Reaching and Re-Engaging People Living with HIV Who Are Out of Care: A Mixed-Methods Exploration of Patient Preferences for Strategies to Enhance Clinic Communication and Outreach.

Half of all people living with HIV (PLWH) in the United States are not retained in HIV medical care. The utility of appointment reminders and clinic-based retention support services is often limited by the inability to contact PLWH who are out of care (PLWH-OOC) due to disconnected phone lines, full voice mails, and housing instability. Between June 2019 and May 2021, as part of a larger mixed-methods study in Metro Atlanta, Georgia, we conducted surveys with 50 PLWH-OOC and interviews with 13 PLWH holding a variety of clinic stakeholder roles (patients, Community Advisory Board members, and peer navigators) to explore preferences for clinic communication and peer outreach and factors impacting uptake. Although phone calls, text messages, and calling secondary contacts were most preferred, the spread of preferences was wide. Surveys and interviews highlighted the high acceptance of peer outreach visits, with trust, support, and privacy being key factors driving the uptake. Findings underscore the need for clinics to offer a suite of communication and outreach strategies and assess patient preferences for traditional and nontraditional outreach models to more effectively reach, re-engage, and ultimately retain PLWH-OOC.

One size does not fit all: Preferences for HIV care delivery among out-of-care people living with HIV in the Southeastern United States.

Approximately half of the people with HIV (PWH) in the United States are retained in HIV care and only 57% have achieved viral suppression, due to barriers including transportation access, stigma, poor mental health, substance use, and medical mistrust. Community-based HIV care models have potential to address the diverse needs of patients and to improve retention in care, but their success is contingent on acceptance by patients and key community stakeholders. Recognizing that the preferences of PWH who are out-of-care (PWH-OOC) likely differ from those retained in care, we conducted a mixed-methods study from June 2019 to May 2021 composed of surveys with PWH-OOC (n = 50) and in-depth interviews with key clinic and community stakeholders (n = 41) to examine the relative preference and perceived advantages and disadvantages for six different community-based HIV care models versus the traditional fixed-clinic model. Survey data was analyzed to assess average rank preference for each care model and interview transcripts were thematically coded to examine factors influencing model acceptance. The highest preference for care delivery was via a mobile clinic, followed by community-based peer navigation, primary care clinics, telemedicine, traditional HIV subspeciality clinic, homeless shelter, and drug treatment center. Common factors influencing preference included convenience, accessibility, potential to preserve confidentiality, quality of care assurance, opportunity to develop rapport with their HIV care provider, access to a smart device, and potential to alleviate versus exacerbate HIV stigma. Participants discussed need for integration of care models and for individuals to choose different care models at different times. Providers and patients differed in preference for care model and weighting of relative advantages and disadvantages of each. Findings highlight the need to integrate alternative, community-based care models into the national plan to end the HIV epidemic and to allow for PWH-OOC to choose the model most fitting based on individual circumstances.

Examining HIV Organizational Structures and their Influence on Engagement with Young Black Gay, Bisexual, and other Men who have Sex with Men in Atlanta, Georgia.

Young Black gay, bisexual, and other men who have sex with men (YB-GBMSM) are disproportionately impacted by HIV. Structural influences on these disparities, including characteristics of the various organizations that serve YB-GBMSM living with HIV, remain understudied. We drew on Weick's model of organizing to conduct and analyze qualitative interviews with 28 HIV service providers representing healthcare and community-based organizations in Atlanta, Georgia. Enactment of HIV service provision was described as following simplified and standardized responses-defined as "rules", and/or more dynamic exchanges to formulate responses -otherwise known as "communication behavior cycles" (CBCs). Rules, including patient quotas and limited hours of operation, were viewed as rigid, out-of-touch, and inhibiting engagement with YB-GBMSM. CBCs, such as patient feedback loops and rejection of traditional hierarchies, fostered creative insights to combating the epidemic and increased levels of cultural awareness and community buy-in. Organizations should strive to enact CBCs, to foster culturally congruent approaches to service delivery for YB-GBMSM.

Feasibility and acceptability of B6: a social capital program for young Black gay, bisexual and other men who have sex with men living with HIV.

Young Black gay, bisexual and other men who have sex with men (YB-GBMSM) are disproportionately burdened by HIV and often exhibit suboptimal engagement in HIV care. With the goal of increasing engagement in HIV care, we designed a culturally specific, theory-based group-level program, Brothers Building Brothers by Breaking Barriers (B6), which aimed to strengthen resilience and social capital among YB-GBMSM living with HIV. We conducted a pilot trial to evaluate the program's acceptability and feasibility. Through clinic-based recruitment and community outreach events, we recruited and enrolled 71 YB-GBMSM into the study. Participants were randomized to either the B6 program or a control comparison program. Post-session evaluation surveys and in-depth qualitative interviews showed B6 to have high levels of acceptability and satisfaction. Specifically, participants described benefits to interacting in a group with other YB-GBMSM, and several described increased comfort with their own gay identities after participation. No adverse events or safety concerns were reported. However, there were challenges to feasibility, as reflected in recruitment and retention rates. The B6 program was highly acceptable among YB-GBMSM living with HIV; however, innovative program delivery methods and implementation strategies will be needed to improve recruitment and retention in future implementation of B6.

Understanding social capital among young black gay and bisexual men living with HIV: a qualitative exploration.

