Development and validation of the mpox stigma scale (MSS) and mpox knowledge scale (MKS).

BACKGROUND: Few validated brief scales are available to measure constructs that may hinder mpox-related prevention and care engagement, such as knowledge and stigma. Both are highly salient barriers to infectious disease care and disease understanding, precursors to evaluating one's risk and need to, for example, accept vaccination. To address this gap, we developed and validated the Mpox Stigma Scale (MSS) and Mpox Knowledge Scale (MKS). METHODS: As part of a full-scale clinical trial, we offered an optional mpox survey to participants who self-identified as African American or Black, were 18-29 years old, and lived in Alabama, Georgia, or North Carolina (2023, N = 330). We calculated psychometric properties through confirmatory factor analyses (CFA) and applied Comparative Fit Index (CFI), Goodness of Fit Index (GFI), and Tucker-Lewis Index (TLI) values equal to or exceeding 0.90 and Root Mean Square Error of Approximation (RMSEA) and Standardized Root Mean Square Residual (SRMR) values less than 0.08 to determine adequate model fit. We computed internal reliability using Cronbach's alpha and calculated Pearson or Spearman correlation coefficients between the MSS and MKS and related variables. RESULTS: For the MSS, CFA results showed that the one-factor model fit the data well (χ2(df = 5, N = 330) = 34.962, CFI = 0.97, GFI = 0.99, TLI = 0.94, RMSEA = 0.13, SRMR = 0.03). For the MKS, the one-factor model provided a good fit to the data (χ2(df = 6, N = 330) = 8.44, CFI = 0.99, GFI = 0.99, TLI = 0.95, RMSEA = 0.15, SRMR = 0.02). Cronbach's alphas were MSS = 0.91 and MKS = 0.83, suggesting good to excellent reliability. The MSS was correlated with the MKS (r = .55, p < .001), stigmatizing attitudes (r = .24, p < .001), attitudes towards mpox vaccination (r=-.12, p = .030), and worry about contracting mpox (r = .44, p < .001). The MKS was correlated with worry about contracting mpox (r = .30, p < .001) and mpox disclosure (r=-.16, p = .003). CONCLUSIONS: The MSS and MKS are reliable and valid tools for public health practice, treatment and prevention research, and behavioral science. Further validation is warranted across populations and geographic locations. TRIAL REGISTRATION: ClinicalTrials.gov NCT05490329.

Associations Between PrEP Stigma, PrEP Confidence, and PrEP Adherence: Conditional Indirect Effects of Anticipated HIV Stigma.

BACKGROUND: Research has linked stigma surrounding preexposure prophylaxis (PrEP) to poor HIV prevention outcomes, including PrEP adherence. However, there remains a limited understanding of the mechanisms through which PrEP stigma affects PrEP adherence, specifically among sexual and gender minority (SGM) youth. In this study, we aimed to investigate the indirect effect of PrEP stigma on PrEP adherence through PrEP confidence and the moderating role of anticipated HIV stigma. METHODS: Participants included 235 SGM youth, assigned male sex at birth, aged 16-24, and self-reported HIV-negative, with an active PrEP prescription from the Prepared, Protected, emPowered randomized controlled trial. Participants were recruited from 9 clinics in the United States between 2019 and 2021. Using baseline data, we tested cross-sectional indirect and conditional indirect effects using the Statistical Package for the Social Sciences Process with confidence intervals and 2000 resamples. RESULTS: We found significant indirect effects, suggesting that PrEP stigma was negatively associated with PrEP confidence, which in turn resulted in both monthly and weekly optimal PrEP adherence (Indirect effects: B = -0.11, Standard Error [SE] = 0.05, CI: [-0.244 to -0.032]; B = -0.09, SE = 0.04, CI: [-0.191 to -0.014], respectively). Anticipated HIV stigma moderated these indirect effects (B = -0.11, SE = 0.08, CI: [-0.315 to -0.001]; B = -0.09, SE = 0.06, CI: [-0.245 to -0.001], respectively), suggesting that the conditional indirect effects were significant at high but not low levels of anticipated HIV stigma. CONCLUSION: Results suggest that SGM youth who are on PrEP anticipating HIV stigma experience a compounding effect of PrEP stigma on PrEP confidence, consequently leading to suboptimal adherence. Interventions addressing the intersectionality of PrEP and HIV stigmas and enhancing confidence could improve PrEP adherence, particularly among SGM youth.

