The landscape of trauma informed care in community-based HIV service organizations in the United States south.

Among people living with HIV, trauma is associated with increased viral loads and obstructed access to HIV care. Trauma-Informed Care (TIC), a SAMHSA Evidence Based Practice, responds to the impact of trauma for service users by focusing on all aspects of service delivery systems and structures. TIC could be potentially lifesaving in regions where HIV rates continue to rise, like the U.S. South. Thus, the purpose of this study is to (1) understand the extent to which HIV service organizations in the U.S. South provide mental health and substance use services and referrals; (2) the extent to which they employ trauma informed care and (3) the barriers of employing trauma informed care. Analyzing quantitative data of 207 organizations, we found that less than a third of organizations provided a trauma informed intervention. Only 44% of organizations had participated in TIC training but 84% expressed interest in TIC training. Organizations who completed TIC training were 10 times more likely than those who did not to report that they implemented at least one trauma informed care strategies. Barriers to TIC implementation included lack of training, capacity, and resources. Building the capacity of organizations to implement TIC will be a key to ending the HIV epidemic.

The geographic reach of community-based organizations in addressing HIV-related stigma in the Deep South.

Community-based organizations (CBOs) have been instrumental in addressing the needs of people living with HIV, however, little is known about their efforts to address HIV-related stigma through stigma reduction efforts. This study examined practices of CBOs related to mitigating HIV-related stigma in nine Deep South states. CBOs were surveyed as part of a larger study through the Gilead COMPASS Initiative. The CBO survey asked CBO leadership about stigma in their communities and services available to address this stigma. Survey respondents (n = 207) indicated that HIV-related stigma was perceived as a substantial barrier to both HIV care and CBO services. Although just over two-thirds of survey participants reported that there were group-level programs to address HIV-related stigma, 73% reported that there were not enough interventions to meet the need in their community. Further, 68% reported a lack of individual-level stigma reduction interventions. A majority reported a lack of public media campaigns to address stigma and a lack of training available to assist CBOs to address stigma. In addition, services to address stigma were reportedly less available in rural areas compared to their urban counterparts. Study findings indicate a need to identify, implement, and scale-up effective interventions to reduce HIV stigma in the US Deep South.

Social media support group: Implementation and evaluation.

Lack of social support and perceived HIV-related stigma increase the risk of negative health-related outcomes among people living with HIV (PLWH). This study examines the social media use of PLWH participating in a behavioral health treatment program, and the association of participation in a "secret" Facebook group with improved client social support, education, and overall behavioral health treatment experience. Eighteen individuals participated in a survey and eight individuals participated in a focus group regarding their familiarity with technology and experience with using social media. Mixed-method analysis revealed that the majority of "secret" Facebook group participants thought that participation in the group improved overall personal wellbeing and perceived social support. However, lack of technology and social media experience and privacy concerns may have contributed to lower levels of participation with the "secret" Facebook group. A majority of participants who found Facebook difficult to use and/or had less technology experience were over the age of 50. Incorporating additional technology training for individuals who lack technology experience has the potential to improve clients' overall proficiency with technology and social media, as well as build confidence that could translate into an increased willingness to participate in a social media-based intervention.

The Relationship of HIV-related Stigma and Health Care Outcomes in the US Deep South.

HIV-related stigma is prevalent in the US Deep South; however, information regarding the types of stigma and their effects on HIV-related outcomes is limited. This study examined the prevalence of different forms of stigma and the association of stigma with medication and medical visit adherence in the Deep South. Survey participants included 201 individuals living with HIV recruited from Infectious Diseases Clinics (ID) and AIDS Service Organizations (ASOs) in four Deep South states. Study participants reported high levels of experienced, perceived, and internalized stigma. Multivariable analysis revealed that internalized stigma and recent stigmatizing experiences were significantly associated with poorer HIV medication adherence. Internalized stigma was also associated with having missed an HIV medical care visit in the last 6 months. These findings suggest the need to identify and develop effective interventions to address internalized HIV-related stigma and to address community HIV stigma to improve outcomes for individuals living with HIV.

State of HIV in the US Deep South.

