Development of an mHealth App to Support the Prevention of Sexually Transmitted Infections Among Black Men Who Have Sex With Men Engaged in Pre-exposure Prophylaxis Care in New Orleans, Louisiana: Qualitative User-Centered Design Study.

BACKGROUND: Sexual health disparities exist for Black men who have sex with men (BMSM) in New Orleans, Louisiana. Rates of sexually transmitted infections (STIs) are high for both BMSM and those taking HIV pre-exposure prophylaxis (PrEP). OBJECTIVE: In this study, we introduced an existing PrEP adherence app to new potential users-BMSM engaged in PrEP care in New Orleans-to guide app adaptation with STI prevention features and tailoring for the local context. METHODS: Using a user-centered design, we conducted 4 focus group discussions (FGDs), with interim app adaptations from December 2020 to March 2021. During the FGDs, a video of the app, app website, and mock-ups were shown to participants. We asked about facilitators of and barriers to STI prevention in general, current app use, impressions of the existing app, new app features to potentially facilitate STI prevention, and how the app should be tailored for BMSM. We used applied qualitative thematic analysis to identify themes and needs of the population. RESULTS: Overall, 4 FGDs were conducted with 24 BMSM taking PrEP. We grouped themes into 4 categories: STI prevention, current app use and preferences, preexisting features and impressions of the prep'd app, and new features and modifications for BMSM. Participants noted concern about STIs and shared that anxiety about some STIs was higher than that for others; some participants shared that since the emergence of PrEP, little thought is given to STIs. However, participants desired STI prevention strategies and suggested prevention methods to implement through the app, including access to resources, educational content, and sex diaries to follow their sexual activity. When discussing app preferences, they emphasized the need for an app to offer relevant features and be easy to use and expressed that some notifications were important to keep users engaged but that they should be limited to avoid notification fatigue. Participants thought that the current app was useful and generally liked the existing features, including the ability to communicate with providers, staff, and each other through the community forum. They had suggestions for modifications for STI prevention, such as the ability to comment on sexual encounters, and for tailoring to the local context, such as depictions of iconic sights from the area. Mental health emerged as an important need to be addressed through the app during discussion of almost all features. Participants also stressed the importance of ensuring privacy and reducing stigma through the app. CONCLUSIONS: A PrEP adherence app was iteratively adapted with feedback from BMSM, resulting in a new app modified for the New Orleans context and with STI prevention features. Participants gave the app a new name, PCheck, to be more discreet. Next steps will assess PCheck use and STI prevention outcomes.

Acceptability and feasibility of a mobile health application for blood pressure monitoring in rural Uganda.

BACKGROUND: Mobile technologies to improve blood pressure control in resource-limited settings are needed. We adapted and evaluated the acceptability and feasibility of PositiveLinks, a mobile phone application for self-monitoring, social support, and engagement in care for people living with HIV, among patients with hypertension in rural Uganda. METHODS: We enrolled adults on treatment for hypertension at Mbarara Regional Referral Hospital and Mbarara Municipal health center IV, southwestern Uganda. We provided and educated all participants on the use of PositiveLinks application and automated blood pressure monitors. We administered a baseline questionnaire and performed in-depth interviews 30 days later to explore acceptability, feasibility, medication adherence, social support, and blood pressure control. RESULTS: A total of 37 participants completed the interviews, mean age of 58 years (SD 10.8) and 28 (75.7%) were female. All participants embraced the PositiveLinks mobile app and were enthusiastic about self-monitoring of blood pressure, 35 (94.6%) experienced peer to peer support. Among the 35 participants non-adherent to medications at baseline, 31 had improved medication adherence. All except 1 of the 31(83.8%) who had uncontrolled blood pressure at baseline, had self-reported controlled blood pressure after 30 days of use of PositiveLinks. CONCLUSION: Patients with hypertension in rural Uganda embraced the PositiveLinks mobile application and had improved medication adherence, social support, and blood pressure control. Further assessment of cost-effectiveness of the application in blood pressure control in resource-limited settings will be pursued in future studies.

Feasibility and Acceptability of Tele-Colposcopy on the Caribbean Coast of Nicaragua: A Descriptive Mixed-Methods Study.

