Implementation Science for HIV Prevention and Treatment in Indigenous Communities: a Systematic Review and Commentary.

PURPOSE OF REVIEW: We systematically reviewed implementation research conducted in Indigenous communities in the Americas and the Pacific that focused on improving delivery of HIV preventive or treatment services. We highlight strengths and opportunities in the literature and outline principles for Indigenous-led, HIV-related implementation science. RECENT FINDINGS: We identified 31 studies, revealing a consistent emphasis on cultural tailoring of services to Indigenous communities. Common barriers to implementation included stigma, geographic limitations, confidentiality concerns, language barriers, and mistrust. Community involvement in intervention development and delivery emerged as a key facilitator, and nearly half of the studies used community-based participatory research methods. While behavioral HIV prevention, especially among Indigenous youth, was a major focus, there was limited research on biomedical HIV prevention and treatment. No randomized implementation trials were identified. The findings underscore the importance of community engagement, the need for interventions developed within Indigenous communities rather than merely adapted, and the value of addressing the social determinants of implementation success. Aligned to these principles, an indigenized implementation science could enhance the acceptability and reach of critical HIV preventive and treatment services in Indigenous communities while also honoring their knowledge, wisdom, and strength.

Lifetime HIV testing among three samples of adults with histories of incarceration in Southern California.

ABSTRACTJustice-impacted persons may inconsistently access HIV testing. This cross-sectional secondary analysis investigates lifetime HIV testing prevalence among adults with prior histories of incarceration in Southern California, United States, participating in health-focused programming (n = 3 studies). Self-reported demographic and lifetime HIV testing data were collected between 2017-2023; descriptive analyses were conducted. Across the three samples, at least 74% of participants were male; Latino and African American individuals accounted for nearly two-thirds of participants. Lifetime HIV testing ranged from 72.8% to 84.2%. Males were significantly more likely than females to report never being tested in two samples and accounted for >95% of those never tested. No statistically significant differences in testing were observed by race/ethnicity. Single young adults (ages 18-26) were less likely than their partnered peers to report testing. HIV testing is critical for ensuring that individuals access prevention and treatment. HIV testing among justice-impacted adults in this study was higher than in the general population, potentially due to opt-out testing in correctional settings. Nevertheless, these findings underscore the importance of implementing targeted interventions to reduce structural (e.g., health insurance, access to self-testing kits) and social barriers (e.g., HIV stigma) to increase HIV testing among justice-impacted males and single young adults.

A randomized clinical trial testing a health literacy intervention to reduce disparities in access to care among Justice-Impacted Adults (JIA).

BACKGROUND: Low health literacy is costly and observed among justice-impacted adults (JIA), a group that often faces numerous barriers in accessing healthcare and a disproportionate burden of illness. Health literacy interventions for JIA are critically needed to improve healthcare access and related outcomes. METHODS: This manuscript describes the protocol for a longitudinal mixed-methods randomized clinical trial that assesses the effectiveness of a coach-guided health literacy intervention on JIA's healthcare access. The intervention was previously piloted with justice impacted adults. We will recruit 300 JIA ages 18 + in San Diego, California. Participants will be randomized 1:1 to the Treatment Group (i.e., coach-guided intervention providing 12 sessions of individualized health coaching and service navigation over 6 months) or the Control Group (i.e., self-study of the health coaching program, and brief service navigation support). We will quantitatively assess JIA's healthcare access defined as: use of healthcare, health insurance status, and regular source of care at 6-months as the primary outcomes. Participants will also be surveyed at 12-months. Statistical analyses will incorporate the intent-to-treat (ITT) principle and we will estimate mixed-effects logistic regression for the primary outcomes. We will also conduct qualitative interviews at 6 and 12-months with 40 purposively sampled participants, stratified by study arm, who reported healthcare access barriers at baseline. Interviews will explore participants' satisfaction with the intervention, healthcare attitudes, self-efficacy for and barriers to healthcare access over time, perceived contribution of the intervention to health and well-being, and diffusion of intervention-related information within participants' social networks. We will conduct deductive thematic analyses of qualitative data. DISCUSSION: Low health literacy among JIA is a foundational challenge requiring tailored intervention strategies. Findings from this trial may inform policies and the structure of service delivery models to build health literacy among JIA in institutional and community settings throughout the United States and elsewhere. TRIAL REGISTRATION: This study is registered with the United States' ClinicalTrials.gov registry under protocol # 161,903.

Community-Identified Implementation Strategies for Promoting the Adoption of HIV Self-Testing in a Southern California American Indian community: A Rapid Qualitative Analysis.