The Southern United States has been disproportionately affected by HIV diagnoses and mortality. To inform efforts to effectively address HIV in the South, this manuscript synthesizes recent data on HIV epidemiology, care financing, and current research literature on factors that predispose this region to experience a greater impact of HIV. The manuscript focuses on a specific Southern region, the Deep South, which has been particularly affected by HIV. Epidemiologic data from the Centers from Disease Control and Prevention indicate that the Deep South had the highest HIV diagnosis rate and the highest number of individuals diagnosed with HIV (18,087) in 2014. The percentage of new HIV diagnoses that were female has decreased over time (2008-2014) while increasing among minority MSM. The Deep South also had the highest death rates with HIV as an underlying cause of any US region in 2014. Despite higher diagnosis and death rates, the Deep South received less federal government and private foundation funding per person living with HIV than the US overall. Factors that have been identified as contributors to the disproportionate effects of HIV in the Deep South include pervasive HIV-related stigma, poverty, higher levels of sexually transmitted infections, racial inequality and bias, and laws that further HIV-related stigma and fear. Interventions that address and abate the contributors to the spread of HIV disease and the poorer HIV-related outcomes in the Deep South are warranted. Funding inequalities by region must also be examined and addressed to reduce the regional disparities in HIV incidence and mortality.

A Review of Recent Literature on Trauma Among Individuals Living with HIV.

Persons living with HIV (PLWH) report disproportionately high levels of exposure to traumatic events in childhood and adulthood. Traumatic experiences are associated with negative health and behavioral outcomes. Current research in this area seeks to further explicate the myriad health effects of trauma on PLWH and the pathways through which trauma operates. In this paper, we review articles published in English between January 2014 and June 2015 that examine traumatic experiences among PLWH, including intimate partner violence (IPV), domestic abuse, child abuse, and other forms of violence. A selection of studies examining trauma among PLWH and its associations with mental health, antiretroviral medication adherence, clinical outcomes, HIV disclosure, and sexual risk behaviors were included. Studies describing trauma coping strategies and interventions were also included. We conclude with recommendations for care of trauma-exposed PLWH and directions for future research.

HIV Diagnoses, Prevalence and Outcomes in Nine Southern States.

A group of nine states in the Southern United States, hereafter referred to as the targeted states, has experienced particularly high HIV diagnosis and case fatality rates. To provide additional information about the HIV burden in this region, we used CDC HIV surveillance data to examine characteristics of individuals diagnosed with HIV in the targeted states (2011), 5-year HIV and AIDS survival, and deaths among persons living with HIV (2010). We used multivariable analyses to explore the influence of residing in the targeted states at diagnosis on deaths among persons living with HIV after adjustment for demographics and transmission risk. In 2011, the targeted states had a higher HIV diagnosis rate (24.5/100,000 population) than the US overall (18.0/100,000) and higher proportions than other regions of individuals diagnosed with HIV who were black, female, younger, and living in suburban and rural areas. Furthermore, the targeted states had lower HIV and AIDS survival proportions (0.85, 0.73, respectively) than the US overall (0.86, 0.77, respectively) and the highest death rate among persons living with HIV of any US region. Regional differences in demographics and transmission risk did not explain the higher death rate among persons living with HIV in the targeted states indicating that other factors contribute to this disparity. Differences in characteristics and outcomes of individuals with HIV in the targeted states are critical to consider when creating strategies to address HIV in the region, as are other factors identified in previous research to be prominent in the region including poverty and stigma.

HIV/AIDS in the Southern USA: a disproportionate epidemic.

This research synthesis examined HIV/AIDS surveillance and health care financing data and reviewed relevant research literature to describe HIV epidemiology, outcomes, funding, and contributing factors to the HIV epidemic in the Southern USA with particular focus on a group of Southern states with similar demographic and disease characteristics and comparable HIV epidemics (Alabama, Georgia, Florida, Los Angeles, Mississippi, North Carolina, South Carolina, Tennessee, and Texas). These states are hereafter referred to as "targeted Southern states." Eight of the 10 states with the highest HIV diagnosis rates in 2011 were in the Southern USA; six were targeted states. Forty-nine percent of HIV diagnoses were in the South in 2011, which contains only 37% of the US population. The targeted states region had the highest HIV diagnosis rate than any other US region in 2011. The South was also found to have the highest HIV-related mortality and morbidity rates in the USA. The high levels of poverty, HIV-related stigma, and STDs found in the South, particularly in the targeted Southern states, likely contribute to greater HIV incidence and mortality. The disproportionate impact of HIV in the South, particularly among targeted states, demonstrates a critical need to improve HIV prevention and care and address factors that contribute to HIV disease in this region.