Background: Cervical cancer, a preventable cancer of disparities, is the primary cause of cancer death for women in Nicaragua. Clinics and personnel in rural and remote Nicaragua may not be accessible to perform recommended screening or follow-up services. Objective: To assess acceptability and feasibility of integrating innovations for high-quality screening and treatment follow-up (tele-colposcopy) into existing pathways on Nicaragua's Caribbean Coast within the context of the National Cervical Cancer Control Program. Methods: Provider focus groups, key informant interviews, and environmental scans were conducted for 13 clinics on the Caribbean Coast of Nicaragua. Topics discussed included a smartphone-based mobile colposcope (MobileODT hardware and mobile platform), mobile connectivity capacity, clinic resources, provider acceptability, and current diagnostic and clinical protocols. We tested device connectivity through image upload availability and real-time video connection and simulated clinical encounters utilizing MobileODT and a low-cost cervical simulator. We developed a database of colposcopic images to establish feasibility of integrating this database and clinical characteristics into the cervical cancer registry. Results: Provider acceptability of integrating tele-colposcopy into existing cancer control efforts was high. Image upload connectivity varied by location (mean = 1 h 9 min). Most clinics had running water (84.6%) and consistent electricity (92.3%), but some did not have access to landline telephones (53.8%). Conclusions: As faster connectivity becomes available in remote settings, Mobile Health tools such as tele-colposcopy will be increasingly feasible to provide access to high-quality cervical cancer follow-up. World Health Organization guidance on integrating technology into existing programs will remain important to ensure programmatic efficacy, local relevance, and sustainability.

Financial, Food, and Housing Insecurity Due to Coronavirus Disease 2019 Among At-Risk People With Human Immunodeficiency Virus in a Nonurban Ryan White HIV/AIDS Program Clinic.

Coronavirus disease 2019 negatively impacts social determinants of health that contribute to disparities for people with human immunodeficiency virus (HIV). Insecurity of food, housing, and employment increased significantly in April 2020 among patients with lower incomes at a Ryan White HIV/AIDS program clinic in the Southern United States.

A qualitative study of perceived barriers to hepatitis C care among people who did not attend appointments in the non-urban US South.

BACKGROUND: Most people diagnosed with hepatitis C virus (HCV) have not linked to care, despite the availability of safe and effective treatment. We aimed to understand why people diagnosed with HCV have not pursued care in the non-urban Southern United States. METHODS: We conducted a survey and semi-structured interview with participants referred to an HCV clinic who did not attend an appointment between 2014 and 2018. Our clinic is located in a non-urban region of Virginia at a university hospital. Qualitative data collection was guided by the Health Belief Model (HBM). Data was analyzed using qualitative content analysis to identify key factors influencing patient perceptions regarding HCV and pursuit of care. RESULTS: Over half of previously referred patients (N = 200) could not be reached by phone. Eleven participants enrolled, including 7 men and 4 women. Based on survey responses, unreliable transportation, unstable housing, substance use, and lack of insurance were common. Participants demonstrated good knowledge of HCV disease, complications, and treatment. On qualitative analysis of semi-structured interviews, final themes emerged from within and between HBM constructs. Emerging themes influencing patient perceptions included (1) structural barriers, (2) stigma, (3) prior experiences of HCV disease and treatment, (4) discordance between the recognized severity of HCV and expected impacts on one's own health, and (5) patient-provider relationship. Substance use was not identified to be a barrier to care. CONCLUSIONS: Participants perceived individual and structural barriers to linking to care. A strong HCV knowledge base was not sufficient to motivate pursuit of care. Efforts to improve linkage to care must address barriers at multiple levels, and system-level changes are needed. As the majority of previously referred patients could not be contacted by phone, current approaches to patient engagement are not effective for reaching these populations. Expansion of HCV care to primary care settings with an established patient-provider relationship or co-located treatment within substance use treatment programs may serve to increase access to HCV treatment.

Development of an Interdisciplinary Telehealth Model of Provider Training and Comprehensive Care for Hepatitis C and Opioid Use Disorder in a High-Burden Region.

