HIV Activist Identity, Commitment, and Orientation Scale (HAICOS): Psychometric Evaluation to Assess Clinician's Propensity Towards HIV Activism in Malaysia.

HIV activism has a long history of advancing HIV treatment and is critical in dismantling HIV-related stigma. This study evaluated the psychometric quality of the HIV Activist Identity, Commitment, and Orientation Scale (HAICOS) to assess clinicians' propensity towards HIV activism in Malaysia. From November 2022 to March 2023, 74 general practitioners and primary care physicians in Malaysia participated in the study. The exploratory factor analysis (EFA) extracted an internally consistent three-factor solution with 13 items: (1) HIV activist identity and commitment, orientation towards (2) day-to-day, and (3) structural activism. The Cronbach's alpha value was 0.91, and intra-class correlation coefficient for test-retest reliability was 0.86. Stigma-related (prejudice and discrimination intent) and clinical practice (comfort in performing clinical tasks with key populations and knowledge about HIV pre-exposure prophylaxis) measures supported the construct validity of the scale. The study provided concise, structurally valid, and reliable measures to evaluate HIV activism among clinicians.

RESUMEN: El activismo del VIH tiene una larga historia de avanzar el tratamiento del VIH y es crítico para desmantelar el estigma relacionado al VIH. Este estudio evaluó la calidad psicométrica de la Escala de Identidad, Compromiso y Orientación de Activistas del VIH (HAICOS) para evaluar la propensión de los médicos hacia el activismo del VIH en Malasia. Desde noviembre del 2022 hasta marzo del 2023, 74 médicos generales y de atención primaria en Malasia participaron en este estudio. El análisis factorial exploratorio (AFE) extrajo una solución de tres factores internamente consistente con 13 ítems: (1) identidad y compromiso del activismo del VIH; orientación hacia (2) el activismo cotidiano y (3) el activismo estructural. El valor alfa de Cronbach fue de 0.91 y el coeficiente de correlación intraclase para la confiabilidad prueba-reprueba fue de 0.86. Las medidas relacionadas con el estigma (prejuicio e intención de discriminación) y la práctica clínica (comodidad realizando tareas clínicas con poblaciones claves y conocimiento sobre la profilaxis pre-exposición del VIH) respaldaron la validez de constructo de la escala. El estudio proporcionó medidas concisas, estructuralmente válidas y confiables para evaluar el activismo de VIH entre los médicos.

"I want the doctors to know that I am as bright as a candle": : Experiences with and Hopes for Doctor Interactions Among Malaysian Key Populations and People Living with HIV.

Stigma in healthcare settings is a pernicious barrier to HIV prevention and treatment in contexts with strong HIV-related structural stigma. Previous work has documented substantial stigma towards key populations and people living with HIV (PLWH) among Malaysian doctors. The perspectives of Malaysian key populations and PLWH, however, remain understudied. In 2021, 34 Malaysian participants representing key populations and PLWH engaged in a photovoice study designed to qualitatively explore their experiences with and hopes for doctor interactions. Many participants reported stigma from their doctors, perceiving that doctors view them as not normal, sinful, misguided, and incapable. Several emphasized that they wear figurative masks to conceal aspects of themselves from doctors. Yet, many also remain hopeful for constructive relationships with doctors. They want their doctors to know that they are bright, capable, kind, and valuable. Interventions are needed to address stigma among doctors working in contexts with strong structural stigma.

