Building an Infectious Disease Diversity, Equity, and Antiracism (ID2EA) Curriculum: A Single Center's Experience and Reflections.

In response to longstanding healthcare inequities unmasked by the COVID-19 pandemic, the Infectious Diseases Section at the Yale School of Medicine designed and implemented a pilot curriculum integrating Diversity, Equity, and Anti-racism (ID2EA) into Infectious Disease educational training and measured program outcomes. We herein describe a mixed-methods assessment of Section members on whether the ID2EA curriculum impacted their beliefs and behaviors regarding racism and healthcare inequities. Participants rated the curriculum as useful (92% averaging across sessions) and effective in achieving stated learning objectives (89% averaging across sessions), including fostering understanding of how inequities and racism are linked to health disparities and identifying strategies to effectively deal with racism and inequities. Despite limitations in response rates and assessment of longer-term behavioral change, this work demonstrates that training in diversity, equity, and anti-racism can be successfully integrated into Infectious Disease physicians' educational activities and impact physicians' perspectives on these topics.

Experience delivering an integrated service model to people with criminal justice system involvement and housing insecurity.

BACKGROUND: People returning to communities from prison or jail face stressors related to securing housing, including discrimination, restrictions based on prior felony convictions, and limited economic and social resources. Existing housing programs can effectively reduce housing instability but often do not fully address the needs of people involved in the criminal justice system experiencing homelessness who often have co-occurring chronic medical issues, and psychiatric and substance use disorders. METHODS: Project CHANGE is an ongoing program to deliver person-centered, integrated care and services to individuals involved with the criminal justice system and experiencing homelessness. Applying a Screening, Brief Intervention, (Referral to) Treatment framework, a comprehensive needs assessment is followed by delivery of intensive housing and vocational case management; and psychiatric, substance use, and medical services in a single location by an interdisciplinary team. Participants are followed with study interviews for 12 months. The current analysis was designed to assess the baseline characteristics and needs of the sample population, and the intensity of contact required for integrated service delivery. RESULTS: Between November 2019 and September 2021, 86 participants were enrolled, of whom 64% had been released from prison/jail in the past 6 months; the remainder were on parole, probation, or intensive pretrial supervision. Participants were unstably housed (64%) or residing outdoors (26.7%) or in a shelter (24.4%). Most participants had high medical need and frequent healthcare engagement through outpatient and emergency department visits. Most participants were at-risk for clinical depression, and half were diagnosed with anxiety, dissociative, stress-related, somatoform, and other non-psychotic psychiatric disorders. Over 12-month follow-up, the interdisciplinary team made over 500 contact encounters, over half of which resulted in direct services provided, including obtaining vital documents for homelessness verification, housing applications, and employment coaching. CONCLUSION: Navigation of services can be particularly challenging for individuals experiencing criminal justice involvement, homelessness, and co-occurring medical, psychiatric, and substance use issues, which can be addressed holistically in an integrated service model. Integrated service delivery was time-, resource-, and staffing-intensive, and challenged by the COVID-19 pandemic, requiring innovative solutions to sustain participant engagement.

Willingness to Be Vaccinated Against COVID-19 Among People With HIV in the United States: Results From a National Survey.

Background: Approximately 215 million Americans have been fully vaccinated for COVID-19, representing over 65% of the total population. People with HIV (PWH) may be more susceptible to COVID-19 infection or severe disease, elevating the importance of COVID-19 vaccination uptake in the population. We report results from a national survey of PWH to evaluate the likelihood of receiving a COVID-19 vaccine. Methods: We conducted an online survey of 1,030 PWH living in the United States between December 6, 2020 and January 8, 2021 to evaluate likelihood of receiving a COVID-19 vaccine. Results: Overall, participants were highly willing to be vaccinated, with 83.8% stating they "strongly agree" (65.7%) or "somewhat agree" (18.1%). Participants' top vaccine-related concerns were side-effects (39.3%), safety (14.7%), and fair/equitable distribution of the vaccine to affected communities (13.6%). Participants were more willing to be vaccinated if they reported receiving an annual influenza vaccination (p < 0.001), had previously tested positive for (p = 0.043) COVID-19, had been hospitalized for (p = 0.027) COVID-19 infection, or had an undetectable HIV viral load (p = 0.002). Black (p < 0.001), politically conservative (p < 0.001), and participants with an annual income of ≤ $19,999 (p = 0.005) were significantly less willing to be vaccinated for COVID-19. Conclusions: The vast majority of PWH were willing to be vaccinated, though predominantly those who were already engaged in HIV care or directly affected by COVID-19. Findings from this large survey of PWH suggest intensive outreach efforts are needed to support engagement in vaccination programs, particularly among Black and politically conservative PWH.

COVID-19 Vaccine Hesitancy and Associated Factors among People with HIV in the United States: Findings from a National Survey.

