Multilevel Determinants of Rapid Antiretroviral Treatment Implementation and Demand in Miami-Dade County.

BACKGROUND: Rapidly linking newly diagnosed HIV patients to antiretroviral treatment (ART) is the best practice for achieving optimal treatment outcomes, including viral suppression. However, rapid ART implementation varies throughout the United States, highlighting the importance of identifying rapid ART implementation determinants in US HIV epicenters, such as Miami-Dade County (MDC). METHODS: Clinic focus groups (N = 4 clinics) and patient interviews (N = 31 recently diagnosed patients) systematically and qualitatively assessed rapid ART implementation determinants in MDC. Independent coders analyzed focus groups and interviews using a directed content analysis approach guided by the Consolidated Framework for Implementation Research. RESULTS: For clinic stakeholders, key rapid ART implementation determinants included the following: complexity and adaptability (innovation characteristics); networks between clinics and patient needs rooted in structural inequities (outer setting); leadership and available resources (inner setting); staff/provider flexibility (characteristics of individuals); and appointing patient navigators and champions (process). For patients, key determinants included complexity and relative advantage of rapid treatment (innovation characteristics); patient needs and clinic networks (outer setting); provider knowledge and skills (inner setting); provider warmth and affirmation (characteristics of individuals); and need for improved outreach (process). CONCLUSIONS: Multilevel factors impact clinic implementation and patient demand for rapid ART in MDC. Informed by these factors, we identified potential implementation strategies to enhance rapid ART implementation throughout MDC. These implementation strategies can be tested in an implementation trial, enhancing the toolkit of strategies to ensure that evidence-based tools, particularly rapid ART, are readily available to the most impacted communities.

Enhancing the Routine Screening Infrastructure to Address a Syphilis Epidemic in Miami-Dade County.

BACKGROUND: In a recent sexually transmitted disease surveillance report from the Centers for Disease Control and Prevention, Miami-Dade County had the nation's fourth highest rate of infectious syphilis, with rates of congenital syphilis on the rise. As a public health response, Homestead Hospital, in collaboration with the Florida Department of Health, enhanced their emergency department's routine HIV/HCV "opt-out" screening infrastructure to include a syphilis smart screening algorithm. The purpose of this article is to describe the development, implementation, and evaluation of the algorithm. METHODS: A retrospective evaluation of patient records prompted the development of the algorithm. Homestead Hospital's electronic health record system automatically triggers a syphilis test based on the reason for medical visit (e.g., rash, penile discharge, a positive pregnancy test, historical or present sexually transmitted disease result). If a patient tests positive, he/she is counseled and linked to care. RESULTS: Since implementation (April 2018 to August 2019), the smart screening algorithm triggered 4806 syphilis tests: 122 patients tested positive (2.5% seropositivity). After confirmatory testing, 59 patients were positive for syphilis, of which 27 were pregnant. CONCLUSIONS: The Homestead Hospital and Department of Health-Miami-Dade's response to Miami-Dade County's syphilis problem is innovative and replicable. The program embraces technology, enhances the routine opt-out screening model, and does not affect preexisting workflows. Ultimately, implementation of this algorithm allows patients to get treatment, receive comprehensive prevention services, and, in some cases, avert congenital syphilis.

Implementation of an Immediate HIV Treatment Initiation Program in a Public/Academic Medical Center in the U.S. South: The Miami Test and Treat Rapid Response Program.

Test and Rapid Response Treatment (TRRT) linkage programs have demonstrated improved HIV suppression rates. This paper describes the design and implementation of the Miami TRRT initiative and its clinical impact. Assisted by a dedicated care navigator, patients receiving a reactive HIV rapid test at the Florida Department of Health STD Clinic were offered same-day HIV care at the University of Miami/Jackson Memorial Medical Center Adult HIV Outpatient Clinic. Patient retention and labs were tracked for 12 months. Of the 2337 individuals tested, 46 had a reactive HIV test; 41 (89%) consented to participate. For the 36 patients in continued care for a year, 33 (91.7%) achieved virological suppression (< 200 copies/mL) within 70 days of their reactive HIV rapid test; at 12 months, 35 (97.2%) remained suppressed, and mean CD4 T cell counts increased from 452 ± 266 to 597 ± 322 cells/mm3. The Miami TRRT initiative demonstrated that immediate linkage to care is feasible and improves retention and suppression in a public/academic medical center in the U.S. South.