When HIPAA hurts: legal barriers to texting may reinforce healthcare disparities and disenfranchise vulnerable patients.

Effective health communication between healthcare providers and patients is a cornerstone of quality healthcare. It underpins trust, comprehension, and patient-informed care. Robust research shows that effective communication, including the use of text messaging for communication can improve maternal/fetal and neonatal outcomes and patient satisfaction, particularly among vulnerable patients. Health information privacy laws that do not evolve with technological advances can inadvertently create barriers to effective health communication, reinforcing perinatal disparities. This is particularly true regarding maternal and child health, where the use of text messaging for patient communication has the potential to make a substantial impact on health disparities. This article explores the complex interplay between health information privacy laws and text messaging, highlighting challenges and examining potential solutions. It stresses the need for consistent health information privacy laws that protect the privacy security of health information for pregnant patients and new mothers, while also aligning with evolving communication technologies.

Community recommendations for promoting HIV testing to Black young men who have sex with men in the southern United States.

BACKGROUND: Considering the need to increase HIV testing among racial minority youth in the southern United States, we conducted an exploratory study in Alabama to elucidate recommendations on improving testing rates among Black young men who have sex with men (BYMSM). METHODS: We conducted in-depth interviews and focus groups with BYMSM and prevention and outreach workers. Data collection occurred online and in person between 2020-2022. RESULTS: Our sample included data from n = 56 BYMSM and n = 12 prevention and outreach workers. BYMSMs' mean age = 24 years. Among prevention and outreach workers, 58% identified as male with mean age = 39 years; 83% identified as Black. Transcripts were coded thematically; five concurrent themes emerged from both BYMSM and prevention and outreach workers: promoting testing at younger ages, need for visibility and outreach, connecting through shared experiences, value of nonjudgmental approaches, and need to increase HIV knowledge in BYMSM. CONCLUSIONS: Findings suggest that cultivating trust is salient to promoting HIV testing in BYMSM. To end the epidemic in the southern United States, a region that is heavily rural with high rates of HIV, it may be necessary to begin prevention conversations at younger ages and equip prevention and outreach workers with communication skills that leverage de-stigmatizing approaches.

Conquering hypertension in Vietnam: 12- month follow up results from a cluster-randomised controlled trial.

Background: Approximately 20% of adults in Vietnam have hypertension, and management of this chronic condition remains challenging. This study aimed to assess the effectiveness of a multicomponent intervention in reducing blood pressure (BP) in adults with uncontrolled hypertension. Methods: This cluster randomised controlled trial was conducted in sixteen communities (8 intervention and 8 comparison) in a rural setting in Vietnam (2017-2022). Consenting adults (aged ≥ 18 years) with uncontrolled hypertension were enrolled. Sixteen communities were equally randomised to an intervention or comparison group stratified by district. Consenting adults were assigned to study groups by community. The comparison arm received training sessions about hypertension prevention and management for health workers, and patient education materials. The intervention arm received training sessions about hypertension prevention and management for health workers, and patient education materials and three enhancement components including a storytelling intervention, home BP self-monitoring, and expanded community health worker services. The primary outcome was the difference in changes in patient's levels of systolic BP between the study groups over a 12-month follow-up period. Patients and outcome assessors were masked. Findings: A total of 671 patients (340: intervention, 331: comparison) were enrolled in the trial. The mean age was 66 years and 45% were men. At the 12-month follow-up, the mean systolic BP declined by 18.4 mmHg in the intervention group and 3.7 mmHg in the comparison group (differential decline of 14.7 mmHg [95% CI: 11.8-17.6]). The intervention group also achieved better BP control and medication adherence than the comparison group. There were no serious adverse events related to study participation. Interpretation: The results of this trial demonstrate that a multicomponent intervention can effectively reduce elevated BP in individuals with uncontrolled hypertension in Vietnam. Trial registration: This trial was registered at ClinicalTrials.gov, NCT03590691. Funding: National Heart, Lung, and Blood Institute.

Living a private lie: intersectional stigma, depression and suicidal thoughts for selected young key populations living with HIV in Zambia.

