Assessing the Impact of Social Determinants of Health on HIV Care Engagement in the Southern United States: A Cross-Sectional Study.

Recent studies have shown social determinants of health (SDOH) to impact HIV care engagement. This cross-sectional study (Oct 20-Apr 21) assessed the impact of a range of SDOH on HIV care engagement using data from HIV Care Connect, a consortium of three HIV care facility-led programs (Alabama, Florida, Mississippi). The exposures were captured using the PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences) scale. The outcome was captured using the Index of Engagement in HIV Care scale. Participants (n = 132) were predominantly non-White (87%) and male (52%) with a median age of 41 years. Multivariable logistic regression adjusted for various sociodemographics showed lower HIV care engagement to be associated with being uninsured/publicly insured, having 1-3 unmet needs, socially integrating ≤five times/week, and having stable housing. Factors such as unmet needs, un-/underinsurance, and social integration may be addressed by healthcare and community organizations.

Assessing How Social Drivers of Health Affect Engagement in HIV Care in the Southern United StatesIt has been found that social factors that have a direct impact on health affect engagement in HIV Care among people living with HIV. We included various social drivers of health to see how they affect engagement in HIV Care. We used data between October 2020 and April 2021 from a project titled HIV Care Connect, which is a group of three facilities providing HIV care in Alabama, Florida, and Mississippi. We used social drivers of health as risk factors from a scale called PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences). Engagement in HIV care was measured by using a scale called Index of Engagement in HIV Care. A total of 132 participants were included. Majority of the participants were of races other than white (87%), male (52%) and were aged 41 years on average. Statistical analysis showed that participants without insurance or with public insurance, participants with 1-3 unsatisfied needs, participants that met with other people less than or equal to five times a week, and participants that had reliable housing had lower engagement in HIV care. These factors have a potential to be addressed by healthcare and community organizations.

Factors Associated With Willingness to Use Preexposure Prophylaxis Among Black Cisgender Women Residing in Rural and Urban Areas: A Cross-Sectional Study.

BACKGROUND: Black cisgender women (CGW) are disproportionately impacted by the human immunodeficiency virus (HIV) epidemic in the United States. Black women account for 57% of the total new diagnoses among CGW. In addition, Black CGW women are 9 times more likely to be diagnosed with HIV than their White counterparts. METHODS: We conducted surveys (September 2019-March 2020) and collected information on sociodemographics, HIV/preexposure prophylaxis (PrEP) knowledge, HIV/PrEP stigma, sexual practices, and other factors identified as PrEP barriers among Black CGW (n = 795). This cross-sectional study used logistic regression models to assess intrapersonal, interpersonal, and structural factors among individuals willing to use PrEP versus individuals unwilling or unsure to use PrEP. RESULTS: Our study population had a mean age of 37 years, predominantly lived in urban areas (65%), had stable housing (96.7%), and had private insurance/Medicare (78.2%). Overall, 29.6% reported willingness to use PrEP, 35.6% reported unwillingness to use PrEP, and 34.8% were unsure of PrEP use. The multivariable analysis showed that, compared with individuals reporting unwillingness/unsure to PrEP use, those reporting willingness to PrEP use were younger (adjusted odds ratio [AOR; 95% confidence interval {CI}], 0.97 [0.96-0.99]), had lower odds of intimate partner violence (AOR [95% CI], 0.87 [0.78-0.98), and had higher odds of organizational religiosity (AOR [95% CI], 1.10 [1.01-1.20]), HIV knowledge (AOR [95% CI], 1.08 [1.03-1.13]), and perceived need for PrEP (AOR [95% CI], 6.38 [3.36-12.11]). CONCLUSIONS: Preexposure prophylaxis willingness among Black CGW was impacted by individual-level, interpersonal, and structural factors. Improving PrEP willingness and uptake among Black CGW will require multilevel interventions.

"Sex. Maybe We Should Do Things to be Healthy About It." Adolescent-Caregiver Discussions About Sex.

