Addressing disparities in Pre-exposure Prophylaxis (PrEP) access: implementing a community-centered mobile PrEP program in South Florida.

BACKGROUND: Pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but disparities in PrEP access remain considerable, particularly among Black and Latino men who have sex with men (MSM). To address this, the University of Miami Mobile PrEP Program was created, offering mobile HIV prevention/PrEP services in areas throughout South Florida where HIV incidence is high and PrEP access is geographically limited. Using a community-centered participatory approach, the program strategized and executed expansion into the Liberty City neighborhood of Miami. This study qualitatively assessed factors affecting Mobile PrEP implementation as perceived by community stakeholders, clients, and program staff. METHODS: Forty-one in-depth interviews were conducted with 21 Mobile PrEP clients, 10 key informants from local health organizations, and 10 program staff. Interview questions queried perceived organizational and positional barriers and facilitators to mobile clinic implementation. Service satisfaction, setting preferences, social factors, and likelihood of recommending Mobile PrEP were also assessed. A thematic content analysis was performed using the Consolidated Framework for Implementation Research (CFIR) taxonomy as the guiding constructs for the analysis. RESULTS: Participant statements indicated that providing no-cost services, convenient location, program-covered rideshares, individualized patient navigation, and a community-centric approach to patient care, which included staff members with shared lived experiences to increase positive interactions and renewed trust among poorly served communities, were facilitators of PrEP access and intervention uptake. The importance of program familiarization with the community before implementation, particularly for Black and African American communities, who may experience unique barriers to accessing sexual healthcare was strongly emphasized by participants. CONCLUSIONS: The Mobile PrEP intervention was found to be an acceptable and accessible mode of HIV/STI preventive care. The importance of pre-implementation community engagement and preparation is emphasized. Future research is needed to refine understanding of the intervention's components and evaluate implementation determinants in other highly impacted neighborhoods.

How Does Black History Help Doctors? Addressing Cultural Competency through Cinemeducation at a Diverse Medical School.

ABSTRACT: Racial minorities will account for >50% of the United States population by 2045, yet race and ethnicity persist as leading predictors of morbidity. Although minorities achieve better outcomes when treated by racially concordant providers, the number of minority physicians is disproportionately low compared with the rapidly growing minority population. This imbalance creates a cultural gap between many minority patients and their healthcare providers. Research suggests that educational initiatives addressing health inequity through a historical lens can help providers better understand the root causes of disparities; however, extensive clinical demands severely limit the time providers can dedicate to non-medical learning. OBJECTIVES: To address this gap, the University of Miami/Jackson Memorial Hospital System developed and piloted a short film about the history of Black people in South Florida, highlighting significant events that shaped the health-seeking behaviors of this population. METHODS: A 20-minute documentary exploring the sociocultural history of Black communities in Miami-Dade County was presented to 188 first-year postgraduate residents in June 2017. Residents completed pre-post surveys to measure changes in knowledge and care delivery intentions. RESULTS: Analyses performed between March and July 2018 revealed moderate improvements in the knowledge and awareness of the socioeconomic history of Miami's Black communities. Before watching the video, a majority indicated that increasing awareness of the sociocultural history of their patient population was a valuable learning activity. CONCLUSIONS: These findings suggest that brief videos focused on the history of culturally distinct populations may be a successful pedagogical strategy to introduce physicians to the communities they serve and improve provider knowledge.

Beyond the Barefoot Doctors: Using Community Health Workers to Translate HIV Research to Service.

Miami-Dade leads the nation in new HIV infections, and its Black communities experience the greatest disparities in outcomes. Our prior research found that street-based HIV testing facilitated by community health workers improved access to testing and care among Black adults in a controlled trial setting. Herein, we describe our efforts translating this CHW-led intervention into a community service for diverse Blacks in Miami. From December 2016 through August 2017, CHWs educated 1672 individuals about HIV transmission, prevention methods, and risk factor modification; 529 received HIV testing and/or linkage to care services. Approximately 5% of participants (n = 26) had rapid reactive results. This efficacious and culturally-acceptable model represents a powerful change in the delivery of HIV care and demonstrates how public health leaders can foster community engagement in the transition from research to service.

Propositional speech in unselected stroke: The effect of genre and external support.

Distinguished from nominal language, propositional language generation refers to the spontaneous and voluntary aspect of language that introduces novel concepts to a specific context. Propositional language can be impaired in a range of neurological disorders, including stroke, despite well-preserved nominal language. Although external support can increase speech rate in patients with reduced propositional speech, no specific investigation of propositional speech has been carried out in unselected stroke patients. The current study investigated propositional language in an unselected post-acute stroke group (N = 18) with mild cognitive impairment and prominent executive dysfunction, but without significant aphasia. Specifically, we investigated whether genre or external support affected the number of words, sentences, and novel ideas produced, compared to healthy controls (N = 27). Results showed that discourse genre was not associated with differential performances. By contrast, speech quantity increased without external support although, for stroke patients, speech novelty decreased. Overall, the novelty deficit in unselected stroke patients highlights the importance of assessing cognition and propositional speech. Our findings suggest that for stroke patients with mild cognitive deficits, including executive dysfunction, introducing external support improved speech quality but not quantity. Implications for both assessment and rehabilitation of social communication are discussed.