Understanding HIV Care Provider Attitudes Regarding Intentions to Prescribe PrEP.

INTRODUCTION: Preexposure prophylaxis (PrEP) is a promising approach to reducing HIV incidence. So, garnering the support of HIV providers, who are most familiar with antiretrovirals and likely to encounter patients in HIV serodiscordant relationships, to scale-up PrEP implementation is essential. We sought to determine whether certain subgroups of HIV providers were more likely to intend to prescribe PrEP. METHODS: Surveys were administered to HIV providers in Miami, Florida and Washington, District of Columbia. Composite scores were developed to measure PrEP knowledge, experience, and likelihood of prescribing. Latent class analysis was used to stratify provider attitudes toward PrEP. RESULTS: Among 142 HIV providers, 73.2% had cared for more than 20 HIV-infected patients in the previous 3 months; 17% had ever prescribed PrEP. Latent class analysis identified 2 classes of providers (entropy, 0.904); class 1 (n = 95) found PrEP less effective and perceived barriers to prescribing it; class 2 (n = 47) perceived PrEP as moderately effective and perceived fewer barriers to prescribing it. Compared with class 2, class 1 had significantly less experience with PrEP delivery (t(22.7) = 2.88, P = 0.009) and was significantly less likely to intend to prescribe to patients with multiple sex partners (20% vs. 43%, P = 0.04) and those with a drug use history (7% vs. 24%, P = 0.001). CONCLUSIONS: Although most HIV providers found PrEP to be effective, those considering it less effective had limited knowledge and experience with PrEP and had lesser intentions to prescribe. Provider training regarding whom should receive PrEP and addressing potential barriers to PrEP provision are needed if this HIV prevention method is to be optimized.

Association of individual and systemic barriers to optimal medical care in people living with HIV/AIDS in Miami-Dade County.

Barriers to retention in HIV care are detrimental to patients' progress along the HIV continuum of care. Previous literature has focused on individual, client-level barriers, and interventions to address them. In contrast, less work has examined the role of system-level barriers on HIV care outcomes. This study seeks to understand how individual and systemic barriers individually are associated with clinic appointment attendance and virologic suppression in HIV-infected patients attending the largest HIV clinic in Miami-Dade, FL. In addition, we examined the synergistic effects of these barriers as potential syndemic factors on these health outcomes. Barriers to clinic attendance were determined in a face-to-face study interview with 444 HIV-infected outpatients (187 regular attenders, 191 irregular attenders, and 66 nonattenders) identified from electronic medical records. Compared with the other attendance groups, nonattenders had higher viral loads, were less likely to be virologically suppressed, had lower CD4 counts, had higher depressive symptoms, life chaos, lower quality of life, and higher rates of food insecurity, and recent drug use. Additionally, nonattenders compared with regular attenders had lower physician relationship ratings, had lower medical information clarity and more often reported transportation as a barrier to clinic attendance. When viewed as a syndemic, compared with patients not reporting any barriers, patients with 3 or more individual-level barriers were more likely to have a detectable viral load (odds ratio = 3.60, 95% CI: 1.71 to 7.61). Our findings suggest that patients presenting to the clinic with multiple barriers should be prioritized for assistance and future interventions to improve retention in care. Interventions should address multiple individual and system-level barriers simultaneously with particular attention to addressing depressive symptoms, organizational skills, relationship with the physician, and HIV-related health education.

Using High-Impact HIV Prevention to Achieve the National HIV/AIDS Strategic Goals in Miami-Dade County, Florida: A Case Study.