BACKGROUND: Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia. METHODS: We applied a mixed-methods design. Data were collected from January 2022 to May 2022. Qualitative data were collected using in-depth interviews while quantitative data were collected using a questionnaire. Qualitative transcripts were coded using thematic analysis while paper-based questionnaire data were entered into Kobo Connect. Descriptive statistics, using chi-squared tests were calculated using Excel. In this paper, we provide a descriptive profile of the sample and then focus on the qualitative findings on intersectional stigma, depression, and contemplation of suicide. RESULTS: We recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants' mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of TGW had moderate to significant symptoms of depression (40%) or major depression (10%) compared to MSM, at 33% and 6%, respectively (X2 = 0.65; p = 0.42). Similarly, more TGW (55%) had contemplated suicide than MSM peers (36%, X2=1.87; p = 0.17). In the qualitative data, four emergent themes about the forms, manifestations, and effects of intersectional stigma were (1) HIV, sexual orientation, and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience. Overall, having to hide both one's sexuality and HIV status had a compounding effect and was described as living "a private lie." CONCLUSION: Effectively addressing stigmas and poor mental health outcomes among young HIV-positive MSM and TGW will require adopting a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening of authentic community-informed public health efforts.

Structural barriers to maternity care in Cameroon: a qualitative study.

BACKGROUND: The maternal mortality and perinatal mortality rate in Cameroon are among the highest worldwide. To improve these outcomes, we conducted a formative qualitative assessment to inform the adaptation of a mobile provider-to-provider intervention in Cameroon. We explored the complex interplay of structural barriers on maternity care in this low-resourced nation. The study aimed to identify structural barriers to maternal care during the early adaptation of the mobile Medical Information Service via Telephone (mMIST) program in Cameroon. METHODS: We conducted in-depth interviews and focus groups with 56 key stakeholders including previously and currently pregnant women, primary healthcare providers, administrators, and representatives of the Ministry of Health, recruited by purposive sampling. Thematic coding and analysis via modified grounded theory approach were conducted using NVivo12 software. RESULTS: Three main structural barriers emerged: (1) civil unrest (conflict between Ambazonian militant groups and the Cameroonian government in the Northwest), (2) limitations of the healthcare system, (3) inadequate physical infrastructure. Civil unrest impacted personal security, transportation safety, and disrupted medical transport system. Limitations of healthcare system involved critical shortages of skilled personnel and medical equipment, low commitment to evidence-based care, poor reputation, ineffective health system communication, incentives affecting care, and inadequate data collection. Inadequate physical infrastructure included frequent power outages and geographic distribution of healthcare facilities leading to logistical challenges. CONCLUSION: Dynamic inter-relations among structural level factors create barriers to maternity care in Cameroon. Implementation of policies and intervention programs addressing structural barriers are necessary to facilitate timely access and utilization of high-quality maternity care.

HIV and intersectional stigma among people living with HIV and healthcare workers and antiretroviral therapy adherence in the Dominican Republic.

BACKGROUND: HIV-related stigma, discrimination, and social marginalization undermines optimal HIV care outcomes. More research examining the impact of HIV-related stigma, discrimination, other interlocking forms of oppression, and antiretroviral therapy (ART) adherence is needed to optimize HIV treatment programming. This study uses data from two clinics in the Dominican Republic to examine client and healthcare worker (HCW) perceptions of HIV and intersectional stigmas among people living with HIV. METHODS: Surveys exploring demographics, HIV-related stigma, various dimensions of discrimination (race/ethnicity, HIV status, sexual orientation), healthcare engagement, and medication adherence were collected from 148 clients and 131 HCWs. Analysis of variance was conducted to examine differences in stigma by clinic and logistic regressions were used to determine predictors of optimal client medication adherence. RESULTS: Perceived discrimination in healthcare facilities due to clients' sexual orientation retained significance in crude and multivariable logistic regression models and was negatively associated with ART adherence (aOR:0.79; 95% CI:0.66, 0.95). DISCUSSION: Findings highlight the importance of implementing strategies to address stigma, discrimination, and social marginalization, particularly within healthcare facilities.

Patient and Provider Perceptions of Barriers and Facilitators to Pre-exposure Prophylaxis Access and Adherence in Black and Latinx Young Men Who Have Sex with Men.