RESUMEN: El estigma en los ambientes de atención médica es una barrera perniciosa en la prevención y el tratamiento del VIH. Investigaciones anteriores han documentado un estigma sustancial hacia los grupos de población clave y las personas que viven con el VIH (PLWH por sus siglas en inglés) entre los médicos de Malasia. Sin embargo, las perspectivas de los grupos de población clave y las PLWH en Malasia siguen sin estudiarse. En 2021, 34 participantes que representaban los grupos de población clave y PLWH en Malasia participaron en un estudio de fotovoz diseñado para explorar cualitativamente sus experiencias y esperanzas en las interacciones con los médicos. Muchos participantes describieron el estigma de sus médicos, percibiendo que los médicos los ven como no normales, pecaminosos, equivocados e incapaces. Varios enfatizaron que usan máscaras figurativas para ocultar aspectos de ellos mismos a los médicos. Sin embargo, muchos también mantienen la esperanza de tener relaciones constructivas con los médicos. Quieren que sus médicos sepan que son inteligentes, capaces, amables y valiosos. Se necesitan intervenciones para abordar el estigma estructural entre los médicos que trabajan en la prevención y el tratamiento del VIH.

Acceptability and Feasibility of Online, Asynchronous Photovoice with Key Populations and People Living with HIV.

Photovoice is an action-oriented qualitative method involving photography and story-telling. Although photovoice yields a powerful form of data that can be leveraged for research, intervention, and advocacy, it has arguably been underutilized within HIV research. Online, asynchronous photovoice methods represent a promising alternative to traditional in-person methods, yet their acceptability and feasibility with key populations and people living with HIV (PLWH) have yet to be explored. The current study describes the methods and evaluation of an online, asynchronous photovoice project conducted with 34 members of key populations and PLWH in Malaysia in 2021. A HIPAA-compliant website incorporating a series of instructional videos was created to facilitate participant engagement and data collection. Quantitative and qualitative indicators suggest that participants found the project to be highly acceptable and feasible. Online, asynchronous photovoice methods hold potential for increasing the scale of this powerful and versatile qualitative research method with key populations and PLWH.

RESUMEN: La fotovoz es un método cualitativo orientado a la acción que usa fotografía y narración de historias. Aunque la fotovoz produce una poderosa forma de datos que se puede utilizar para la investigación, la intervención y la promoción, podría decirse que ha sido poca aplicada en la investigación del VIH. Los métodos de fotovoz asincrónicos en línea representan una alternativa prometedora a los métodos en persona tradicionales, pero aún no se ha explorado su aceptabilidad y viabilidad con los grupos de población clave y las personas que viven con el VIH (PLWH por sus siglas en inglés). El estudio actual describe los métodos y la evaluación de un proyecto de fotovoz asincrónico en línea realizado con 34 miembros de grupos de población clave y PLWH en Malasia en 2021. Se creó un sitio web compatible con HIPAA que incorpora una serie de videos instructivos para facilitar la participación y la recopilación de datos. Los indicadores cuantitativos y cualitativos sugieren que los participantes encontraron el proyecto altamente aceptable y realizable. La fotovoz asincrónica en línea es un poderoso y versátil método cualitativo de investigación la cual tiene potencial para usarse más con los grupos de población clave y PLWH.

Emerging Lessons and Policy Options for Sexually Transmitted Infection Telehealth Payment: A Narrative Review.

ABSTRACT: Long before the SARS-CoV-2 (hereafter COVID-19) pandemic, sexually transmitted infection (STI) prevention and control was underresourced in the United States, leading to large and sustained increases in reportable STIs and harmful sequelae of these infections. The abrupt disruption associated with the national shutdown of many public services in early 2020 forced STI clinics and programs to rapidly adopt new models of care, including the greatly increased use of telehealth services. Federal policy makers took actions to relax many requirements in Medicare and other programs that previously impeded the use of telehealth. Numerous states also adopted emergency policies to facilitate the delivery of telehealth services through Medicaid, many of which are related to payment for services. It is unresolved whether and which policies will or should be extended after the public health emergency. How these services are financed and reimbursed underpins the ability to effectively prevent and treat STIs and improve public health. Ultimately, payment systems need to support the solvency and stability of sexual health clinics and other health care services organizations in ways that support providers and that also improve patient satisfaction and retention in care. The Centers for Disease Control and Prevention and state/local health departments have important roles to play in supporting the dialogue needed to create new payment models and facilitate communication and technical assistance across public health and insurance systems. Sexual health providers must be engaged in iterative processes that continue to evolve and can be evaluated over time.