Tailoring HIV Care for Black Populations: A Pilot Feasibility Prospective Cohort Study.

BACKGROUND: Research has shown that integrating community health workers (CHWs) into the formal health care system can improve outcomes for people living with HIV, yet there is limited literature exploring this framework among marginalized minority populations. OBJECTIVE: Herein, we discuss the feasibility of a clinic-embedded CHW strategy to improve antiretroviral therapy adherence among Black people living with HIV in Miami-Dade County, Florida, a designated priority region for the US Department of Health and Human Services' Ending the HIV Epidemic Initiative. METHODS: From December 2022 to September 2023, three CHWs were trained and integrated into the hospital workflow to provide support as members of the clinical team. Ten Black adults with an HIV viral load over 200 copies/mL were enrolled to received 3 months of CHW support focused on navigating the health system and addressing poor social determinants of health. Intervention feasibility was based on 4 criteria: recruitment rate, demographic composition, study fidelity, and qualitative feedback on CHW perceptions. RESULTS: Participants were recruited at a rate of 5.7 participants per month, with the sample evenly distributed between men and women. Retention was moderately strong, with 7 (70%) of the 10 participants attending more than 75% of CHW sessions. Qualitative feedback reflected CHW perceptions on clinical interactions and intervention length. CONCLUSIONS: Outcomes indicate that a clinic-integrated CHW approach is a feasible and acceptable methodology to address adverse social determinants and improve HIV treatment adherence. By offering targeted social and clinical support, CHWs may be a promising solution to achieve sustained viral suppression and care engagement for Black people living with HIV.

Abortion education: What are future physicians learning in medical school?

OBJECTIVES: The last nationwide evaluation of abortion education in undergraduate medical schools was conducted by Espey et al. more than 15 years ago. To better understand what medical schools are teaching medical students about abortion care, we conducted a brief assessment of abortion education and training at U.S. medical schools. STUDY DESIGN: In April 2019, the study team emailed a three-item survey to the obstetrics and gynecology clerkship directors at Association of American Medical Colleges-accredited U.S. allopathic medical schools (n = 143). The multiple-choice survey assessed the availability and type of reproductive health education students had during their preclinical and clinical experiences. RESULTS: Ninety-one (64%) medical schools responded. Fifty-four (59%) schools reported abortion education as part of their preclinical curriculum, with 26 (29%) dedicating at least one lecture to abortion education. Sixty-seven (74%) institutions provided a clinical abortion experience for students, with 24 (26%) indicating students had to arrange participation on their own. Nine programs (10%) reported offering no formal abortion education. CONCLUSIONS: While the availability of abortion education has increased since the last nationwide survey in 2005, discrepancies in the education offered persist, and many medical students remain without access to this training. IMPLICATIONS: Although abortion plays an essential role in women's health services, discrepancies in training opportunities limit abortion education in U.S. medical schools. Gaps in the education of medical students may have downstream effects on the availability of doctors who are trained in providing medically-safe abortions.

Addressing Disparities in Pre-Exposure Prophylaxis (PrEP) Access: Implementing a Community-Centered Mobile PrEP Program in South Florida.

Background: Pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but disparities in PrEP access remain considerable, particularly among Black and Latino men who have sex with men (MSM). To address this, the University of Miami Mobile PrEP Program was created, offering mobile HIV prevention/PrEP services in areas throughout South Florida where HIV incidence is high and PrEP access is geographically limited. Using a community-centered participatory approach, the program strategized and executed expansion into the Liberty City neighborhood of Miami. This study qualitatively assessed factors affecting Mobile PrEP implementation as perceived by community stakeholders, clients, and program staff. Methods: Forty-one in-depth interviews were conducted with 21 Mobile PrEP clients, 10 key informants from local health organizations, and 10 program staff. Interview questions queried perceived organizational and positional barriers and facilitators to mobile clinic implementation. Service satisfaction, setting preferences, social factors, and likelihood of recommending Mobile PrEP were also assessed. A thematic content analysis was performed using the Consolidated Framework for Implementation Research (CFIR) taxonomy as the guiding constructs for the analysis. Results: Participant statements indicated that providing no-cost services, convenient location, program-covered rideshares, individualized patient navigation, and a community-centric approach to patient care, which included staff members with shared lived experiences to increase positive interactions and renewed trust among poorly served communities, were facilitators of PrEP access and intervention uptake. The importance of program familiarization with the community before implementation, particularly for Black and African American communities, who may experience unique barriers to accessing sexual healthcare was strongly emphasized by participants. Conclusions: The Mobile PrEP intervention was found to be an acceptable and accessible mode of HIV/STI preventive care. The importance of pre-implementation community engagement and preparation is emphasized. Future research is needed to refine understanding of the intervention's components and evaluate implementation determinants in other highly impacted neighborhoods.

Is Medicine Just a DREAM for DACA Students? DACA Practices and Policies Among U.S. Medical Schools.