In the United States, the use of pre-exposure prophylaxis (PrEP) has led to a substantial decrease in HIV prevalence and incidence. However, some populations, including young men who have sex with men (YMSM) of color, continue to be disproportionately impacted, highlighting the need for tailored interventions addressing barriers to adequate PrEP access. In collaboration with partner clinics, we recruited 19 PrEP clients and 19 PrEP providers (n = 35) to participate in hour-long in-depth interviews. Although client interviews explored personal experiences with stigma, barriers, and motivators to PrEP and information preferences, provider interviews explored providers' perceived stigma in their clinic, perceived barriers and motivators to meeting clients' PrEP needs, and rapport building with clients. Most participants were affiliated with one of the southern partner clinics. Clients and providers noted similar determinants to PrEP access, uptake, and adherence. Both recognized the impact of personal barriers such as routine adjustments and perception of need, as well as institutional barriers such as transportation and financial difficulties. Clients emphasized the role of the client-provider relationship as part of contributing to willingness to disclose information such as HIV status and sexual practices. Providers noted the importance of sexual health and LGBTQ+ topics in their training. Despite limited geographical scope and the sensitive nature of HIV-related topics, this study has several implications. PrEP clinics may benefit from hiring providers who share identities and experiences with YMSM clients of color and operating with a flexible schedule. Medical provider training should include comprehensive sexual health and LGBTQ+ competencies to reduce bias in care.

A Moderated Mediation Analysis of HIV and Intersectional Stigmas and Antiretroviral Adherence in People Living with HIV in the Dominican Republic.

Experiencing HIV and intersectional stigmas in healthcare settings may affect antiretroviral treatment (ART) adherence among people with HIV (PWH), given their need for frequent interactions with clinical settings and healthcare providers. Considering the importance of reducing stigmas to promote well-being and the need to elucidate how stigma influences health across various settings, we examined how experienced HIV stigma in Dominican Republic healthcare settings impacts ART adherence through internalized HIV stigma and whether race or sexual orientation stigma moderates this relationship. Participants were 471 PWH (aged 17-71) who were recruited from two HIV clinics in the Dominican Republic in 2021-2022. Results revealed a significant mediation effect (B=-0.10, SE = 0.05, CI [-0.234, - 0.014]) after adjusting for effect of age and time since HIV diagnosis, suggesting that experienced HIV stigma in healthcare settings was associated with more internalized HIV stigma (B = 0.39, SE = 0.11, p = .001), subsequently linked to lower ART adherence (B=-0.26, SE = 0.11, p = .016). The indirect effect was significant at low levels of race stigma (B=-0.16, SE = 0.09, CI [-0.369, - 0.001]) but not at high levels of race stigma (B=-0.06, SE = 0.05, CI [-0.175, 0.038]). This indirect effect was also significant at low levels of sexual orientation stigma (B=-0.19, SE = 0.10, CI [-0.401, - 0.023]) but not at high levels of sexual orientation stigma (B=-0.04, SE = 0.06, CI [-0.160, 0.074]). These findings suggest that addressing experienced HIV stigma in Dominican Republic healthcare settings, along with various dimensions of HIV-related stigma (e.g., internalized stigma) and intersecting stigmas (e.g., race, sexual orientation), is vital for improving health outcomes, such as optimal ART adherence.