Buprenorphine maintenance treatment retention improves nationally recommended preventive primary care screenings when integrated into urban federally qualified health centers.

Buprenorphine maintenance therapy (BMT) expands treatment access for opioid dependence and can be integrated into primary health-care settings. Treating opioid dependence, however, should ideally improve other aspects of overall health, including preventive services. Therefore, we examined how BMT affects preventive health-care outcomes, specifically nine nationally recommended primary care quality health-care indicators (QHIs), within federally qualified health centers (FQHCs) from an observational cohort study of 266 opioid-dependent patients initiating BMT between 07/01/07 and 11/30/08 within Connecticut's largest FQHC network. Nine nationally recommended preventive QHIs were collected longitudinally from electronic health records, including screening for chronic infections, metabolic conditions, and cancer. A composite QHI score (QHI-S), based on the percentage of eligible QHIs achieved, was categorized as QHI-S ≥80% (recommended) and ≥90% (optimal). The proportion of subjects achieving a composite QHI-S ≥80 and ≥90 % was 57.1 and 28.6%, respectively. Screening was highest for hypertension (91.0%), hepatitis C (80.1%), hepatitis B (76.3%), human immunodeficiency virus (71.4%), and hyperlipidemia (72.9%) and lower for syphilis (49.3%) and cervical (58.5%), breast (44.4%), and colorectal (48.7%) cancer. Achieving QHI-S ≥80% was positively and independently associated with ≥3-month BMT retention (adjusted odds ratio (AOR) = 2.19; 95% confidence interval (CI) = 1.18-4.04) and BMT prescription by primary care providers (PCPs) rather than addiction psychiatric specialists (AOR = 3.38; 95% CI = 1.78-6.37), and negatively with being female (AOR = 0.30; 95% CI = 0.16-0.55). Within primary health-care settings, achieving greater nationally recommended health-care screenings or QHIs was associated with being able to successfully retain patients on buprenorphine longer (3 months or more) and when buprenorphine was prescribed simultaneously by PCPs rather than psychiatric specialists. Decreased preventive screening for opioid-dependent women, however, may require gender-based strategies for achieving health-care parity. When patients can be retained, integrating BMT into urban FQHCs is associated with improved health outcomes including increased multiple preventive health-care screenings.

Integrating methadone into primary care settings in Ukraine: effects on provider stigma and knowledge.

INTRODUCTION: Stigma has undermined the scale-up of evidence-based HIV prevention and treatment. Negative beliefs influence clinicians' discriminatory behaviour and ultimately have wide-ranging effects across the HIV prevention and treatment continuum. Stigma among clinicians can be mitigated in several ways, including through interpersonal contact. In this study, we test whether interactions with people who inject drugs (PWID) influence attitudes of both direct and indirect providers of opioid agonist therapies (OATs) within the same primary care clinics (PCCs) where OAT is newly introduced. METHODS: In a cluster randomized controlled trial integrating OAT and HIV care into PCCs in Ukraine, clinicians at 24 integrated care sites (two sites in 12 regions) from January 2018 to August 2022 completed a structured survey at baseline, 12 and 24 months. The survey included feeling thermometers and standardized scales related to clinician attitudes towards patients and evidence-based care. Nested linear mixed-effects models were used to examine changes in mean scores over three timepoints for both direct and indirect clinicians. RESULTS: There were fewer significant changes in any of the scales for direct providers (n = 87) than for indirect providers (n = 155). Direct providers became less tough-minded about substance use disorders (p = 0.002), had less negative opinions about PWID (p = 0.006) and improved their beliefs regarding OAT maintenance (p<0.001) and medical information (p = 0.004). Indirect providers reported improvements in most stigma constructs, including a significant decrease in prejudice (p<0.001), discrimination (p = 0.001), shame (p = 0.007) and fear (p = 0.001) towards PWID. CONCLUSIONS: Integrating OAT services within primary settings was associated with significantly reduced stigma constructs and improved attitudes towards PWID, possibly through increased intergroup contact between PWID and general clinical staff. Unlike most stigma reduction interventions, re-engineering clinical processes so that PWID receive their care in PCCs emerges as a multilevel stigma reduction intervention through the integration of specialized services in PCCs. Integration influences different types of stigma, and has positive effects not only on health outcomes, but also improves clinician attitudes and efficiently reduces clinician stigma.