: In response to the release of the National HIV/AIDS Strategy, the Centers for Disease Control and Prevention developed the "Enhanced Comprehensive HIV Prevention Planning" project, which provided support to health departments in 12 Metropolitan Statistical Areas with the highest AIDS prevalence to strengthen local HIV programs. We describe a case study of how 1 Metropolitan Statistical Area, Miami-Dade County, developed and implemented a locally tailored plan. Examples include actions to reinforce local partnerships and identify neighborhoods with highest unmet needs, an improved condom distribution system to assist local HIV care providers, collaboration with local stakeholders to establish a new walk-in center for transgender client needs, and overcoming incompatibilities in health department and Ryan White Program computer record systems to facilitate faster and more efficient patient services. These examples show how jurisdictions both within Florida and elsewhere can create low-cost and sustainable activities tailored to improve local HIV prevention needs.

HIV medical providers' perceptions of the use of antiretroviral therapy as nonoccupational postexposure prophylaxis in 2 major metropolitan areas.

INTRODUCTION: In 2005, the Centers for Disease Control and Prevention expanded its recommendation of postexposure prophylaxis (PEP) use in the workplace to include nonoccupational exposures (nPEP). The availability and extensive use of nPEP have not achieved widespread acceptance among health-care providers of high-risk populations, and public health and primary care agencies have been sparse in their implementation of nPEP promotion, protocols, and practices. METHODS: We conducted a survey of HIV providers (n = 142, response rate = 61%) in Miami-Dade County (Florida) and the District of Columbia that focused on their knowledge, attitudes, beliefs, and practices related to the delivery of nPEP. We then analyzed differences in survey responses by site and by history of prescribing nPEP using bivariate and multivariate logistic regression. RESULTS: More District of Columbia providers (59.7%) reported ever prescribing nPEP than in Miami (39.5%, P < 0.048). The majority of practices in both cities did not have a written nPEP protocol and rarely or never had patients request nPEP. Multivariable analysis for history of prescribing nPEP was dominated by having patients request nPEP [odds ratio (OR) = 21.53] and the belief that nPEP would lead to antiretroviral resistance (OR = 0.14) and having a written nPEP protocol (OR = 7.49). DISCUSSION: Our findings are consistent with earlier studies showing the underuse of nPEP as a prevention strategy. The significance of having a written nPEP protocol and of patient requests for nPEP speaks to the importance of using targeted strategies to promote widespread awareness of the use of HIV antiretroviral medications as a prevention intervention.

Efficacy of a health educator-delivered HIV prevention intervention for Latina women: a randomized controlled trial.

OBJECTIVES: We developed and assessed AMIGAS (Amigas, Mujeres Latinas, Inform andonos, Gui andonos, y Apoy andonos contra el SIDA [friends, Latina women, informing each other, guiding each other, and supporting each other against AIDS]), a culturally congruent HIV prevention intervention for Latina women adapted from SiSTA (Sistas Informing Sistas about Topics on AIDS), an intervention for African American women. METHODS: We recruited 252 Latina women aged 18 to 35 years in Miami, Florida, in 2008 to 2009 and randomized them to the 4-session AMIGAS intervention or a 1-session health intervention. Participants completed audio computer-assisted self-interviews at baseline and follow-up. RESULTS: Over the 6-month follow-up, AMIGAS participants reported more consistent condom use during the past 90 (adjusted odds ratio [AOR] = 4.81; P < .001) and 30 (AOR = 3.14; P < .001) days and at last sexual encounter (AOR = 2.76; P < .001), and a higher mean percentage condom use during the past 90 (relative change = 55.7%; P < .001) and 30 (relative change = 43.8%; P < .001) days than did comparison participants. AMIGAS participants reported fewer traditional views of gender roles (P = .008), greater self-efficacy for negotiating safer sex (P < .001), greater feelings of power in relationships (P = .02), greater self-efficacy for using condoms (P < .001), and greater HIV knowledge (P = .009) and perceived fewer barriers to using condoms (P < .001). CONCLUSIONS: Our results support the efficacy of this linguistically and culturally adapted HIV intervention among ethnically diverse, predominantly foreign-born Latina women.