Social capital, defined as the sum of an individual's resource-containing, reciprocal and trustworthy social network connections, has been associated with improved engagement in care among people living with HIV globally. We conducted a qualitative interview study of social capital among 28 young Black gay, bisexual and other men who have sex with men ages 18-29 living with HIV in Atlanta, Georgia. We asked participants about bonding capital (relationships between individuals with similar demographic characteristics), bridging capital (relationships with individuals of different backgrounds), collective efficacy (involvement with community organisations) and satisfaction with their social networks. We found that participants described bonding capital from friends and family in depth, while more gaps were noted in bridging capital and collective efficacy. Bonding capital derived from families was especially critical to participants' satisfaction with their social capital. Findings suggest that interventions targeting young Black gay, bisexual and other men who have sex with men should build upon strong bonds with family and friends, and/or fill gaps in bridging capital and collective efficacy by connecting young men to mentors and organisations.

Understanding and addressing privacy and confidentiality concerns associated with the provision of mobile HIV care: a qualitative study.

Less than half the people with HIV (PLWH) in the United States (US) are retained in HIV care, underscoring the importance of novel reengagement and retention strategies. Mobile HIV clinics (MHCs) are one such strategy, but privacy and confidentiality concerns have limited their use. As part of a larger mixed-methods study in Atlanta, Georgia, from June 2019- July 2020, we conducted 41 qualitative interviews with key stakeholders to explore confidentiality, privacy and stigma concerns and strategies to address them. Interviews were recorded, transcribed and coded thematically. Four key themes emerged: 1) the need to understand MHC acceptance in the context of high HIV stigma in the South, 2) the multidimensionality of confidentiality and stigma concerns (e.g., related to exterior labeling, layout, location attracting unwanted attention), 3) the counter perspective: potential for MHCs to positively reframe HIV and reduce stigma, and 4) strategies to overcome stigma and confidentiality concerns, including co-delivery of non-HIV services, unidirectional flow, and non-HIV exterior labeling. In furthering understanding of the breadth of privacy and confidentiality concerns associated with an MHC and strategies for addressing them, this exploratory study lays a critical foundation for the development of an MHC to reengage and retain PLWH in the US.

Barriers and facilitators to use of a mobile HIV care model to re-engage and retain out-of-care people living with HIV in Atlanta, Georgia.

Novel strategies to re-engage and retain people living with HIV (PLWH) who are out of care are greatly needed. While mobile clinics have been used effectively for HIV testing and linkage, evidence guiding their use in providing HIV care domestically has been limited. To guide the development of a mobile HIV clinic (MHC) model as a strategy to re-engage and retain PLWH who are out of care, we aimed to explore stakeholder perceptions of barriers and facilitators to MHC implementation and use. From June 2019-July 2020, we conducted 41 in-depth interviews with HIV clinic providers, administrators, staff, legal authorities, and community advisory board members, PLWH, AIDS service organizations and city officials in Atlanta, Georgia, and domestic and international mobile health clinics to explore barriers and facilitators to use of MHCs. Interviews were transcribed, coded and thematically analysed. Barriers raised include potential for: breach of confidentiality with resulting heightened stigmatization, fractured continuity of care, safety concerns, staffing challenges, and low community acceptance of MHC presence in their locality. Participants provided suggestions regarding appropriate exterior design, location, timing, and co-delivery of non-HIV services that could facilitate MHC acceptance and address the concerns. In identifying key barriers and facilitators to MHC use, this study informs design and implementation of an MHC as a novel strategy for re-engaging and retaining PLWH who are out of care.

Exploring influences on methamphetamine use among Black gay, bisexual and other men who have sex with men in Atlanta: A focus group study.

BACKGROUND: Methamphetamine use is a contributor to HIV risk and poor health outcomes among gay, bisexual and other men who have sex with men (GBMSM). There is a paucity of research examining methamphetamine use and its social context specifically among Black GBMSM. We therefore sought to: (1) describe trends in methamphetamine use among Black GBMSM in Atlanta, Georgia, and (2) examine the risk environment (micro-, meso­ and macro-level factors operating in the political, social, physical, economic, and healthcare environments) that might elevate risk for methamphetamine use in this population. METHODS: We conducted a qualitative study consisting of eight focus groups with 54 key informants between December 2019 and March 2020. Participants represented community-based and healthcare organizations that work closely with Black GBMSM. Our thematic analysis included an iterative, team coding approach combining deductive and inductive elements. RESULTS: Participants unanimously agreed that methamphetamine use was increasingly prevalent among Black GBMSM in Atlanta, with many describing a historical arc in which methamphetamine use - previously associated with predominantly white, affluent GBMSM - was now common among younger, lower socioeconomic status Black GBMSM. At the micro-level, participants described contributors to increasing methamphetamine use including use as a sex drug, and the interrelated burdens of stress and mental illness, housing instability, geographic mobility and poverty. At the meso­level, participants described virtual and physical sex scenes including use of geosocial networking apps that facilitated the spread of methamphetamine use in the Black GBMSM community. At the macro-level, participants described how policies prioritizing other concerns (e.g., HIV, opioids) seemed to limit resources available for methamphetamine prevention and treatment programming. CONCLUSION: Multi-level environmental influences are working together to elevate risk for methamphetamine use among Black GBMSM in Atlanta, with potential to adversely impact health and well-being and undermine HIV prevention and treatment efforts.