HIV incidence increased by 18% between 2015 and 2019 among American Indians (AIs) despite declining rates in other racial/ethnic groups. Culturally-appropriate implementation of prevention programs is needed to address the intersectional conditions contributing to HIV vulnerabilities experienced by AIs. The objectives of this study were to understand factors influencing HIV testing decisions and identify implementation strategies to promote the acceptability of HIV self-testing (HIVST) in a southern California AI community. A total of 15 semi-structured interviews were completed with adult community members of a southern California AI reservation. Analysis used a rapid analytic approach that was guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework and expert recommendations for implementing change (ERIC) compilation. Two team members applied a standardized summary template to elucidate implementation determinants and implementation strategies for adopting HIVST. Barriers to HIV testing identified by community members included HIV-related stigma and privacy concerns within their community. Community members expressed positive perceptions of the acceptability of HIVST, with many identifying ease of use and privacy as appealing attributes. Several implementation strategies were suggested for facilitating the adoption of HIVST, including increasing access to tests by mailing kits to community members and increasing demand for kits through media campaigns (e.g., local flyers, social media posts, and booths at tribal events). Community members also recommended discreet packaging of kits and cultural adaptation of accompanying materials (e.g., educational videos featuring community members). The qualitative input from AI community members facilitated identification of implementation strategies that may promote the acceptability and culturally-appropriateness of HIVST.

RESUMEN: Entre 2015 y 2019, la incidencia del VIH entre los indígenas norteamericanos (INs) aumentó un 18%, a pesar de que en otros grupos étnicos y raciales se observaron reducciones. La implementación culturalmente apropiada de programas preventivos es fundamental para abordar las circunstancias interseccionales que contribuyen a la vulnerabilidad al VIH entre INs. Los objetivos de este estudio fueron comprender los factores que influyen en la decisión de hacerse la prueba del VIH e identificar estrategias para fomentar la aceptabilidad de las auto pruebas, en una comunidad de INs en el Sur de California. Se realizaron 15 entrevistas semiestructuradas con los miembros adultos de una reserva situada en el Sur de California. El análisis se realizó utilizando un método cualitativo rápido, basado en el marco Exploration, Preparation, Implementation and Sustainment (EPIS) (español: Exploración, Preparación, Implementación y Sostenimiento) así como una recopilación de sugerencias de expertas en implementación de intervenciones, conocida como ERIC. Dos miembros del equipo de investigación utilizaron una plantilla estandarizada resumida para investigar factores determinantes y estrategias para la adopción de las auto pruebas del VIH. Los miembros de la reserva de INs identificaron el estigma asociado al VIH, así como preocupación por la privacidad entre la comunidad, como barreras para realizarse las pruebas del VIH. Los miembros reaccionaron positivamente a la aceptabilidad de las auto pruebas del VIH, destacándola facilidad del uso y la privacidad asociadas con estas pruebas. También, se sugirieron varias estrategias para facilitar la adopción de las auto pruebas, incluyendo el envío de pruebas a miembros de la comunidad y el aumento de la demanda de pruebas a través de difusión (e.g., folletos, publicaciones en las redes sociales, y puestos en eventos tribales). Los miembros también recomendaron que los empaques de las auto pruebas sean discretos, y que contengan materiales educativos culturalmente apropiados. Las contribuciones cualitativas de la comunidad INs ayudaron identificar estrategias de implementación que pueden fomentar la aceptabilidad de las auto pruebas del VIH en una manera culturalmente apropiada.

Cumulative Lifetime Violence and Bacterial Vaginosis Infection in Sexually Transmitted Infections: Findings From a Retrospective Cohort Study Among Black Women at Risk for HIV.

Introduction: Bacterial vaginosis is the most common vaginal condition among women of reproductive age and has been associated with sexually transmitted infections. This study examines the association between cumulative lifetime violence exposure, bacterial vaginosis, and sexually transmitted infections among Black women at risk for HIV. Methods: HIV-negative Black women in a retrospective cohort study (N=230) completed survey questions on cumulative violence (exposure to sexual or physical abuse before age 18 years and exposure to intimate partner violence or sexual violence [partner or other] after age 18 years and past year), bacterial vaginosis (lifetime and past year), and sexually transmitted infection diagnosis (lifetime and past year). Logistic regression models estimated the associations between cumulative violence, bacterial vaginosis, and sexually transmitted infections. Bacterial vaginosis was examined as a moderator in the association between cumulative violence and sexually transmitted infections. Results: Many women reported cumulative violence exposure (40%), lifetime bacterial vaginosis diagnosis (53%), and lifetime sexually transmitted infection diagnosis (73%). Cumulative violence experience was significantly associated with increased adjusted odds of lifetime bacterial vaginosis diagnosis (AOR=1.98; 95% CI=1.10, 3.54). Lifetime bacterial vaginosis diagnosis (AOR=2.76; 95% CI=1.45, 5.22) and past-year bacterial vaginosis diagnosis (AOR=2.16; 95% CI=1.14, 4.10) were significantly associated with increased odds of lifetime sexually transmitted infection diagnosis. Lifetime bacterial vaginosis diagnosis (AOR=2.10; 95% CI=1.19, 3.70) and past-year bacterial vaginosis diagnosis (AOR=3.00; 95% CI=1.70, 5.31) were significantly associated with past-year sexually transmitted infection diagnosis. Lifetime bacterial vaginosis infection significantly increased the odds of lifetime sexually transmitted infection diagnosis with increasing cumulative violence exposure. Conclusions: Our findings support educating and screening Black women who experience cumulative violence for bacterial vaginosis to reduce the risk of untreated bacterial vaginosis and sexually transmitted infections.

Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysis.

BACKGROUND: Supervised consumption services (SCS) prevent overdose deaths onsite; however, less is known about their effect on population-level overdose mortality. We aimed to characterise overdose mortality in Toronto, ON, Canada, and to establish the spatial association between SCS locations and overdose mortality events. METHODS: For this ecological study and spatial analysis, we compared crude overdose mortality rates before and after the implementation of nine SCS in Toronto in 2017. Data were obtained from the Office of the Chief Coroner of Ontario on cases of accidental death within the City of Toronto for which the cause of death involved the use of an opiate, synthetic or semi-synthetic opioid, or other psychoactive substance. We assessed overdose incident data for global spatial autocorrelation and local clustering, then used geographically weighted regression to model the association between SCS proximity and overdose mortality incidence in 2018 and 2019. FINDINGS: We included 787 overdose mortality events in Toronto between May 1, 2017, and Dec 31, 2019. The overdose mortality rate decreased significantly in neighbourhoods that implemented SCS (8·10 deaths per 100 000 people for May 1-July 31, 2017, vs 2·70 deaths per 100 000 people for May 1-July 31, 2019; p=0·037), but not in other neighbourhoods. In a geographically weighted regression analysis that adjusted for the availability of substance-use-related services and overdose-related sociodemographic factors by neighbourhood, the strongest local regression coefficients of the association between SCS and overdose mortality location ranged from -0·60 to -0·64 per mile in 2018 and from -1·68 to -1·96 per mile in 2019, suggesting an inverse association. INTERPRETATION: We found that the period during which SCS were implemented in Toronto was associated with a reduced overdose mortality in surrounding neighbourhoods. The magnitude of this inverse association increased from 2018 to 2019, equalling approximately two overdose fatalities per 100 000 people averted in the square mile surrounding SCS in 2019. Policy makers should consider implementing and sustaining SCS across neighbourhoods where overdose mortality is high. FUNDING: The Canadian Institutes of Health Research.

Prevalence of HIV/STIs and correlates with municipal characteristics among female sex workers in 13 Mexican cities / Prevalencia de VIH/ITS y correlaciones con carácterísticas municipales entre trabajadoras sexuales en 13 ciudades mexicanas

Abstract: Objective: To identify correlates of HIV/STI prevalence among 13 cities with varying sizes of female sex worker (FSW) populations and municipal characteristics in Mexico. Materials and methods: FSWs underwent interviews and testing for HIV, syphilis, gonorrhea and chlamydia. Logistic regression explored variations in HIV/STI prevalence. Results: Among FSWs (n=1 092), prevalence across 13 sites was: HIV: 0.4% (range: 0%-1.4%): syphilis: 7.8% (range: 0%-17.2%); chlamydia: 15.3% (range: 5.7%-32.2%); gonorrhea: 2.9% (range 0%-13.8%), and any HIV/STI: 23% (range: 9.9%-46%). Municipalities with high human development scores and a lower municipal marginalization index had higher odds of combined HIV/STI prevalence. After controlling for site-specific variability in municipal characteristics, greater risk of HIV/STIs was associated with lower education, having a spouse diagnosed or treated for an STI, unaffordability of condoms, and having non-Mexican clients. Conclusions: Prevalence of HIV/STIs varies across Mexican municipalities indicating the need for surveillance to identify hotspots for targeted resource allocation.

Resumen: Objetivo: Identificar correlaciones de la prevalencia de VIH / ITS entre 13 ciudades con diferentes tamaños de población de trabajadoras sexuales y características municipales en México. Material y métodos: Las trabajadoras sexuales fueron entrevistadas y recibieron pruebas de VIH, sífilis, gonorrea y clamidia. La regresión logística exploró las variaciones en la prevalencia del VIH/ITS. Resultados: Entre las trabajadoras sexuales (n = 1 092), la prevalencia en 13 sitios fue: VIH: 0.4% (rango: 0-1.4%): sífilis: 7.8% (rango: 0-17.2%); clamidia: 15.3% (rango: 5.7-32.2%); gonorrea: 2.9% (rango 0-13.8%) y cualquier VIH/ITS: 23% (rango: 9.9-46%). Los municipios con altos puntajes de desarrollo humano y menor índice de marginación municipal tuvieron una mayor probabilidad de prevalencia combinada de VIH/ITS. Después de controlar la variabilidad específica del sitio en las características municipales, el mayor riesgo de VIH / ITS se asoció con menor educación, tener un cónyuge diagnosticado o tratado para una ITS, imposibilidad de conseguir condones y tener clientes no mexicanos. Conclusiones: La prevalencia de VIH/ITS varía entre los municipios mexicanos, lo que indica la necesidad de una vigilancia para identificar hotspots para la asignación selectiva.