RESUMEN: Experimentar estigmas relacionados con el VIH e interseccionales en entornos de atención médica puede afectar la adherencia al tratamiento antirretroviral (TAR) entre las personas que viven con VIH (PVVIH), dado que necesitan interacciones frecuentes con entornos clínicos y proveedores de atención médica. Considerando la importancia de reducir los estigmas para promover el bienestar y la necesidad de esclarecer cómo el estigma influye en la salud en diversos contextos, examinamos cómo el estigma del VIH experimentado en entornos de atención médica en la República Dominicana impacta la adherencia al TAR a través del estigma internalizado del VIH y si el estigma racial o de orientación sexual modera esta relación. Los participantes fueron 471 PVVIH (de 17 a 71 años) que fueron reclutados de dos clínicas de VIH en la República Dominicana en 2021­2022. Los resultados revelaron un efecto de mediación significativo (B=-0.10, SE = 0.05, CI [-0.234, − 0.014]) después de ajustar por el efecto de la edad y el tiempo desde el diagnóstico de VIH, sugiriendo que el estigma del VIH experimentado en entornos de atención médica estaba asociado con un mayor estigma internalizado del VIH (B = 0.39, SE = 0.11, p = .001), vinculado posteriormente a una menor adherencia al TAR (B=-0.26, SE = 0.11, p = .016). El efecto indirecto fue significativo en niveles bajos de estigma racial (B=-0.16, SE = 0.09, CI [-0.369, − 0.001]) pero no en niveles altos de estigma racial (B=-0.06, SE = 0.05, CI [-0.175, 0.038]). Este efecto indirecto también fue significativo en niveles bajos de estigma por orientación sexual (B=-0.19, SE = 0.10, CI [-0.401, − 0.023]) pero no en niveles altos de estigma por orientación sexual (B=-0.04, SE = 0.06, CI [-0.160, 0.074]). Estos hallazgos sugieren que abordar el estigma del VIH experimentado en entornos de atención médica en la República Dominicana, junto con diversas dimensiones del estigma relacionado con el VIH (por ejemplo, estigma internalizado) y estigmas interseccionales (por ejemplo, raza, orientación sexual), es vital para mejorar los resultados de salud, como la adherencia óptima al TAR.

Re-evaluating the relationship between youth with HIV and BMI in an age of increasing rates of overweight and obese youth.

BACKGROUND: Newer antiretrivirals (ART) have shifted the metabolic experiences of people with HIV (PWH) from those of wasting syndrome to increases in body mass index (BMI). This study sought to examine the relationship between BMI and ART use among youth with HIV (YWH). METHODS: Charts from YWH ages 10-24 with at least two documented BMIs at least 6 months apart between 2017 and 2020 were included (N = 44). Statistical analyses were conducted in SAS 9.4. RESULTS: Clients were predominately African American (66%) males (73%) aged 19-24 years (64%), with men having sex with men (48%) being the most common mode of transmission. YWH on non-integrase inhibitor (INSTI) regimens had greater absolute increases in BMI compared to those on INSTI regimens (p = 0.03). Fourteen percent of clients using INSTI experienced an increase in BMI class from normal to overweight or overweight to obese; no non-INSTI users changed BMI class. Time since diagnosis and BMI change due to weight gain were positively associated (p = 0.03) among behaviorally-acquired YWH. CONCLUSIONS: Increasing BMI and changing BMI classes may be more likely among YWH using INSTI. More longitudinal studies inclusive of diet and exercise profiles are needed to understand the relationship between INSTI and YWH BMI.

The Characteristics of Youth With Missed HIV Visits in Alabama.

Gaps in knowledge remain related to understanding missed human immunodeficiency virus (HIV) visits and youth with HIV (YWH). This study examined data from an Alabama academic HIV clinic with clients aged 16 to 24 years old and found that non virally suppressed and older YWH were associated with missed visits among YWH.

Viral load and sexually transmitted infection testing among youth with HIV in a southern United States clinic.

Background: As compared to their older peers, youth with HIV (YWH) are less likely to attain viral suppression and have higher rates of sexually transmitted infections (STI). In this exploratory study, we examine the relationship between HIV viral suppression, STI testing, and STI diagnosis among YWH receiving care at a clinic in the southern United States.Methods: Data from 933 clinical visits (2017-2020) were aggregated into singular patient records for YWH aged 10-24 years in Alabama (N = 139). Analyses included univariate generalized linear mixed models performed with the PROC GLIMMIX procedure approximating the marginal likelihood by using Laplace's method.Results: Sample median age was 22 years at the index visit. Most YWH were 20-24 years old (69.1%), male (67.6%), and identified as Black (77%); 58.3% were virally unsuppressed at index visit. YWH who identified as White or of other races had 4.79 times higher odds of being virally suppressed as compared to Black YWH (p < .01); STI testing behavior and STI positive diagnosis were associated with lower odds of being virally suppression.Conclusions: Findings suggest that among YWH, receiving STI testing and having an STI diagnosis is associated with a lack of viral suppression, suggesting that extra efforts may be necessary to support YWH who have an STI to attain suppression. Research is needed to examine individual behaviors, structural forces, and clinic features that could impact STI care engagement, specifically among unsuppressed YWH.

Quantifying the association of individual-level characteristics with disparities in kidney transplant waitlist addition among people with HIV.