Provider perspectives on screening and treatment for opioid use disorder and mental health in HIV care: A qualitative study.

BACKGROUND: HIV, opioid use disorder (OUD), and mental health challenges share multiple syndemic risk factors. Each can be effectively treated with routine outpatient appointments, medication management, and psychosocial support, leading implementers to consider integrated screening and treatment for OUD and mental health in HIV care. Provider perspectives are crucial to understanding barriers and strategies for treatment integration. METHODS: We conducted in-depth qualitative interviews with 21 HIV treatment providers and social services providers (12 individual interviews and 1 group interview with 9 participants) to understand the current landscape, goals, and priorities for integrated OUD, mental health, and HIV care. Providers were purposively recruited from known clinics in Mecklenburg County, North Carolina, U.S.A. Data were analyzed using applied thematic analysis in the NVivo 12 software program and evaluated for inter-coder agreement. RESULTS: Participants viewed substance use and mental health challenges as prominent barriers to engagement in HIV care. However, few organizations have integrated structured screening for substance use and mental health into their standard of care. Even fewer screen for opioid use. Although medication assisted treatment (MAT) is effective for mitigating OUD, providers struggle to connect patients with MAT due to limited referral options, social barriers such as housing and food insecurity, overburdened staff, stigma, and lack of provider training. Providers believed there would be clear benefit to integrating OUD and mental health treatment in HIV care but lacked resources for implementation. CONCLUSIONS: Integration of screening and treatment for substance use and mental health in HIV care could mitigate many current barriers to treatment for all three conditions. Efforts are needed to train HIV providers to provide MAT, expand resources, and implement best practices.

Results of a pilot test of a brief computer-assisted tailored HIV prevention intervention for use with a range of demographic and risk groups.

There is a need for brief HIV prevention interventions that can be disseminated and implemented widely. This article reports the results of a small randomized field experiment that compared the relative effects of a brief two-session counselor-delivered computer-tailored intervention and a control condition. The intervention is designed for use with African-American, non-Hispanic white and Hispanic males and females who may be at risk of HIV through unprotected sex, selling sex, male to male sex, injecting drug use or use of stimulants. Participants (n = 120) were recruited using a quota sampling approach and randomized using block randomization, which resulted in ten male and ten female participants of each racial/ethnic group (i.e. African-American, non-Hispanic white and Hispanic) being assigned to either the intervention or a control arm. In logistic regression analyses using a generalized estimating equations approach, at 3-month followup, participants in the intervention arm were more likely than participants in the control arm to report condom use at last sex (Odds ratio [OR] = 4.75; 95 % Confidence interval [CI] = 1.70-13.26; p = 0.003). The findings suggest that a brief tailored intervention may increase condom use. Larger studies with longer followups are needed to determine if these results can be replicated.

Using Small Grants to SPARK! Substantial Reach to Reduce HIV-related Stigma.

Community-based organizations (CBOs) are well-positioned to address the negative effects of HIV stigma, which is prevalent in the U.S. South. This article describes a Gilead COMPASS-funded small grants and capacity-building program for CBOs to address stigma and describes the broad reach and positive outcomes associated with program implementation.

The POWER of LEARNing and LEADing Together: Shared Learning Communities.

Southern community-based organizations often lack adequate resources to implement high-quality, culturally appropriate HIV programs and services. Shared learning communities (SLCs) combine in-depth training, tailored coaching, and peer-to-peer learning to strengthen HIV programs and services. This paper describes five SLCs, participant characteristics, and their capacity-building components.

Relationship between trauma and high-risk behavior among HIV-positive men who do not have sex with men (MDSM).

The incidence of heterosexual HIV transmission continues to increase in the USA. However, little is known about factors that influence high-risk behavior among men who do not have sex with men (MDSM). This study examines the association of childhood sexual abuse and high-risk behaviors among MDSM. The Coping with HIV/AIDS in the Southeast (CHASE) study included 611 HIV-positive individuals in the Southeastern US Bivariate statistics were used to examine the influence of childhood sexual abuse among MDSM, men who have sex with men (MSM), and women. Study findings indicated that among MDSM with HIV, childhood sexual abuse predicted a higher number of sexual partners, alcohol and drug use problems, depression, post-traumatic stress disorder (PTSD), and less trust in medical providers. Similar statistically significant relationships between childhood sexual abuse and negative outcomes were not found for MSM and women with the exception of childhood sexual abuse predicting PTSD and alcohol use in women. Study findings indicate a need for more in-depth research to examine the role of childhood sexual abuse in shaping adult risk behaviors among MDSM as well as a need to assess for and address childhood sexual abuse in this population.

