Individual and Collective Forms of Stigma Resistance: Pathways Between HIV and Sex Work Stigma and Viral Suppression Among Female Sex Workers in the Dominican Republic.

Intersecting forms of stigma including both HIV and sex work stigma have been known to impede HIV prevention and optimal treatment outcomes among FSW. Recent research has indicated that intersectional stigma can be resisted at the community and individual level. We assessed pathways between HIV stigma, sex work stigma, social cohesion and viral suppression among a cohort of 210 FSW living with HIV in the Dominican Republic. Through Poisson regression we explored the relationship between HIV outcomes and internalized, anticipated and enacted HIV and sex work stigma, and resisted sex work stigma. We employed structural equation modeling to explore the direct effect of various forms of stigma on HIV outcomes, and the mediating effects of multi-level stigma resistance including social cohesion at the community level and occupational dignity at the individual level. 76.2% of FSW were virally suppressed and 28.1% had stopped ART at least once in the last 6 months. ART interruption had a significant negative direct effect on viral suppression (OR = 0.26, p < 0.001, 95% CI: 0.13-0.51). Social cohesion had a significant positive direct effect on viral suppression (OR = 2.07, p = 0.046, 95% CI: 1.01-4.25). Anticipated HIV stigma had a significant negative effect on viral suppression (OR = 0.34, p = 0.055, 95% CI: 0.11-1.02). This effect was mediated by the interaction between cohesion and dignity which rendered the impact of HIV stigma on viral suppression not significant. Findings demonstrate that while HIV stigma has a negative impact on viral suppression among FSW, it can be resisted through individual and collective means. Results reinforce the importance of community-driven, multi-level interventions.

Disrupting the Systems: Opportunities to Enhance Methodological Approaches to Address Socio-Structural Determinants of HIV and End the Epidemic Through Effective Community Engagement.

A world without HIV is only possible by addressing the socio-structural determinants of health. Our understanding of socio-structural determinants is constantly changing, and parallel changes must occur with the methodologies used to explain the drivers of the HIV epidemic. We argue for the need to engage communities in the planning, implementation, and dissemination of research on the socio-structural determinants of HIV. Community engagement should cross-cut various types of research including rigorous measurement development of socio-structural determinants and novel analytic techniques to model their role in the trajectory of the epidemic and the impact of interventions. Considering the role of place, we recommend collaboration between scientists and communities in the interpretation of results from studies that map HIV-related behaviors and movement. As we collectively delve into historically oppressive systems with colonial antecedents, we must be ready to challenge these systems and replace them with collaborative models. The success of research-driven HIV policy and programming will best be evaluated with methodologies derived from the insights of the very individuals that these policies and programs aim to serve.

RESUMEN: Un mundo sin VIH es posible sólo si atendemos los determinantes socio-estructurales de la salud. Nuestra comprensión sobre determinantes socio-estructurales cambia constantemente y cambios similares deben ocurrir en las metodologías utilizadas para explicar los factores que rigen la epidemia del VIH. Argumentamos sobre la necesidad de involucrar las comunidades en la planificación, implementación y diseminación de investigaciones sobre los determinantes socio-estructurales del VIH. La participación comunitaria debe ser transversal en varios tipos de investigaciones, incluyendo el desarrollo riguroso de métricas sobre los determinantes socio-estructurales y técnicas noveles para la modelación de su rol en las trayectorias de la epidemia y el impacto de intervenciones. Considerando el rol que tiene el lugar físico, recomendamos la colaboración de científicos y comunidades en la interpretación de resultados de estudios que crean mapas de las conductas relacionadas al VIH y la movilidad de las personas. En la medida en que examinamos sistemas históricamente opresivos con antecedentes coloniales, debemos estar listos para retar estos sistemas y remplazarlos con modelos colaborativos. El logro de políticas y programas de VIH informados por la investigación sería evaluado mejor si se utilizan metodologías guiadas por el conocimiento de las personas a las cuales estas políticas y programas persiguen servir.