PURPOSE: Adolescents are disproportionately burdened with HIV. Numerous barriers limit adolescent pre-exposure prophylaxis (PrEP) use for HIV prevention. We explored adolescent-caregiver perspectives on discussing sexual health and PrEP to inform future caregiver interventions as a possible strategy to promote PrEP use. METHODS: We conducted separate in-depth interviews with adolescents aged 14-18 living in Alabama and their parent/guardian (caregiver). Interviews explored attitudes about sex, knowledge and attitudes about HIV prevention and PrEP, and attitudes about PrEP communication within adolescent-caregiver groups. Thematic analysis of adolescent and caregiver interviews was conducted independently and then triangulated to compare shared themes. RESULTS: Nine adolescents and seven caregivers contributed to five dyads and two triads. Adolescents had a median age of 16 years (range 14-18); five were girls (55%), and five were non-Hispanic Black (55%). Most caregivers were mothers (5, 71%), non-Hispanic Black (5, 71%), with a median age of 41 (36-56) years. All adolescents expressed willingness to involve their caregiver around PrEP use. Major themes included as follows: 1) caregiver efforts to overcome cultural taboos about sex and sexuality foster adolescents' willingness to talk with caregivers about sex; 2) evolving societal norms and reflections on their own upbringings motivate caregivers to discuss and support adolescents with sexual health; and 3) caregivers desire to engage in sexual health discussions with providers and support their teens with PrEP. DISCUSSION: As socio-cultural norms around sex evolve, adolescent-caregiver discussions about sexual health and PrEP may be an opportunity to increase PrEP use and reduce HIV infections among select adolescent sub-populations.

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.

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.

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.

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.

Treatment-related Correlates of Growth in Children With Sickle Cell Disease in the DISPLACE Cohort.

Reduced growth and delayed maturation have been described in children with sickle cell disease (SCD). This study investigated growth and hemolysis in children with SCD in the DISPLACE (Dissemination and Implementation of Stroke Prevention Looking at the Care Environment) cohort. The database includes 5287 children, of which, 3305 had at least 2 growth measurements over a 5-year period. Body mass index was converted to z-scores (zBMI), and 19.8%, 66.1%, 14.2% of children were classified as underweight, normal, and overweight/obese, respectively. Multivariable analysis of growth was conducted and included variables: age, sex, blood pressure, hemoglobin, reticulocyte count, treatment with chronic red cell transfusion therapy (CRCT), or hydroxyurea therapy. Baseline hemoglobin levels were associated with the lower odds of being underweight (odds ratio [OR]=0.93, 95% confidence interval [CI]: 0.86-0.99), and higher odds of being overweight/obese (OR: 1.26, 95% CI: 1.17-1.36) compared with normal zBMI. CRCT was associated with being overweight/obese at baseline (OR: 1.85, 95% CI: 1.31-2.60). Overall, results showed that children who were underweight improved regardless of therapy over the 2-year time period. However, children on CRCT are at higher risk for being overweight and should be monitored closely.

Factors associated with the use of complementary and alternative therapies among patients with hypertension and type 2 diabetes mellitus in Western Jamaica: a cross-sectional study.

BACKGROUND: This study examined the prevalence and predictors of complementary and alternative medicine use among clinic patients with hypertension and/or type 2 diabetes mellitus in western Jamaica. METHODS: A cross-sectional study using an investigator-administered questionnaire was conducted from May to August 2017. Data on sociodemographic factors, complementary and alternative medicine use, and knowledge and perceptions of complementary and alternative medicine were collected from the patients. Multivariable logistic regression analysis was used to examine associations between patient characteristics and knowledge and perceptions of complementary and alternative medicine and complementary and alternative medicine use. RESULTS: A total of 362 patients were invited to participate and 345 (95.3%) completed the questionnaire; 311 (90.1%) had hypertension, 130 (37.7%) had type 2 diabetes mellitus and 96 (27.8%) had both diseases. Seventy-nine percent of the participants with hypertension and 65% with type 2 diabetes mellitus reported current use of complementary and alternative medicine. Self-reported knowledge of complementary and alternative medicine (none/poor vs average/good/excellent) was significantly associated with complementary and alternative medicine use for hypertension (AOR = 0.33, 95% CI = 0.13-0.87) and type 2 diabetes mellitus (AOR = 0.06, 95% CI = 0.01-0.37). Believing that complementary and alternative medicine is a natural method for treating hypertension was significantly associated with complementary and alternative medicine use among patients with hypertension (AOR = 3.9, 95% CI = 1.26-12.00), and belief that it is acceptable to use prescription medication and complementary and alternative medicine simultaneously was significantly associated with complementary and alternative medicine use among patients with type 2 diabetes mellitus (AOR =7.19, CI = 1.34-38.52). CONCLUSIONS: Participants' perceptions of their knowledge and beliefs regarding complementary and alternative medicine strongly influence their use of complementary and alternative medicine. These findings can be used in designing educational interventions to promote the proper use, and mitigate detrimental effects, of complementary and alternative medicine in this population.

Estimating the First 90 of the UNAIDS 90-90-90 Goal: A Review.

Estimating the population with undiagnosed HIV (PUHIV) is the most methodologically challenging aspect of evaluating 90-90-90 goals. The objective of this review is to discuss assumptions, strengths, and shortcomings of currently available methods of this estimation. Articles from 2000 to 2018 on methods to estimate PUHIV were reviewed. Back-calculation methods including CD4 depletion and test-retest use diagnosis CD4 count, or previous testing history to determine likely infection time thus, providing an estimate of PUHIV for previous years. Biomarker methods use immunoassays to differentiate recent from older infections. Statistical techniques treat HIV status as missing data and impute data for models of infection. Lastly, population surveys using HIV rapid testing most accurately calculates the current HIV prevalence. Although multiple methods exist to estimate the number of PUHIV, the appropriate method for future applications depends on multiple factors, namely data availability and population of interest.