BACKGROUND: Hepatitis C virus (HCV) and the opioid epidemic disproportionately affect the Appalachian region. Geographic and financial barriers prevent access to specialty care. Interventions are needed to address the HCV-opioid syndemic in this region. METHODS: We developed an innovative, collaborative telehealth model in Southwest Virginia featuring bidirectional referrals from and to comprehensive harm reduction (CHR) programs and office-based opioid therapy (OBOT), as well as workforce development through local provider training in HCV management. We aimed to (1) describe the implementation process of provider training and (2) assess the effectiveness of the telehealth model by monitoring patient outcomes in the first year. RESULTS: The provider training model moved from a graduated autonomy model with direct specialist supervision to a 1-day workshop with parallel tracks for providers and support staff followed by monthly case conferences. Forty-four providers and support staff attended training. Eight providers have begun treating independently. For the telehealth component, 123 people were referred, with 62% referred from partner OBOT or CHR sites; 103 (84%) attended a visit, 93 (76%) completed the treatment course, and 61 (50%) have achieved sustained virologic response. Rates of sustained virologic response did not differ by receipt of treatment for opioid use disorder. CONCLUSIONS: Providers demonstrated a preference for an in-person training workshop, though further investigation is needed to determine why only a minority of those trained have begun treating HCV independently. The interdisciplinary nature of this program led to efficient treatment of hepatitis C in a real-world population with a majority of patients referred from OBOTs and CHR programs.

Impact of Low-Cost Point-of-Use Water Treatment Technologies on Enteric Infections and Growth among Children in Limpopo, South Africa.

Enteric infections early in life have been associated with poor linear growth among children in low-resource settings. Point-of-use water treatment technologies provide effective and low-cost solutions to reduce exposure to enteropathogens from drinking water, but it is unknown whether the use of these technologies translates to improvements in child growth. We conducted a community-based randomized controlled trial of two water treatment technologies to estimate their effects on child growth in Limpopo, South Africa. We randomized 404 households with a child younger than 3 years to receive a silver-impregnated ceramic water filter, a silver-impregnated ceramic tablet, a safe-storage water container alone, or no intervention, and these households were followed up quarterly for 2 years. We estimated the effects of the interventions on linear and ponderal growth, enteric infections assessed by quantitative molecular diagnostics, and diarrhea prevalence. The silver-impregnated ceramic water filters and tablets consistently achieved approximately 1.2 and 3 log reductions, respectively, in total coliform bacteria in drinking water samples. However, the filters and tablets were not associated with differences in height (height-for-age z-score differences compared with no intervention: 0.06, 95% CI: -0.29, 0.40, and 0.00, 95% CI: -0.35, 0.35, respectively). There were also no effects of the interventions on weight, diarrhea prevalence, or enteric infections. Despite their effectiveness in treating drinking water, the use of the silver-impregnated ceramic water filters and tablets did not reduce enteric infections or improve child growth. More transformative water, sanitation, and hygiene interventions that better prevent enteric infections are likely needed to improve long-term child growth outcomes.

Evidence From a Multistate Cohort: Enrollment in Affordable Care Act Qualified Health Plans' Association With Viral Suppression.

BACKGROUND: Healthcare delivery changes associated with viral suppression (VS) could contribute to the United States' "Ending the HIV Epidemic" (EtHE) initiative. This study aims to determine whether Qualified Health Plans (QHPs) purchased by AIDS Drug Assistance Programs (ADAPs) are associated with VS for low-income people living with HIV (PLWH) across 3 states. METHODS: A multistate cohort of ADAP clients eligible for ADAP-funded QHPs were studied (2014-2015). A log-binomial model was used to estimate the association of demographics and healthcare delivery factors with QHP enrollment prevalence and 1-year risk of VS. A number needed to treat/enroll (NNT) for 1 additional person to achieve viral suppression was calculated. RESULTS: Of the cohort (n = 7776), 52% enrolled in QHPs. QHP enrollment in 2015 was associated with QHP coverage in 2014 (adjusted PR [aPR], 3.28; 95% confidence intervals [CIs], 3.06-3.53) and engagement in care in 2014 (aPR, 1.16; 1.04-1.28). PLWH who were engaged in care (n = 4597) and had QHPs had a higher VS rate than those who received medications from Direct ADAP (86.0% vs 80.2%). QHPs' NNT for an additional person to achieve VS is 20 (14.1-34.5). Starting undetectable (adjusted risk ratio [aRR], 1.39; 1.28-1.52) and enrolling in QHPs in 2015 (aRR, 1.06; 0.99-1.14) was associated with VS. CONCLUSIONS: Once enrolled in ADAP-funded QHPs, ADAP clients stay enrolled. Enrollment is associated with VS across states/demographic groups. ADAPs, especially in the South and in Medicaid nonexpansion states, should consider investing in QHPs because increased enrollment could improve VS rates. This evidence-based intervention could be part of EtHE.