As of 2020, 75 accredited institutions with the Association of American Medical Colleges (AAMC) are described as "DACA-friendly" and welcome undocumented students to apply under the Deferred Action for Childhood Arrivals (DACA) program. However, there is wide variation in their DACA policies, complicating an already demanding application process. Herein, we discuss this process and the common challenges for DACA-recipients. From September 2018 to July 2019, a three-item survey was emailed to admissions representatives at DACA-accepting institutions. While all participating universities were familiar with DACA, only 58% of representatives were aware of their institutional policies. Further, less than 10% of schools reserved funds for DACA-recipients; some required proof of payment for all 4 years prior to matriculation. The number of "DACA-friendly" institutions having enrolled DACA students is limited. Open promotion of institutional DACA policies may increase the number of recipients that successfully complete US medical training.

Untold Risk: HIV Transmission Behaviors in Miami's Historically Black Communities.

Advances in HIV prevention therapies have led to significant reductions in HIV transmission across the USA. However, these resources have not been equally utilized across all populations, with Black communities in the Southeastern USA experiencing among the greatest HIV disparities in the nation. Tailoring HIV programs to align with the cultural norms of minority communities is one approach that can increase uptake of HIV prevention services. However, accomplishing this requires a rich understanding of the unique risk factors and the context of HIV transmission among men and women within culturally distinct communities. To further our understanding, we examined HIV risk behaviors among Black adults living in geographic HIV hotspots of Miami-Dade County. Between December 2016 and April 2019, data on HIV risk behaviors use a standardized HIV assessment developed by the Florida Department of Health. Chi-square and t-test analyses were conducted to examine differences in population demographics and risk factors, and logistic regression was used to test for predictors of HIV status. Results indicate that a significant portion of participants had prior experience with HIV testing, a known protective factor against HIV transmission. Despite this, much of the sample also reported recent engagement in high-risk sexual behaviors. These findings emphasize the need for intervention development within the context of population-specific behaviors. Future research should further consider the importance of transmission behaviors among clusters of demographically similar populations at high risk for or living with HIV.

Hispanic Secondary Stroke Prevention Initiative Design: Study Protocol and Rationale for a Randomized Controlled Trial.

BACKGROUND: Hispanic-Latino populations face a disproportionate stroke burden and are less likely to have sufficient control over stroke risk factors in comparison with other ethnic populations. A promising approach to improving chronic health outcomes has been the use of community health workers (CHWs). OBJECTIVE: The objective of this randomized controlled trial is to evaluate the effectiveness of a CHW intervention among Latino patients at risk of recurrent stroke. METHODS: The Hispanic Secondary Stroke Prevention Initiative (HiSSPI) is a randomized clinical trial of 300 Latino participants from South Florida who have experienced a stroke within the last 5 years. Participants randomized into the CHW intervention arm receive health education and assistance with health care navigation and social services through home visits and phone calls. The intervention also includes a mHealth component in which participants also receive daily text messages (short message service). The primary outcome is change in systolic blood pressure at 12 months. Other secondary outcomes include changes in low-density lipoprotein, glycated hemoglobin, and medication adherence. RESULTS: Study enrollment began in 2015 and will be completed by the end of 2018. The first results are expected to be submitted for publication in 2020. CONCLUSIONS: HiSSPI is one of the first randomized controlled trials to examine CHW-facilitated stroke prevention and will provide rigorous evidence on the impact of CHWs on secondary stroke risk factors among Latino individuals who have had a stroke. TRIAL REGISTRATION: ClinicalTrials.gov NCT02251834; https://clinicaltrials.gov/ct2/show/NCT02251834 (Archived by WebCite at http://www.webcitation.org/72DgMqftq). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/11083.

Cohesive and coherent connected speech deficits in mild stroke.

Spoken language production theories and lesion studies highlight several important prelinguistic conceptual preparation processes involved in the production of cohesive and coherent connected speech. Cohesion and coherence broadly connect sentences with preceding ideas and the overall topic. Broader cognitive mechanisms may mediate these processes. This study aims to investigate (1) whether stroke patients without aphasia exhibit impairments in cohesion and coherence in connected speech, and (2) the role of attention and executive functions in the production of connected speech. Eighteen stroke patients (8 right hemisphere stroke [RHS]; 6 left [LHS]) and 21 healthy controls completed two self-generated narrative tasks to elicit connected speech. A multi-level analysis of within and between-sentence processing ability was conducted. Cohesion and coherence impairments were found in the stroke group, particularly RHS patients, relative to controls. In the whole stroke group, better performance on the Hayling Test of executive function, which taps verbal initiation/suppression, was related to fewer propositional repetitions and global coherence errors. Better performance on attention tasks was related to fewer propositional repetitions, and decreased global coherence errors. In the RHS group, aspects of cohesive and coherent speech were associated with better performance on attention tasks. Better Hayling Test scores were related to more cohesive and coherent speech in RHS patients, and more coherent speech in LHS patients. Thus, we documented connected speech deficits in a heterogeneous stroke group without prominent aphasia. Our results suggest that broader cognitive processes may play a role in producing connected speech at the early conceptual preparation stage.