Data for Care (D4C) Alabama: Clinic-Wide Risk Stratification With Enhanced Personal Contacts for Retention in HIV Care via the Alabama Quality Management Group.

BACKGROUND: The Alabama Quality Management Group (AQMG), a consortium of 9 Ryan White-funded part C and D clinics, distributed statewide was established in 2006 under the guidance from the Health and Resources Services Administration with a clinical quality improvement (CQI) focus. METHODS: We describe the origins and evolution of the AQMG, including requisite shifts from aggregate clinic-wide to de-identified individual-level data reporting for implementation of the Data for Care (D4C-AL) Alabama program. The D4C-AL strategy uses a clinic-wide risk stratification of all patients based on missed clinic visits in the previous 12 months. Intermediate (1-2 missed visits) and high-risk patients (>3 missed visits) receive the evidence-informed Retention through Enhanced Personal Contact intervention. We report on a pilot of the D4CAL program in 4 of 33 primary HIV care clinics at the UAB 1917 Clinic. RESULTS: Among 3859 patients seen between April 2018 and February 2019, the missed visit rate was not significantly different between the D4C-1917 (19.2%) and non-D4C clinics (20.5%) in a preintervention period (May 2017-April 2018). However, a significantly lower missed visit rate was observed in the D4C-1917 vs. non-D4C-1917 clinics during the intervention period (April 2018-February 2019, P = 0.049). CONCLUSIONS: The AQMG has been transformed into a health service research and implementation science platform, building on a shared vision, mission, data reporting, and quality improvement focus. Moreover, CQI may be viewed as an implementation strategy that seeks to enhance uptake and sustained use of effective interventions with D4C-AL representing a prototype for future initiatives embedded within extant quality improvement consortia.

Accessing Pre-exposure Prophylaxis (PrEP): Perceptions of Current and Potential PrEP Users in Birmingham, Alabama.

Limited studies to date assess barriers to and facilitators of PrEP uptake and utilization using a patient-centered access to care framework, among diverse socio-demographic groups, or in the U.S. Deep South, an area with disproportionate HIV burden. We examine perceptions of PrEP access in qualitative interviews with 44 current and potential PrEP users in Birmingham, Alabama. Participants were 32 years old on average, 66% Black, 66% gay or lesbian, 70% male, and 66% single. Perceived barriers to PrEP access included: lack of PrEP awareness and advertisement; sexuality-related stigma; time and resource constraints; and concerns about the adequacy and technical quality of PrEP services. Perceived facilitators to PrEP access were: PrEP-related information gathering and sharing; increased dialogue and visibility around PrEP; social, programmatic, and clinical support; and, lastly, self-preservation; personal motivation; and treatment self-efficacy. Results point to opportunities to address complex barriers to equitable PrEP access using multilevel and multimodal solutions.

Race Plays a Role in the Knowledge, Attitudes, and Beliefs of Women with Osteoporosis.

Using a concurrent mixed methods design, we investigated how knowledge, attitudes, values, and beliefs among women with osteoporosis can explain racial disparities in bone health. We recruited African American and White women ≥ 65 years of age with osteoporosis to participate in focus groups. We quantitatively compared scores of the "Osteoporosis & You" knowledge scale and each domain (internal, powerful others, and chance) of the Multidimensional Health Locus of Control scale by race using t tests. We qualitatively explored potential racial differences in attitudes, values, and beliefs in the domains: (1) osteoporosis and bone health concerns, (2) knowledge about osteoporosis, (3) utilization of medical services for osteoporosis, (4) facilitators of osteoporosis prevention activities, and (5) barriers to osteoporosis prevention activities. A total of 48 women (White: 36; African American: 12) enrolled in the study. White women had a mean (SD) of 7.8 (0.92), whereas African American women score a 6.6 (2.6) (p = 0.044) out of 10 on the Osteoporosis & You Scale. The powerful others domain was significantly higher among African American for both general and bone health [General Health - African American: 26.7 (5.9) vs. White: 22.3 (3.8); p = 0.01]. Qualitative thematic analysis revealed differences by race in knowledge, types of physical activity, coping with comorbidities, physician trust, religion, and patient activation. Using both quantitative and qualitative methods, our study identified racial differences in knowledge, attitudes, and beliefs in women with osteoporosis that could result in racial disparities in bone health, indicating the need to improve education and awareness about osteoporosis in African American women.