Secure Messaging Through PositiveLinks: Examination of Electronic Communication in a Clinic-Affiliated Smartphone App for Patients Living with HIV.

Purpose: Secure messaging between patients and their health care team can facilitate chronic care management. PositiveLinks® (PL) is a clinic-affiliated smartphone application designed for patients living with HIV that includes a secure messaging feature for patients, PL staff, and clinic providers to communicate. Our aim was to examine the content and function of messaging within PL. Methodology: We examined messages exchanged through PL from November 2017 through January 2018. Qualitative analysis included categorization of topics as: related to the app, medical care, or social needs. Messaging functions were categorized as information exchange or rapport building. Results: Of the 1,474 PL messages analyzed, 44% were sent by PL staff, 38% by patients, and 18% by providers, whereas 61% were received by patients, 22% by providers, and 17% by PL staff. Message topics included app-related (57.6%), medical care (34.3%), and social concerns (12.4%). App-related messages addressed technical difficulties, software updates, or coordinating phone payments. Medical messages included medical information, medications, appointments, outreach, and care coordination for physical and mental health. Social messages related to insurance, transportation, housing, food, utilities, disability, finances, and work absences. Message function coding showed that 87.3% of messages contained information exchange and 33.8% contained rapport building. Messages sent by providers were most likely to contain rapport building at 54.8%. Conclusion: PL messaging was used to handle medical and social needs with potential impact on patients' health and offers an opportunity to strengthen patient-provider relationships through responsiveness and rapport building. Secure messaging through a clinic-affiliated smartphone app could enhance patient-centered care between clinical visits.

Disparities in Hepatitis C Linkage to Care in the Direct Acting Antiviral Era: Findings From a Referral Clinic With an Embedded Nurse Navigator Model.

Background: Direct acting antivirals (DAAs) have simplified and expanded access to Hepatitis C virus (HCV) treatment. Only 17% of the 2.4 million Americans with HCV have linked to HCV care. We aimed to evaluate linkage to care (LTC) in a non-urban HCV referral clinic with a nurse navigator model and identify disparities in LTC. Methods: A single-center retrospective cohort analysis was performed among all patients referred to an infectious diseases HCV clinic between 2014 and 2018. The primary outcome was LTC, defined as attendance at a clinic appointment. A multivariable Poisson regression model estimated the association of variables with LTC. Results: Among 824 referred patients, 624 (76%) successfully linked to care and 369 (45%) successfully achieved sustained virologic response. Forty-six percent of those referred were uninsured. On multivariable analysis, LTC rates were higher among women (Incidence Rate Ratio [IRR] 1.11, 95% CI 1.03-1.20, p-value = 0.01) and people with cirrhosis (IRR 1.20, 95% CI 1.11-1.30, p-value < 0.001). Lower LTC rates were found for young people (<40 years; IRR 0.88, 95% CI 0.79-0.98, p-value = 0.02) and uninsured people (IRR 0.85, 95% CI 0.77-0.94, p-value = 0.002). Among those without LTC, 10% were incarcerated. Race, proximity to care, substance use, and HIV status were not associated with LTC. Conclusions: Using an embedded nurse navigator model, high LTC rates were achieved despite the prevalence of barriers, including a high uninsured rate. Disparities in LTC based on age, sex, and insurance status are present. Substance use was not associated with LTC. Future interventions to improve care should include expanded access to insurance and programs bridging care for incarcerated populations.

Facilitators and Barriers: Clients' Perspective on the Virginia AIDS Drug Assistance Program's Affordable Care Act Implementation.