BACKGROUND: Over 45% of people with HIV (PWH) in the United States at least 50 years old and are at heightened risk of aging-related comorbidities including end-stage kidney disease (ESKD), for which kidney transplant is the optimal treatment. Among ESKD patients, PWH have lower likelihood of waitlisting, a requisite step in the transplant process, than individuals without HIV. It is unknown what proportion of the inequity by HIV status can be explained by demographics, medical characteristics, substance use history, and geography. METHODS: The United States Renal Data System, a national database of all individuals ESKD, was used to create a cohort of people with and without HIV through Medicare claims linkage (2007-2017). The primary outcome was waitlisting. Inverse odds ratio weighting was conducted to assess what proportion of the disparity by HIV status could be explained by individual characteristics. RESULTS: Six thousand two hundred and fifty PWH were significantly younger at ESKD diagnosis and more commonly Black with fewer comorbidities. PWH were more frequently characterized as using tobacco, alcohol and drugs. Positive HIV-status was associated with 57% lower likelihood of waitlisting [adjusted hazard ratio (aHR): 0.43, 95% confidence interval (CI): 0.46-0.48, P  < 0.001]. Controlling for demographics, medical characteristics, substance use and geography explained 39.8% of this observed disparity (aHR: 0.69, 95% CI: 0.59-0.79, P  < 0.001). CONCLUSION: PWH were significantly less likely to be waitlisted, and 60.2% of that disparity remained unexplained. HIV characteristics such as CD4 + counts, viral loads, antiretroviral therapy adherence, as well as patient preferences and provider decision-making warrant further study.

Influence of provider openness and leadership behaviors on adherence to motivational interviewing training implementation strategies: Considerations for evidence-based practice delivery.

Background: Adherence to intervention training implementation strategies is at the foundation of fidelity; however, few studies have linked training adherence to trainee attitudes and leadership behaviors to identify what practically matters for the adoption and dissemination of evidence-based practices. Through the conduct of this hybrid type 3 effectiveness-implementation cluster randomized controlled trial, we collected Exploration, Preparation, Implementation, and Sustainment (EPIS) data and merged it with tailored motivational interviewing training adherence data, to elucidate the relationship between provider attitudes toward evidence-based practices, leadership behaviors, and training implementation strategy (e.g., workshop attendance and participation in one-on-one coaching) adherence. Method: Our sample included data from providers who completed baseline (pre-intervention) surveys that captured inner and outer contexts affecting implementation and participated in tailored motivational interviewing training, producing a dataset that included training implementation strategies adherence and barriers and facilitators to implementation (N = 77). Leadership was assessed by two scales: the director leadership scale and implementation leadership scale. Attitudes were measured with the evidence-based practice attitude scale (EBPAS-50). Adherence to training implementation strategies was modeled as a continuous outcome with a Gaussian distribution. Analyses were conducted in SPSS. Results: Of the nine general attitudes toward evidence-based practice, openness was associated with training adherence (estimate [EST] = 0.096, p < .001; 95% CI = [0.040, 0.151]). Provider general (EST = 0.054, 95% CI = [0.007, 0.102]) and motivational interviewing-specific (EST = 0.044, 95% CI = [0.002, 0.086]) leadership behaviors were positively associated with training adherence (p < .05). Of the four motivational interviewing-specific leadership domains, knowledge and perseverant were associated with training adherence (p < .05). As these leadership behaviors increased, knowledge (EST = 0.042, 95% CI = [0.001, 0.083]) and perseverant (EST = 0.039, 95% CI = [0.004, 0.075]), so did provider adherence to training implementation strategies. Conclusions: As implementation science places more emphasis on assessing readiness prior to delivering evidence-based practices by evaluating organizational climate, funding streams, and change culture, consideration should also be given to metrics of leadership. A potential mechanism to overcome resistance is via the implementation of training strategies focused on addressing leadership prior to conducting training for the evidence-based practice of interest.