Design, implementation and preliminary results of a type-2 hybrid cluster-randomized trial of integrating screening and treatment for major depressive disorder into specialty clinics providing opioid agonist therapies in Ukraine.

INTRODUCTION: Ukraine has a high prevalence of co-occurring disorders (COD), defined as having both substance use (SUD) and psychiatric disorders. Major depressive disorder (MDD) is the most prevalent psychiatric disorder among people with SUD. People with COD experience poor health outcomes, and international agencies propose integrated COD care. In Ukraine, treatment for SUD is delivered in specialized substance use clinics, without providing any other medical services for comorbidities, including MDD. Here we present the protocol, along the with the preliminary results of the MEDIUM project, including observations over the first 6 months. METHODS: A cluster-randomized type-2 hybrid trial was conducted to integrate MDD treatment into specialty clinics providing opioid agonist therapies (OAT) in Ukraine. Twelve clinics in four regions underwent randomization to control (N = 1) vs experimental arms (N = 2) in each region. Clinicians at experimental sites received tele-education through modified project ECHO using a facilitated screening, evaluation, and treatment algorithm of depression, with or without financial incentives. Service-, patient- and provider-level data were collected for the analysis every 6 months for 24 months. PRELIMINARY RESULTS: For service delivery outcomes, 4421 patients enrolled on OAT across all sites were assessed for MDD for screening (76.7%), evaluation with diagnosis (43.5%) and treatment (30.7%) for MDD; 13.8% continued treatment at least for 6 months. For patient-level outcomes, 1345 patients and 54 providers participated in serial surveys every six months. CONCLUSION: This study will be the first to explore integrated COD care in Ukraine and generate evidence on effective service integration and delivery strategies for people with COD receiving treatment at substance use clinics with broader implications for Eastern Europe and Central Asia region.

Barriers and Facilitators to Implementing Project ECHO in Malaysia During the COVID-19 Pandemic.

Objective: In Malaysia, HIV is concentrated among key populations who experience barriers to care due to stigma and healthcare discrimination. The COVID-19 pandemic has increased barriers to healthcare. Project ECHO (Extension for Community Healthcare Outcomes) is a transformative tele-education strategy that could improve HIV prevention and treatment. Methods: Practicing physicians who were aged 18 years or older and had internet access participated in asynchronous online focus groups. Results: Barriers to Project ECHO were conflicting priorities, time constraints, and technology. Facilitators included content and format, dedicated time, asynchronized flexible programming, incentives, and ensuring technology was available. Conclusion: Project ECHO is a promising intervention that can increase physicians' knowledge and skill set in specialty medicine during the COVID-19 pandemic. Interventionists in Malaysia in particular, but also in general, should consider these barriers and facilitators when developing Project ECHO as they may aid in developing a more robust program and increase participation.

Rectal specimen self-collection for chlamydia and gonorrhea screening: a cross-sectional feasibility study at a community health center.