Many AIDS drug assistance programs (ADAPs) purchased Affordable Care Act (ACA) qualified health plans (QHPs) for low-income people living with HIV. To date, little has been written about this from the client perspective. The study's objective was to gain information about the experience of Virginia ADAP-funded QHP enrollment and the impact of this change. English-speaking clients who were eligible for ADAP-funded QHPs were recruited at three HIV clinics in Virginia. The goal was to enroll ≥5% of those who were eligible for ADAP-funded QHPs in two Virginia Department of Health planning districts. Participants were surveyed about demographic characteristics, and semi-structured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (n = 53) met our recruitment goal. Two-thirds gained their ACA knowledge at HIV clinics from case managers and social workers. Many barriers to enrollment were identified, including internet access/literacy. Almost 9 out of 10 participants had concerns about privacy, which centered on QHP's mandated use of mail-order pharmacies. Except for medication concerns, most participants had positive perceptions of the impact of QHP enrollment on their health care. HIV clinic case managers and social workers are often the primary source of knowledge for patients about insurance options and their assistance is crucial for QHP enrollment. Our findings indicate that reducing identified barriers and addressing privacy concerns by allowing people to opt out of mail order pharmacies may encourage QHP enrollment.

Rising rates of injection drug use associated infective endocarditis in Virginia with missed opportunities for addiction treatment referral: a retrospective cohort study.

BACKGROUND: Injection drug use (IDU) is a growing public health threat in Virginia, though there is limited knowledge of related morbidity. The purpose of this study was to describe the temporal, geographic and clinical trends and characteristics of infective endocarditis associated with IDU (IDU-IE) and to identify opportunities for better-quality care of people who inject drugs (PWID). METHODS: We reviewed charts for all admissions coded for both IE and drug use disorders at the University of Virginia Medical Center (UVA) from January 2000 to July 2016. A random sample of 30 admissions coded for IE per year were reviewed to evaluate temporal trends in the proportion of IDU associated IE cases. RESULTS: There were a total of 76 patients with IDU-IE during the study period, 7.54-fold increase (prevalence ratio: 8.54, 95% CI 3.70-19.72) from 2000 to 2016. The proportion of IE that was IDU-associated increased by nearly 10% each year (prevalence ratio of IDU per year: 1.09, 95% CI: 1.05-1.14). Patients with IDU-IE had longer hospital stays [median days (interquartile range); IDU-IE, 17 (10-29); non-IDU-IE, 10 (6-18); p-value = 0.001] with almost twice the cost of admission as those without IDU [median (interquartile range); IDU-IE, $47,899 ($24,578-78,144); non-IDU-IE, $26,460 ($10,220-60,059); p-value = 0.001]. In 52% of cases there was no documentation of any discussion regarding addiction treatment. CONCLUSION: IDU-IE is a severe infection that leads to significant morbidity and healthcare related costs. IDU-IE rates are increasing and will likely continue to do so without targeted interventions to help PWID. The diagnosis and treatment of IDU-IE provides an opportunity for the delivery of addiction treatment, counseling, and harm reduction strategies.

National Survey of United States Human Immunodeficiency Virus Medical Providers' Knowledge and Attitudes About the Affordable Care Act.

Background: The Affordable Care Act (ACA) affects United States' healthcare by offering Medicaid expansion and tax subsidies to persons with low incomes, and its interaction with the current human immunodeficiency virus (HIV) healthcare delivery system is complex. The objective was to explore HIV medical providers' knowledge and attitudes about the ACA. Methods: HIV medical providers were emailed a weblink to a survey. Descriptive statistics, Mann-Whitney U tests, and binary logistic regression were performed. Results: Of the 253 survey participants, the majority (61%) answered all 4 knowledge questions correctly. About 70% knew whether or not their state had decided to expand Medicaid. About 1 in 10 did not know if the ACA eliminated the Ryan White Program. When rating whether the ACA would improve their patients' HIV outcomes from 1-5 with 5 as "strongly agree," the providers' mean responses varied by state Medicaid status: 3.78 (standard deviation [SD], 0.83) for Medicaid expansion compared with 3.37 (SD, 1.00) for Medicaid nonexpansion (P = .002). Adjusting for medical provider type, years of HIV practice, and sources of ACA information, correct ACA knowledge was associated with providing care in a Medicaid nonexpansion state (adjusted odds ratio [aOR], 2.07; 95% confidence interval [CI], 1.11-3.88), obtaining knowledge from case managers (aOR, 1.89; 95% CI, 1.03-3.48), and obtaining knowledge from newspapers/magazines (aOR, 1.94; 95% CI, .99-3.81). Conclusions: Medical providers in Medicaid expansion states were more optimistic about the ACA's likelihood to improve their patients' HIV outcomes. There are gaps in HIV medical providers' understanding of the ACA. Education could enhance systems-based practice.