Researchers and practitioners, who aim to improve the uptake of evidence-based practices, continue to seek ways in which to improve provider participation in training implementation strategies. The persistent challenge in addressing provider disengagement, while linking this disinterest to poor patient outcomes, has been ascertaining how to quantify relevant delivery considerations, for example, provider attitudes and leadership behaviors that may influence commitment to learning or apathy to behavior change, concurrently with training adherence. Through the conduct of this study, we collected both types of data: (1) provider attitudes and leadership behaviors and (2) training adherence outcomes. We found that provider openness, general leadership behaviors, and motivational interviewing-specific leadership behaviors were associated with adherence to training implementation strategies. As more emphasis is placed on assessing clinic readiness prior to adopting new evidence-based practices, a discussion on including metrics of provider attitudes to evidence-based practice, innovation, and the specific intervention is warranted, alongside consideration for how implementation training strategies focused on addressing leadership can bolster change-supportive behaviors prior to delivery of innovations.

Contribution of Health Care Practitioner and Maternity Services Factors to Racial Disparities in Alabama: A Qualitative Study.

OBJECTIVE: Black patients are three times more likely to die of pregnancy-related causes than White patients in the United States, and Alabama has the third worst maternal mortality rate in the nation. We sought to identify health care practitioner and maternity service factors contributing to disparities in Alabama, as well as potential strategies to address these contributors. METHODS: We conducted key informant interviews with obstetricians, nurses, doulas, lactation counselors, health system administrators, and representatives of professional organizations who deliver maternity care to racially and ethnically diverse patients in Alabama. The interview guide was developed using Howell's conceptual framework on racial and ethnic disparities in severe maternal morbidity and mortality. Adopting a thematic analysis approach, we coded and analyzed transcripts using NVivo 12 software. Open coding and selective coding were conducted to identify themes related to health care practitioner- and maternity services-level determinants. RESULTS: Overall, 20 health care practitioners or administrators were interviewed. Primary themes related to health care practitioners included implicit bias and explicit racism, lack of communication and lack of positive patient-health care practitioner relationships, lack of cultural sensitivity, and variation in clinical knowledge and experience. Primary themes related to maternity services included lack of accessibility, inadequate quality and content of care, lack of continuity of care, discriminatory facility policies, and workforce shortages and lack of diversity. Strategies suggested by participants to address these factors included bias trainings for health care practitioners, improvements in racial and interdisciplinary diversity in the maternity workforce, and evidence-based interventions such as group prenatal care, disparities dashboards, simulation trainings, early warning signs criteria, and coordinated care. CONCLUSION: We gained diverse perspectives from health care practitioners and administrators on how maternity health care practitioner and maternity health services factors contribute to inequities in maternal health in Alabama. Strategies to address these contributing factors were multifaceted.

Community and Systems Contributors and Strategies to Reduce Racial Inequities in Maternal Health in the Deep South: Provider Perspectives.

Purpose: Black pregnant individuals in Alabama are disproportionately affected by severe maternal morbidity and mortality (SMM). To understand why racial disparities in maternal health outcomes persist and identify potential strategies to reduce these inequities, we sought perspectives from obstetric health care providers, health administrators, and members of local organizations who provide pregnancy, delivery, and postpartum care services in Alabama. Methods: We conducted qualitative in-depth interviews with stakeholders (n=20), purposively recruited from community-based organizations, clinical settings, government organizations, and academic institutions. Interview guides were based on Howell's conceptual model of pathways to racial disparities in maternal mortality. Data were coded using a modified framework theory approach and analyzed thematically. Results: Racism, unjust laws and policies, and poverty/lack of infrastructure in communities emerged as major themes contributing to racial disparities in maternal health at the community and systems levels. Inadequate health insurance coverage was described as a strong driver of the disparities. Service providers suggested strategies for Alabama should be community focused, evidence based, and culturally sensitive. These should include Medicaid expansion, expanded parental leave, and removal of laws restricting choice. Community- and systems-level interventions should include community infrastructure improvements, choice in maternity services, and provision of digital communication options. Conclusions: Providers shared perspectives on community and structural areas of intervention to reduce racial inequities in SMM. These results can inform discussions with health system and community partners about Alabama and other Deep South initiatives to improve maternal health outcomes in black communities.

Cardiovascular Risk Assessment Among Adolescents and Youths Living With HIV: Evaluation of Electronic Health Record Findings and Implications.