BACKGROUND: Men who have sex with men (MSM) are at increased risk for extra-genital sexually transmitted infections (STIs). Without extra-genital screening, many chlamydia and gonorrhea infections would be missed among MSM. Yet, many barriers exist to extra-genital testing, and, in particular, to rectal collection. Self-collection increases screening and detection of asymptomatic chlamydia and gonorrhea among at-risk MSM and transgender women. This feasibility study assessed use of rectal self-collection and its acceptance among patients and primary care providers (PCPs) at a large, general practice community health center. The primary objective of this project was to assess the feasibility of including rectal self-collection as part of an implementation study looking to embed an STI care program in a safety-net primary care setting that would shift routine screening tasks to non-provider clinical team members such as medical assistants and nurses. METHODS: Three PCPs identified and offered rectal self-collection to their MSM and transgender female patients who were due for routine or risk-based STI screening. For those patients who elected to participate in the study, the PCP's medical assistant (MA) reviewed the self-collection instructions with them as part of their routine preventive care duties, and patients collected their own sample. Patients and PCPs completed brief cross-sectional surveys assessing the self-collection process. RESULTS: Of 1191 patients with sexual orientation and gender identity (SOGI) data on file who were seen for a medical visit by one of the three PCPs, 87 (7.3%) identified as MSM or transgender female. Seventy-five were due for rectal screening, of whom 33 (44%) were offered and completed rectal self-collection. Survey results indicated that self-collection was acceptable to and preferred over clinician-collection by both PCPs and patients. CONCLUSIONS: This study demonstrated that rectal self-collection is feasible as part of STI screening in a high-volume primary care setting, and can be administered as part of the clinical tasks that MAs routinely conduct. The overall acceptance by both PCPs and patients will allow the inclusion of rectal self-collection in an implementation study looking to increase STI screening at a large community health center by facilitating MA-led collection during medical provider visits and by establishing standalone nurse-led STI visits.

Case series of buprenorphine injectors in Kuala Lumpur, Malaysia.

Diversion of buprenorphine has been described in settings where it is legally prescribed and has become an increasing concern in Malaysia; it resulted in banning of buprenorphine in Singapore where unsubstantiated case reports suggested that buprenorphine injection was associated with particularly poor outcomes. We therefore conducted a case series of qualitative interviews with buprenorphine injectors in Kuala Lumpur, Malaysia to examine further the issues surrounding buprenorphine injection as well as the abuse of midazolam in combination with buprenorphine. Interviews with 19 men do not suggest significant adverse health consequences from buprenorphine injection alone and injectors have adapted diverted buprenorphine as a treatment modality. A subset of these injectors, however, combined buprenorphine and midazolam for euphoric effects with resultant symptoms of a possible pharmacological interaction. Prospective cohort studies, rather than hospital-derived samples, are needed to better understand the safety of buprenorphine injection.

Integrating buprenorphine maintenance therapy into federally qualified health centers: real-world substance abuse treatment outcomes.

BACKGROUND: Few studies have examined real-world effectiveness of integrated buprenorphine maintenance treatment (BMT) programs in federally qualified health centers (FQHCs). METHODS: Opioid dependent patients (N=266) inducted on buprenorphine between July 2007 and December 2008 were retrospectively assessed at Connecticut's largest FQHC network. Six-month BMT retention and opioid-free time were collected longitudinally from electronic health records; 136 (51.1%) of patients were followed for at least 12 months. RESULTS: Participants had a mean age of 40.1 years, were primarily male (69.2%) and treated by family practitioners (70.3%). Co-morbidity included HCV infection (59.8%), mood disorders (71.8%) and concomitant cocaine use (59%). Retention on BMT was 56.8% at 6 months and 61.6% at 12 months for the subset observed over 1 year. Not being retained on BMT at 12 months was associated with cocaine use (AOR=2.18; 95% CI=1.35-3.50) while prescription of psychiatric medication (AOR=0.36; 95% CI 0.20-0.62) and receiving on-site substance abuse counseling (AOR=0.34; 95% CI 0.19, 0.59) improved retention. Two thirds of the participants experienced at least one BMT gap of 2 or more weeks with a mean gap length of 116.4 days. CONCLUSIONS: Integrating BMT in this large FQHC network resulted in retention rates similarly reported in clinical trials and emphasizes the need for providing substance abuse counseling and screening for and treating psychiatric comorbidity.