Mexico’s northern border conflict: collateral damage to health and human rights of vulnerable groups / El conflicto en la frontera norte de México: daños colaterales a la salud y los derechos humanos en grupos vulnerables

Objective. To compare distributions of human rights violations and disease risk; to juxtaposethese patterns against demographic and structural environmental variables, and to formulateimplications for structural interventions.Methods. Female sex workers who inject drugs were surveyed in Tijuana and CiudadJuarez, Mexico. Structured interviews and testing for sexually transmitted infections (STIs)were conducted (October 2008 to October 2009). Frequencies of individual and environmentalfactors, including police abuse, risk of HIV infection, and protective behaviors, were comparedbetween sites using univariate logistic regression.Results. Of 624 women, almost half reported police syringe confiscation despite syringesbeing legal; 55.6% reported extortion (past 6 months), with significantly higher proportions inCiudad Juarez (P < 0.001). Reports of recent solicitation of sexual favors (28.5% in Tijuana,36.5% in Ciudad Juarez, P = 0.04) and sexual abuse (15.7% in Tijuana, 18.3% in CiudadJuarez) by police were commonplace. Prevalence of STIs was significantly lower in Tijuanathan in Ciudad Juarez (64.2% and 83.4%, P < 0.001), paralleling the lower prevalence ofsexual risk behaviors there. Ciudad Juarez respondents reported significantly higher mediannumber of monthly clients (6.8 versus 1.5, P < 0.001) and lower median pay per sex act(US$ 10 versus US$ 20, P < 0.001) (in the past month). Relative to Tijuana, security deployment,especially the army’s presence, was perceived to have increased more in Ciudad Juarezin the past year (72.1% versus 59.2%, P = 0.001).Conclusions. Collateral damage from police practices in the context of Mexico’s drug conflictmay affect public health in the Northern Border Region. Itinerant officers may facilitate diseasespread beyond the region. The urgency for mounting structural interventions is discussed.

Objetivo. Comparar las distribuciones de las violaciones a los derechos humanos yel riesgo de enfermedades; yuxtaponer los patrones obtenidos con las variables demográficasy estructurales del entorno, y formular las implicaciones de llevar a cabointervenciones estructurales.Métodos. Se entrevistaron trabajadoras del sexo que consumían drogas inyectablesen Tijuana y Ciudad Juárez, México. Entre octubre del 2008 y octubre del 2009 sellevaron a cabo entrevistas estructuradas y pruebas para detectar infecciones de transmisiónsexual (ITS). Se compararon entre las dos ciudades las frecuencias de factoresindividuales y ambientales, como el abuso policial, el riesgo de infección por el VIH ylas conductas protectoras, usando regresión logística de una sola variable.Resultados. De 624 mujeres, casi la mitad comunicaron la confiscación de jeringaspor la policía a pesar de que es legal poseerlas; 55,6% informaron extorsión (en losúltimos 6 meses), con proporciones significativamente mayores en Ciudad Juárez(P < 0,001). Los informes de solicitación reciente de favores sexuales (28,5% en Tijuana,36,5% en Ciudad Juárez, P = 0,04) y de abuso sexual (15,7% en Tijuana, 18,3%en Ciudad Juárez) por la policía fueron comunes. La prevalencia de ITS fue significativamentemenor en Tijuana que en Ciudad Juárez (64,2% y 83,4%, P < 0,001), en formaanáloga a la menor prevalencia de conductas sexuales de riesgo en la primera ciudad.Las mujeres entrevistadas en Ciudad Juárez informaron una mediana del número declientes mensual significativamente mayor (6,8 frente a 1,5, P < 0,001) y una medianadel pago por acto sexual menor (US$ 10 frente a US$ 20, P < 0,001) en el último mes.En el último año, las mujeres entrevistadas percibieron un mayor aumento del desplieguede seguridad, especialmente la presencia del ejército, en Ciudad Juárez queen Tijuana (72,1% frente a 59,2%, P = 0,001).Conclusiones. Los daños colaterales derivados de las prácticas policiales en el contextodel conflicto de narcotráfico de México pueden afectar a la salud pública enla región de la frontera norte de México. Los oficiales itinerantes pueden facilitar lapropagación de enfermedades más allá de la región. Se analiza la urgencia para establecerintervenciones estructurales.