The COVID-19 Pandemic: Impact on Southern HIV Service Organizations, Staff, and Clients.

The COVID-19 pandemic has exacerbated HIV-related disparities and has likely disrupted service provision by organizations providing critical HIV-related services, especially in the U.S. Deep South, an area disproportionately affected by HIV. To assess the impact of COVID-19 on organizations providing services for people living with HIV and/or sexual and gender minorities throughout the Deep South, an online survey was developed and disseminated from January to June 2021 regarding service disruption, organizational changes and needs, and staff and client impact and needs. Organizations reported ongoing organization-level financial and structural complications, staff difficulties including mental health challenges and lack of technology proficiency, and exacerbated challenges for clients including increased mental health concerns, substance use, and housing instability, among others. Organizations will need to be supported as they navigate the exacerbated mental health challenges of clients and staff as well as financially supported as they address economic disparities related to the pandemic.

Identification and Reporting of Gender Identity in HIV Surveillance Data in the Deep South.

Introduction: Although studies have identified high prevalence of HIV among individuals who are transgender, HIV surveillance data regarding gender identity is incomplete, resulting in uncertainty regarding the gender identity, including transgender and other diverse gender identities, of individuals diagnosed with HIV. This information is critical to planning strategies for HIV prevention and care. Methods: From August 2018 to March 2019, interviews were conducted with HIV surveillance leadership (including Surveillance Directors, Epidemiologists, and HIV/STI Prevention Staff) at offices of epidemiology from eight US Deep South states regarding their practices related to gender identity documentation in HIV surveillance data and the barriers encountered in these documentation processes as well as their recommendations for improving gender identity data collection. Results: Interview findings indicated significant barriers to collection of accurate gender identity information in HIV surveillance data including lack of standardized data systems for collecting gender identity; difficulty obtaining gender identity information from HIV testing sites, laboratories, and medical databases; and need for enhanced cultural sensitivity and gender identity knowledge at all levels of the data collection process. Recommendations from the state HIV surveillance staff, leaders, and epidemiologists are included in the findings. Conclusions and Policy Implications: Effective, well-coordinated strategies are needed to improve gender identity information in HIV surveillance reporting. Recommendations include standardizing and enhancing data collection strategies, providing cultural sensitivity training at all levels of HIV testing/reporting, and developing formal guidance and providing technical assistance that targets and educates laboratories and medical organizations to implement systems of data collection that routinely and safely capture gender identity data.

Adaptation and Preliminary Testing of an Intervention to Reduce Stigma among Individuals Living with HIV in the Deep South.

HIV-related stigma has been implicated as a contributor to the disproportionate impact of HIV in the US Deep South. However, effective interventions aimed at reducing HIV-related stigma are limited in the region. This study adapted and piloted an HIV-related stigma reduction intervention, the UNITY Workshop, for use among people living with HIV in the Deep South following a modified framework of the ADAPT-ITT model and the five principles of Corrigan's Model of Strategic Stigma Change. The adapted intervention, named the YOUNITY Workshop, was conducted in an experiential, group format and focused on enhancing stigma coping skills. Workshop satisfaction was high, and most participants reported acquiring new skills for coping with HIV-related stigma and HIV status disclosure. Participants also reported benefitting from the social support generated from the workshop and desired additional opportunities to connect with others in the future. This pilot study demonstrated the feasibility and positive preliminary outcomes of conducting a group-based HIV stigma reduction workshop in the Deep South. Future rigorous testing of the YOUNITY Workshop is planned to better examine health outcomes associated with participation.

Identification of Determinants and Implementation Strategies to Increase PrEP Uptake Among Black Same Gender-Loving Men in Mecklenburg County, North Carolina: The PrEP-MECK Study.