Community-based management of complex type 2 diabetes: adaptation of an integrated model of care in a general practice setting.

BACKGROUND: Overburdened hospital clinics can have adverse outcomes. AIMS: To evaluate the effectiveness and patient acceptability of an integrated model of complex type 2 diabetes care delivered in a community-based general practice by upskilled general practitioners (GP) co-located with an endocrinologist and diabetes nurse educator. METHODS: Patients transferred from hospital clinic lists or referred by local GP were assessed in two southern Perth practices. An upskilled GP and endocrinologist developed a management plan which was communicated to the participant's usual GP. Up to two follow-up visits over 6 months ensured that management was acceptable and effective. RESULTS: A total of 464 people with type 2 diabetes (mean ± standard deviation age = 59.3 ± 13.7 years, 52.2% males) was enrolled. Their mean glycated haemoglobin (HbA1c ) was 9.3% (78 mmol/mol) and their mean body mass index 33.7 kg/m2 . Use of injectable blood glucose-lowering therapies increased between the initial and final visit in association with a median HbA1c reduction of 1.2% (13 mmol/mol) which was sustained to 12 months in assessable participants. There were also reductions in blood pressure, and serum low-density lipoprotein cholesterol and triglyceride concentrations. Patient satisfaction with current treatment, time for self-management, time spent in diabetes-related appointments and diabetes knowledge increased significantly. Non-attendance for scheduled appointments was <10%. Local hospital referrals and waiting lists reduced over the study period. CONCLUSIONS: This study confirms the value of integrated community-based care of complex type 2 diabetes which could represent a sustainable solution to overburdened hospital diabetes outpatient clinics.

Family planning use and correlates among female sex workers in a community empowerment HIV prevention intervention in Iringa, Tanzania: a case for tailored programming.

BACKGROUND: Female sex workers in sub-Saharan Africa face high unmet need for family planning and higher risk for unintended pregnancy. Community empowerment HIV prevention approaches have the potential to increase family planning uptake and present an opportunity to integrate HIV, reproductive health, and contraception. This article describes family planning use and pregnancy among female sex workers in Iringa, Tanzania and evaluates whether engagement in a community empowerment HIV prevention program is associated with contraceptive use. METHODS: This study consists of secondary analysis from a two-community randomized controlled trial following a longitudinal cohort over 18 months. We implemented a year-long community empowerment intervention consisting of 1) a community-led drop-in-center; 2) venue-based peer education, condom distribution, and HIV testing; 3) peer service navigation; 4) sensitivity trainings for providers and police; and 5) text messages to promote engagement. Additionally, monthly seminars were held at the drop-in-center, one of which focused on family planning. Modified Poisson regression models were used to estimate the association between program exposure and family planning use in the intervention arm. (Trials Registration NCT02281578, Nov 2, 2014.) RESULTS: Among the 339 participants with follow-up data on family planning, 60% reported current family planning use; 6% reported dual use of modern contraception and condoms; over 90% had living children; and 85% sought antenatal care at their most recent pregnancy. Among the 185 participants in the intervention arm, the adjusted relative risk (aRR) of family planning use among female sex workers who reported ever attending the Shikamana drop-in-center and among female sex workers who reported attending a family planning-related workshop was respectively 26% (aRR 1.26 [95% Confidence Interval (CI): 1.02-1.56]) and 36% (aRR 1.36 [95%CI: 1.13-1.64) higher than among those who had not attended. CONCLUSION: There is a clear need for family planning among this population. General program exposure and exposure to a family planning workshop were associated with higher family planning use, which suggests that community empowerment models have potential to increase family planning uptake for this vulnerable group.

Research Capacity Strengthening in Sub-Saharan Africa: Recognizing the Importance of Local Partnerships in Designing and Disseminating HIV Implementation Science to Reach the 90-90-90 Goals.

