improves HIV health outcomes. However, there is limited research examining ways that structural (eg, strategies like syringe service programmes) and/or relational (patient-provider relationship) harm reduction approaches in HIV clinical settings can mitigate experiences of stigma, affect patient-provider relationships and improve outcomes for PWH who use drugs. Our mixed methods, multisite, observational study aims to fill this knowledge gap and develop an intervention to operationalise harm reduction care for PWH who use drugs in HIV clinical settings. METHODS AND ANALYSIS: Aim 1 will explore the relationship between healthcare providers' stigmatising attitudes towards working with PWH who use drugs and providers' acceptance and practice of structural and relational harm reduction through surveys (n=125) and interviews (n=20) with providers. Aim 2 will explore the interplay between patient-perceived harm reduction, intersectional stigma and clinical outcomes related to HIV, hepatitis C (if applicable) and substance use-related outcomes through surveys (n=500) and focus groups (k=6, total n=36) with PWH who use drugs. We will also psychometrically evaluate a 25-item scale we previously developed to assess relational harm reduction, the Patient Assessment of Provider Harm Reduction Scale. Aim 3 will use human-centred design approaches to develop and pretest an intervention to operationalise harm reduction care for PWH who use drugs in HIV clinical settings. ETHICS AND DISSEMINATION: This study was approved via expedited review by the University of Pittsburgh Institutional Review Board (STUDY21090002). Study findings will be presented in peer-reviewed journals and public health conferences as well as shared with patient participants, community advisory boards and harm reduction organisations. TRIAL REGISTRATION NUMBER: NCT05404750.

Community-engaged Processes for Restarting Federally Funded Research in a Community-based Organization during the Coronavirus Disease 2019 Pandemic.

BACKGROUND: Birmingham AIDS Outreach (BAO) is one of three study sites partnering with the University of Pittsburgh Graduate School of Public Health (Pitt Public Health) for a National Institutes of Health-funded randomized controlled trial on a financial management intervention for people with HIV who are experiencing homelessness or housing instability. After the onset of the coronavirus disease 2019 (COVID-19) pandemic in March 2020, the study team used a community-engaged approach to adapt research protocols at this site. We sought to describe a community-engaged approach to restarting National Institutes of Health-funded research during the COVID-19 pandemic. METHODS: Partners at Pitt Public Health and BAO developed a set of agency-wide COVID-19 policies and procedures for BAO organized around Rhodes' critical elements of community engagement. CONCLUSIONS: The challenges presented by COVID-19 in the research sector have provided an opportunity to reevaluate study activities and increase the extent to which research is conducted in a community-centered manner.

NanoSIMS Imaging Reveals the Impact of Ligand-ASO Conjugate Stability on ASO Subcellular Distribution.

The delivery of antisense oligonucleotides (ASOs) to specific cell types via targeted endocytosis is challenging due to the low cell surface expression of target receptors and inefficient escape of ASOs from the endosomal pathway. Conjugating ASOs to glucagon-like peptide 1 (GLP1) leads to efficient target knockdown, specifically in pancreatic ß-cells. It is presumed that ASOs dissociate from GLP1 intracellularly to enable an ASO interaction with its target RNA. It is unknown where or when this happens following GLP1-ASO binding to GLP1R and endocytosis. Here, we use correlative nanoscale secondary ion mass spectroscopy (NanoSIMS) and transmission electron microscopy to explore GLP1-ASO subcellular trafficking in GLP1R overexpressing HEK293 cells. We isotopically label both eGLP1 and ASO, which do not affect the eGLP1-ASO conjugate function. We found that the eGLP1 peptide and ASO are not detected at the same level in the same endosomes, within 30 min of GLP1R-HEK293 cell exposure to eGLP1-ASO. When we utilized different linker chemistry to stabilize the GLP1-ASO conjugate, we observed more ASO located with GLP1 compared to cell incubation with the less stable conjugate. Overall, our work suggests that the ASO separates from GLP1 relatively early in the endocytic pathway, and that linker chemistry might impact the GLP1-ASO function.