PPACA and Low-Income People Living with HIV: 2014 Qualified Health Plan Enrollment in a Medicaid Nonexpansion State.

People living with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) often are uninsured or underinsured, and they may benefit from the Patient Protection and Affordable Care Act (PL 111-148) and its improved access to medical care. Safety net programs, such as AIDS Drug Assistance Programs (ADAP) funded through the Ryan White HIV/AIDS Program, which serve low-income people living with HIV, are incorporating Patient Protection and Affordable Care Act Marketplace-qualified health plans (QHPs) and helping to fund patients' participation. This changing landscape differs from state to state, and one main element contributing to the differing situations is whether a state elected to expand Medicaid. This review examines QHP enrollment of ADAP clients in Virginia, a Medicaid nonexpansion state, and explores some issues that affect people living with HIV in other Medicaid nonexpansion states. Virginia is a leader in the shift of ADAP healthcare delivery from direct medication provision to purchasing QHPs. Virginia ADAP clients accounted for approximately 2% of ADAP clients nationally, but they represent 17% of ADAP clients enrolled in QHPs nationwide. Ensuring good HIV care of the ADAP population is important to each patient's personal longevity, the public health, and the efficient use of healthcare dollars. As healthcare delivery models shift, the effects on patients and health outcomes achieved should be monitored, particularly for chronic diseases such as HIV.

Affordable Care Act Qualified Health Plan Enrollment for AIDS Drug Assistance Program Clients: Virginia's Experience and Best Practices.

With the implementation of the Affordable Care Act (ACA) in 2014, many safety net resources, including state AIDS Drug Assistance Programs (ADAPs), incorporated ACA Qualified Health Plans (QHPs) into their healthcare delivery model. This article highlights the benefits of the ACA for persons living with HIV. It also describes the range of strategies employed by state ADAPs to enroll patients in QHPs. The Virginia ADAP ACA implementation experience is described to illustrate one ADAP's shift to purchasing QHPs in addition to providing direct medications. Virginia ADAP is in a Medicaid nonexpansion state and funds the full costs of the QHP premiums, deductibles, and medication copayments. Virginia's experience is applicable to other Medicaid nonexpansion states and to state ADAPs in Medicaid expansion states, who are looking for options for their Medicaid ineligible clients. This article provides practical details of Virginia ADAP's ACA implementation as well as insights and best practices at both the state and clinic level.

Affordable Care Act Qualified Health Plan Coverage: Association With Improved HIV Viral Suppression for AIDS Drug Assistance Program Clients in a Medicaid Nonexpansion State.

BACKGROUND: With the Patient Protection and Affordable Care Act, many state AIDS Drug Assistance Programs (ADAPs) shifted their healthcare delivery model from direct medication provision to purchasing qualified health plans (QHPs). The objective of this study was to characterize the demographic and healthcare delivery factors associated with Virginia ADAP clients' QHP enrollment and to assess the relationship between QHP coverage and human immunodeficiency virus (HIV) viral suppression. METHODS: The cohort included persons living with HIV who were enrolled in the Virginia ADAP (n = 3933). Data were collected from 1 January 2013 through 31 December 2014. Multivariable binary logistic regression was conducted to assess for associations with QHP enrollment and between QHP coverage and viral load (VL) suppression. RESULTS: In the cohort, 47.1% enrolled in QHPs, and enrollment varied significantly based on demographic and healthcare delivery factors. In multivariable binary logistic regression, controlling for time, age, sex, race/ethnicity, and region, factors significantly associated with achieving HIV viral suppression included QHP coverage (adjusted odds ratio, 1.346; 95% confidence interval, 1.041-1.740; P = .02), an initially undetectable VL (2.809; 2.174-3.636; P < .001), HIV rather than AIDS disease status (1.377; 1.049-1.808; P = .02), and HIV clinic (P < .001). CONCLUSIONS: QHP coverage was associated with viral suppression, an essential outcome for individuals and for public health. Promoting QHP coverage in clinics that provide care to persons living with HIV may offer a new opportunity to increase rates of viral suppression.