Capacity building in implementation science is integral to PEPFAR's mission and to meeting the 90-90-90 goals. The USAID funded Project SOAR sponsored a 4 day workshop for investigators and governmental and non-governmental partners from 12 African countries. The workshop was designed to address both findings from a pre-workshop online needs assessment as well as capacity challenges across the capacity building pyramid, from individual skills to institutional systems and resources. Activities were output-oriented and skill based. An online survey evaluated sessions and changes in perceptions of needs; a majority of respondents strongly agreed that after the workshop, they better understood their personal and institutional capacity strengthening needs. Participants 'strongly agreed' that workshop content was relevant to their jobs (90%) and that they left the workshop with a specific plan for conducting future research (65%). Workshop results suggest that skill-building should be done in conjunction with systems capacity building within the cultural context.

Increasing Access To Perinatal Mental Health Care: The Perinatal Psychiatry Access Program Model.

Perinatal psychiatry access programs offer a scalable approach to building the capacity of perinatal professionals to identify, assess, and treat mental health conditions. Little is known about access programs' implementation and the relative merits of differing approaches. We conducted surveys and semistructured interviews with access program staff and reviewed policy and procedure documents from the fifteen access programs that had been implemented in the United States as of March 2021, when the study was conducted. Since then, the number of access programs has grown to thirty state, regional, or national programs. Access programs implemented up to five program components, including telephone consultation with a perinatal psychiatry expert, one-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, trainings for perinatal professionals, and practice-level technical assistance. Characterizing population-based intervention models, such as perinatal psychiatry access programs, that address perinatal mental health conditions is a needed step toward evaluating and improving programs' implementation, reach, and effectiveness.

Context and Considerations for the Development of Community-Informed Health Communication Messaging to Support Equitable Uptake of COVID-19 Vaccines Among Communities of Color in Washington, DC.

BACKGROUND: Communities of color have been disproportionately impacted by COVID-19. We explored barriers and facilitators to COVID-19 vaccine uptake among African American, Latinx, and African immigrant communities in Washington, DC. METHODS: A total of 76 individuals participated in qualitative interviews and focus groups, and 208 individuals from communities of color participated in an online crowdsourcing contest. RESULTS: Findings documented a lack of sufficient, accurate information about COVID-19 vaccines and questions about the science. African American and African immigrant participants spoke about the deeply rooted historical underpinnings to their community's vaccine hesitancy, citing the prior and ongoing mistreatment of people of color by the medical community. Latinx and African immigrant participants highlighted how limited accessibility played an important role in the slow uptake of COVID-19 vaccines in their communities. Connectedness and solidarity were found to be key assets that can be drawn upon through community-driven responses to address social-structural challenges to COVID-19 related vaccine uptake. CONCLUSIONS: The historic and ongoing socio-economic context and realities of communities of color must be understood and respected to inform community-based health communication messaging to support vaccine equity for COVID-19 and other infectious diseases.

The role of perinatal psychiatry access programs in advancing mental health equity.

This editorial presents: 1) a review of Perinatal Psychiatry Access Programs as an integrated care model with potential for promoting perinatal mental health equity; and 2) a summary of how the model has been and can be further adapted to help achieve perinatal mental health equity in geographically diverse settings. Within the editorial, we highlight Access Programs as a promising model for promoting perinatal mental health equity. This editorial is supported by original descriptive data on the Lifeline for Moms National Network of Perinatal Psychiatric Access Programs. Descriptive data is additionally provided on three statewide Access Programs. The Access Program model, and the accompanying Network of Access Programs, is a multi-level approach demonstrating promise in reducing perinatal mental health inequities. Access Programs demonstrate potential to implement interventions to address well-documented inequities in perinatal mental healthcare access at the patient-, clinician-, practice-, community-, and policy-levels. For Access Programs to leverage their potential to advance perinatal mental health equity, systematic efforts are needed that include partnership with impacted communities and implementation teams.

Acceptability of multiple modalities of pre-exposure prophylaxis (PrEP) among female sex workers in Tanzania: a mixed-methods study.