BACKGROUND: Pre-exposure prophylaxis (PrEP) use is low among Black same gender-loving men (BSGLM) in Mecklenburg County, NC, an Ending the HIV Epidemic priority jurisdiction. We created PrEP-MECK-an investigator partnership among a community-based organization representative, a PrEP provider, and researchers-and conducted iterative preparation research to identify determinants of PrEP uptake and implementation strategies to address them. METHODS: We first established the PrEP-MECK Coalition of community stakeholders. Next, informed by PrEP-MECK Coalition input and PRECEDE-PROCEED's educational/ecological assessment phase, we conducted focus group discussions with BSGLM not using PrEP and in-depth interviews with BSGLM who were currently or had previously taken PrEP to describe determinants and suggest implementation strategies. Based on interim findings, we partnered with clinics participating in the Mecklenburg County PrEP Initiative, which offers free PrEP services to uninsured individuals. We also conducted Consolidated Framework for Implementation Research-informed organizational assessments with community-based organizations and clinics to assess readiness to pilot the implementation strategies. RESULTS: We conducted 4 focus group discussions, 17 in-depth interviews, and 6 assessments. BSGLM were aware of PrEP yet perceived that costs made it unattainable. Awareness of how to access PrEP and the Mecklenburg County PrEP Initiative was lacking, and clinic scheduling barriers and provider mistrust limited access. We identified client-level implementation strategies, primarily focusing on engaging the consumer, to increase comfort with and awareness of how to access PrEP, and clinic-level implementation strategies focusing on changing clinic infrastructure, to make PrEP access easier. CONCLUSION: We plan to evaluate implementation of these strategies once fully developed to determine their acceptability and other outcomes in future research.

HIV Prevention During the COVID-19 Pandemic: Sexual Activity and PrEP Use Among Black Same-Gender-Loving Men and Black Cisgender Women.

Black populations in the U.S. South are disproportionally affected by HIV and COVID-19 due to longstanding inequalities. We conducted 20 in-depth interviews-12 with Black same-gender-loving men and 8 with Black cisgender women-to explore the impact of the initial phase of the COVID-19 pandemic on sexual activities and PrEP use. Almost all participants reduced the frequency of sex and number of partners. Women described little interest in sex, whereas men began to connect with some sexual partners after stay-at-home orders were lifted. Both populations were concerned about contracting COVID-19 through sexual partners, and men described selecting partners based on perceived COVID-19 risk. Participants valued PrEP and could access it, although several men who were not having sex stopped taking it. Risk of acquiring HIV during this time was likely limited. Future qualitative research is needed to understand how sexual behaviors and PrEP use changed as the pandemic continued.

Highly stressed: stressful and traumatic experiences among individuals with HIV/AIDS in the Deep South.

A history of traumatic and/or stressful experiences is prevalent among HIV-infected individuals and has been consistently associated with poorer health outcomes. However, little is known about incident stressful experiences and the factors that predict these experiences among HIV-infected individuals. Data from a longitudinal study of 611 HIV-infected individuals in the Southeastern USA were used to examine the frequency and types of incident stress reported in a 27-month period and to determine predictors associated with three incident stress measures (all stressful events, severe stressful events, and traumatic events such as physical assault). Incident stressful experiences frequently occurred among study participants, as 91% reported at least one stressful experience (median=3.5 experiences) and 10% of study participants reported traumatic stress in any given nine-month reporting period. Financial stressors were the most frequently reported by study participants. Greater emotional distress, substance use, and a higher number of baseline stressful experiences were significantly associated with reporting a greater number of incident stressful experiences and any traumatic experiences. Study results indicate that efforts are needed to identify individuals at risk for traumatic events and/or substantial stressors and to address the factors, including mental health and substance abuse, that contribute to these experiences.

HIV Stigma Reduction Through Peer-Led Advocacy Training.

HIV-related stigma is pervasive in the U.S. South and has potential negative effects on health outcomes and emotional well-being, and may act as a barrier to HIV-related advocacy among people living with HIV (PLWH). This article reports on the preliminary outcomes associated with participation in an HIV advocacy training for PLWH, LEAD, that included education and skills building for reducing HIV-related stigma. Fifty-seven PLWH at four sites in the U.S. South participated in the retreat-style training and completed a survey measuring stigma and comfort engaging in advocacy prior to and after the worshop. Participation was associated with statistically significant reduction in internalized HIV stigma and increase in comfort with participation in advocacy; however, participants reported a need for ongoing training and support to further increase comfort with advocacy participation. Although more research is needed on the LEAD Workshop, it shows promise as an option for reducing HIV-related stigma among PLWH.