Cruise ships and bush medicine: globalization on the Atlantic Coast of Nicaragua and effects on the health of Creole women.

OBJECTIVES: Global health research into the relationship between health, economic inequalities, and globalization is necessary to address increasing health disparities in low income countries. Nicaragua has high levels of poverty and extreme poverty when compared with other Central and South American Countries. DESIGN AND SAMPLE: Photovoice and ethnographic research methods were used to explore health experiences of Creole women in Bluefields, Nicaragua and the intersections between culture, socioeconomic status, and gender. Twelve Creole women participants, ages 18-45. MEASURES: After initial focus groups, participants used disposable cameras to document health experiences. Follow-up interviews were conducted about the meaning of each photo. Participants then selected photos to be included in a city-wide photoshow. RESULTS: In initial focus groups, participants described great distress over changes they perceived in Creole culture and how these changes affect the health of the next generation. Participants related most of these changes to the economy and globalization. Photos taken were primarily of aspects of Creole culture, including household practices and traditional remedies from Creole culture. CONCLUSIONS: Findings on the relationships between culture, disease, and community-identified health risks in this minority population can help health care providers and public health policymakers develop and sustain culturally appropriate health interventions.

Development of a personalized bidirectional text messaging tool for HIV adherence assessment and intervention among substance abusers.

We describe the development of a two-way text messaging intervention tool for substance users who are non-adherent with HIV medications, and examine message flow data for feasibility and acceptability. The assessment and intervention tool, TxText, is fully automated, sending participants mood, substance use, and medication adherence queries by text message. Participants respond, the tool recognizes the category of response, and sends the personalized intervention message that participants designed in return. In 10months, the tool sent 16,547 messages (half initial, half follow-up) to 31 participants assigned to the TxText condition, who sent 6711 messages in response to the initial messages. Response rates to substance use (n=2370), medication (n=2918) and mood (n=4639) queries were 67, 69, and 64%, respectively. Responses indicating medication adherence, abstinence from substances, and good moods were more common than negative responses. The TxText tool can send messages daily over a 3month period, receive responses, and decode them to deliver personalized affirming or intervention messages. While we await the outcomes of a pilot randomized trial, the process analysis shows that TxText is acceptable and feasible for substance abusers with HIV, and may serve as a complement to HIV medical care.

A trans-university center for global health.

Can the challenge of improving health engage university faculty and students across all disciplines to more deeply understand the world and its people in order to make it a better place? Faculty and staff at the University of Virginia's (UVa) Center for Global Health (CGH) think it can. The authors argue that by working to understand, teach, and improve the human condition, universities can engage multiple disciplines, help reverse the "brain drain," and even change perspectives.The transuniversity Center for Global Health (CGH) at UVa employs three components for addressing global health issues: (1) scholars: sending UVa students abroad to conduct international fieldwork focused on global health, (2) fellows: inviting international colleagues selected by collaborating institutions abroad to work and train at UVa and return to become leaders in their home institutions, and (3) curricula: supporting and developing global health-related curricula throughout the university.UVa's CGH is associated with sister CGHs in Fortaleza, Brazil; Hefei, China; Manila, Philippines; Accra, Ghana; and Thohoyandou, South Africa. Work with international colleagues in these centers provides opportunities for bilateral training of the next generations of leaders in global health around the world. Universities are uniquely positioned to enlist multiple disciplines to unravel the complex causes of health disparities, sustain international collaborations, and change students' outlook on the world through overseas experiences. A university that actively supports global health becomes increasingly internationalized, grounded in scientific excellence, and committed to addressing the most pressing issues humanity faces today.