OBJECTIVES: Modalities of pre-exposure prophylaxis (PrEP) for HIV prevention offer options to women at high risk including female sex workers (FSW). This study aimed to explore FSW's acceptability and preferences for oral pills, long-acting (LA) injectable and vaginal ring PrEP. DESIGN: Sequential, explanatory, mixed methods. SETTING: Iringa, Tanzania. PARTICIPANTS: FSW aged above 18 were recruited from sex work venues using time-location sampling (n=496); HIV-uninfected (n=293) were included in this analysis. Subsequently, survey participants were recruited for in-depth interviews (n=10) and two focus group discussions (n=20). PRIMARY OUTCOME MEASURES: (1) Acceptability of PrEP (Do you personally think it would be worth it to you to take ART if it could prevent HIV?: yes/no) and (2) preference for LA injectable versus oral pills (If you personally were going to take ART to prevent HIV infection, would you prefer to take it in the form of a daily pill or an injection once every 3 months? Injection/pill). RESULTS: Participants were (92%) unaware of PrEP but 58% thought it would be worth it to personally take PrEP. Acceptability of PrEP was significantly associated with higher social cohesion (aOR 2.12; 95% CI 1.29 to 3.50) and STI symptoms in the past 6 months (aOR 2.52; 95% CI 1.38 to 4.62). Most (88%) preferred LA vs oral PrEP. Qualitative findings revealed generally positive reactions to all types of PrEP, and they were viewed as a welcome backup to condoms. Participants had concerns about pills (burden of daily use, stigma from clients), and the vaginal ring (fear of client noticing and becoming suspicious, fear of infertility) and overall preferred LA-PrEP (less frequent use, easy to hide, belief in higher efficacy). CONCLUSIONS: Offering multiple formulations of PrEP within the context of community-driven HIV prevention interventions among FSW may facilitate increased uptake and adherence. LA injectable PrEP may be a particularly preferred formulation among FSW. TRIAL REGISTRATION NUMBER: NCT02281578.

The Mid-Atlantic Centers for AIDS Research Consortium: Promoting HIV Science Through Regional Collaboration.

The Centers for AIDS Research (CFAR) program was established by the National Institutes of Health in 1988 to catalyze and support high-impact HIV research and to develop the next generation of HIV investigators at academic institutions throughout the United States. In 2014, the Penn CFAR, the Johns Hopkins University CFAR and the District of Columbia CFAR developed a partnership-the Mid-Atlantic CFAR Consortium (MACC)-to promote cross-CFAR scientific collaboration, mentoring, and communication and to address the regional HIV epidemic. Over the past 6 years, the creation of the MACC has resulted in a rich web of interconnectivity, which has fostered scientific collaboration through working groups on the black men who have sex with men (MSM) and Latinx regional HIV epidemics, joint peer-reviewed publications, and successful collaborative grant applications on topics ranging from HIV prevention in young MSM, transgender women, implementation science, and clinical epidemiology; supported developmental activities through the MACC Scholars program, cross-CFAR mentoring, joint symposia, cross-CFAR seminar participation, and keynote speakers; and promoted strategic communication through advisory committees, best practices consultations, and the social and behavioral science research network. The MACC has been highly impactful by promoting HIV science through regional collaboration, supporting a diverse network of scholars across three cities and focusing on the epidemic in underrepresented and marginalized communities. Lessons learned from this consortium may have implications for scientific research centers beyond the field of HIV.

Perinatal Mental Health Care In The United States: An Overview Of Policies And Programs.

In the United States, mental health conditions are the most common complications of pregnancy and childbirth, and suicide and overdose combined are the leading cause of death for new mothers. Although awareness of and action on perinatal mental health is increasing, significant gaps remain. Screening and treatment are widely recommended but unevenly implemented, and policies and funding do not adequately support the mental health of childbearing people. As a result, treatable perinatal mental health conditions can have long-term, multigenerational negative consequences. This article provides an overview of the perinatal mental health landscape in the United States by identifying serious gaps in screening, education, and treatment; describing recent federal and state policy efforts; highlighting successful models of care; and offering recommendations for robust and integrated perinatal mental health care.