BACKGROUND: The HIV epidemic remains a major public health concern, particularly among youths living with HIV. While the availability of antiretroviral therapy has significantly improved the health outcomes of people living with HIV, there is growing evidence that youths living with HIV may be at increased risk of cardiovascular disease. However, the underlying mechanisms linking HIV and cardiovascular disease among youths living with HIV remain poorly understood. One potential explanation is that HIV-related biomarkers, including detectable viral load (VL) and low cluster of differentiation 4 (CD4) lymphocyte counts, may contribute to increased cardiovascular risk. Despite the potential importance of these biomarkers, the relationship between HIV-related biomarkers and cardiovascular risk among youths living with HIV has been understudied. OBJECTIVE: To address this gap, we examined whether detectable VL and low CD4 lymphocyte counts, both of which are indications of unsuppressed HIV, were associated with cardiovascular risk among youths living with HIV. METHODS: We analyzed electronic health record data from 7 adolescent HIV clinics in the United States (813 youths living with HIV). We used multivariable linear regression to examine the relationship between detectable VL and CD4 lymphocyte counts of ≤200 and cardiovascular risk scores, which were adapted from the gender-specific Framingham algorithm. RESULTS: In our study, nearly half of the participants (366/766, 47.8%) had detectable VL, indicating unsuppressed HIV, while 8.6% (51/593) of them had CD4 lymphocyte counts of ≤200, suggesting weakened immune function. We found that those with CD4 lymphocyte counts of ≤200 had significantly higher cardiovascular risk, as assessed by Cardiac Risk Score2, than those with CD4 lymphocyte counts of >200 (P=.002). After adjusting for demographic and clinical factors, we found that for every 1000-point increase in VL copies/mL, the probability of having cardiovascular risk (Cardiac Risk Score2) increased by 38%. When measuring the strength of this connection, we observed a minor effect of VL on increased cardiovascular risk (ß=.134, SE 0.014; P=.006). We obtained similar results with Cardiac Risk Score1, but the effect of CD4 lymphocyte counts of ≤200 was no longer significant. Overall, our findings suggest that detectable VL is associated with increased cardiovascular risk among youths living with HIV, and that CD4 lymphocyte counts may play a role in this relationship as well. CONCLUSIONS: Our study highlights a significant association between unsuppressed HIV, indicated by detectable VL, and increased cardiovascular risk in youths living with HIV. These findings emphasize the importance of implementing interventions that address both VL suppression and cardiovascular risk reduction in this population. By tailoring interventions to meet the unique needs of youths, we can promote overall well-being throughout the HIV care continuum and across the life span. Ultimately, these efforts have the potential to improve the health outcomes and quality of life of youths living with HIV. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/11185.

Racial Disparities in Access to the Kidney Transplant Waitlist Among People with Human Immunodeficiency Virus.

The epidemiology of human immunodeficiency virus (HIV) has shifted such that Black individuals disproportionately represent incident HIV diagnoses. While risk of end-stage kidney disease (ESKD) among people with HIV (PWH) has declined with effective antiretroviral therapies, a substantial racial disparity in ESKD burden exists with the greatest prevalence among Black PWH. Disparities in waitlisting for kidney transplantation, the optimal treatment for ESKD, exist for both PWH and Black individuals without HIV, but it is unknown whether these characteristics together exacerbate such disparities. Six hundred two thousand six ESKD patients were identified from the United States Renal Data System (January 1, 2007 to December 31, 2017), and HIV-status was determined through Medicare claims. Cox proportional hazards regression was used to determine waitlisting rates. Multiplicative interaction terms between HIV-status and race were examined. The 6250 PWH were significantly younger, more commonly Black, and less commonly female than those without HIV. HIV-status and race were independently associated with 50% and 12% lower likelihood of waitlisting, respectively [adjusted hazard ratio (aHR): 0.50, 95% confidence interval (CI): 0.36-0.69, p < 0.001; aHR: 0.88, 95% CI: 0.87-0.90, p < 0.001]. There was also a significant interaction present between HIV-status and Black race (aHR: 0.80, 95% CI: 0.66-0.98, p < 0.001) such that, while HIV-status and Black race were independently associated with decreased waitlisting, the interaction of Black race and HIV-status exacerbated those disparities. While limited by lack of HIV-specific data that may impact inferences with respect to race, additional studies are urgently needed to understand the interplay between HIV risk factors, HIV-stigma, and racism, and how intersectionality may exacerbate disparities in transplantation among PWH.