Enhanced immigration enforcement in the USA and the transnational continuity of HIV care for Latin American immigrants in deportation proceedings.

In our work as clinicians, researchers, and immigrant rights advocates, we have noted increased anxiety about the possibility of deportation and disruptions in care among immigrants with HIV. Before the 2016 US elections, patients rarely asked about HIV treatment in their home countries. However, since the increase in anti-immigrant rhetoric and arrests by US Immigration and Customs Enforcement, patients have voiced concerns about the availability of HIV treatment in their home countries much more frequently. Although antiretroviral therapy is available throughout Latin America, access depends on economic, social, and political circumstances. Maintaining uninterrupted continuity of care among immigrants held in detention or deported to their home countries is challenging. In this Viewpoint, we identify periods of particular vulnerability for immigrants during deportation proceedings, from initial detention to deposition in their country of origin. We discuss the effect of enhanced immigration enforcement on the health and wellbeing of HIV-infected immigrants, and on public health. Finally, we also discuss recommendations for clinicians, immigration authorities, and public health institutions in the USA and in receiving countries.

A Learning Collaborative Model to Improve Human Papillomavirus Vaccination Rates in Primary Care.

OBJECTIVE: Human papillomavirus (HPV) vaccination rates remain low, in part because of missed opportunities (MOs) for vaccination. We used a learning collaborative quality improvement (QI) model to assess the effect of a multicomponent intervention on reducing MOs. METHODS: Study design: pre-post using a QI intervention in 33 community practices and 14 pediatric continuity clinics over 9 months to reduce MOs for HPV vaccination at all visit types. MEASURES: outcome measures comprised baseline and postproject measures of 1) MOs (primary outcome), and 2) HPV vaccine initiation and completion. Process measures comprised monthly chart audits of MOs for HPV vaccination for performance feedback, monthly Plan-Do-Study-Act surveys and pre-post surveys about office systems. INTERVENTION: providers were trained at the start of the project on offering a strong recommendation for HPV vaccination. Practices implemented provider prompts and/or standing orders and/or reminder/recall if desired, and were provided monthly feedback on MOs to assess their progress. ANALYSES: chi-square tests were used to assess changes in office practices, and logistic regression used to assess changes in MOs according to visit type and overall, as well as HPV vaccine initiation and completion. RESULTS: MOs overall decreased (from 73% to 53% in community practices and 62% to 55% in continuity clinics; P < .01, and P = .03, respectively). HPV vaccine initiation increased for both genders in community practices (from 66% to 74% for female, 57% to 65% for male; P < .01), and for male patients in continuity clinics (from 68% to 75%; P = .05). Series completion increased overall in community practices (39% to 43%; P = .04) and for male patients in continuity clinics (from 36% to 44%; P = .03). CONCLUSIONS: Office systems changes using a QI model and multicomponent interventions decreased rates of MO for HPV vaccination and increased initiation and completion rates among some gender subgroups. A learning collaborative model provides an effective forum for practices to improve HPV vaccine delivery.

Promoting Pre-exposure Prophylaxis to Prevent HIV Infections Among Sexual and Gender Minority Hispanics/Latinxs.

Sexual and gender minority Hispanics/Latinxs (henceforth: Latinxs) continue to be disproportionately impacted by HIV/AIDS in the U.S. Pre-exposure prophylaxis (PrEP) is a biomedical prevention approach which holds significant promise for at risk and vulnerable populations. We discuss barriers and facilitators to uptake of PrEP among sexual and gender minority Latinxs living in the U.S. through an ecosocial lens that takes into account structural, community, and individual contexts. The impact of immigration status on PrEP uptake emerges as a major and recurrent theme that must be understood and addressed by HIV prevention programs aiming to promote an inclusive strategy for sexual and gender minority Latinxs living in the U.S.