INTRODUCTION: Scaling up vaccination against COVID-19 is central to controlling the COVID-19 epidemic in the United States. Several vaccines are now approved for the prevention of COVID-19, but public concerns over safety and efficacy have heightened distrust and vaccine hesitancy. This is particularly concerning among people with HIV (PWH) who may be vulnerable to more severe COVID-19 disease. Here, we aimed to identify and understand COVID-19 vaccine hesitancy in a sample of PWH in the U.S. METHODS: We conducted a cross-sectional online survey among PWH in the U.S. between 6 December 2020 and 8 January 2021. Measures included demographics, participants' HIV and health-related attributes, COVID-19 history and experiences, COVID-19 vaccine-related concerns, and standardized measures of attitudes towards COVID-19 vaccines. Multivariate linear regression was used to identify factors associated with vaccine hesitancy in this sample. RESULTS: Among the 1030 respondents, most were male (89.7%), White (66.0%), and identified as gay or lesbian (84.5%). Participants' mean time living with HIV was 17.0 years (standard deviation (SD) = 11.1). The mean score for vaccine hesitancy was 1.5 (SD = 0.5; range: 1-5); 935 participants (90.8%) had a score greater than 1.0, indicating most participants had some degree of vaccine hesitancy. The final multivariate linear regression showed that greater vaccine hesitancy was associated with being Black (b = 0.149, p = 0.005), single (b = 0.070, p = 0.018), politically conservative (b = 0.157, p = 0.010), "anti-vaxxer" (b = 1.791, p < 0.001), concern about side effects (b = 0.226, p < 0.001), concern about safety (b = 0.260, p < 0.001), and being worried that the vaccine will not be effective (b = 0.169, p = 0.008) and they were being experimented on (b = 0.287, p < 0.001). Participants who were male White (b = -0.093, p = 0.008) and university graduates (b = -0.093, p < 0.001) and had a CD4 count of 200 cells/mm3 (b = -0.082, p = 0.048) and a liberal political orientation (b = -0.131, p < 0.001) were associated with lower vaccine hesitancy. CONCLUSIONS: Our findings provide important insights regarding COVID-19 vaccine hesitancy among PWH. Further efforts are required to understand how various social, political, and psychological factors contribute to COVID-19 vaccine hesitancy among key populations.

Experiences with Telemedicine for HIV Care During the COVID-19 Pandemic: A Mixed-Methods Study.

To characterize perspectives and experiences with telemedicine during the COVID-19 pandemic, we conducted a mixed-methods study in two HIV clinics in the US Northeast. Among surveyed patients with HIV (PWH) who had a telemedicine appointment (n = 205), 42.4% perceived telemedicine visits as useful during the pandemic. PWH and clinical staff identified benefits of telemedicine: (1) ability to engage and re-engage patients in care; (2) perceived patient-centeredness and flexibility; (3) opportunity to engage family and multidisciplinary care team members; and (4) opportunity to enhance telemedicine use proficiency through practice and support. Identified barriers included: (1) technical challenges; (2) privacy concerns; (3) loss of routine clinical experiences and interactions; (4) limited objective patient remote monitoring; and (5) reimbursement concerns. Efforts to optimize telemedicine for HIV care should consider strategies to improve technology support for PWH, flexible options to access care, additional platforms to allow patient remote monitoring, and appropriate billing and reimbursement methods.

RESUMEN: Para caracterizar las perspectivas sobre y las experiencias con la telemedicina durante la pandemia de COVID-19, realizamos un estudio de métodos mixtos en dos clínicas de VIH en el noreste de los Estados Unidos. Entre los pacientes con VIH (PWH) encuestados que tuvieron una cita de telemedicina (n = 205), el 42.4% percibió las visitas de telemedicina como útiles durante la pandemia. Los PWH y el personal clínico identificaron como beneficios de la telemedicina: 1) la capacidad para involucrar y reinvolucrar a los pacientes en el cuidado; 2) el cuidado centrado en el paciente y flexibilidad percibidos; 3) la oportunidad de involucrar a la familia y miembros del equipo de cuidado multidisciplinario; y 4) la oportunidad de mejorar la capacidad para usar la telemedicina a través de la práctica y el apoyo. Las barreras identificadas incluyeron: 1) retos tecnológicos; 2) preocupaciones sobre la privacidad; 3) falta de experiencias e interacciones clínicas de rutina; 4) limitada monitorización remota objetiva del paciente; y 5) preocupaciones sobre los reembolsos. Los esfuerzos para optimizar la telemedicina para el cuidado del VIH deben considerar estrategias para mejorar el soporte tecnológico para los PWH, opciones flexibles para acceder a el cuidado, plataformas adicionales que permitan el monitoreo remoto del paciente, y métodos apropiados de facturación y reembolso.

Differential impacts of COVID-19 across racial-ethnic identities in persons with opioid use disorder.

OBJECTIVE: The COVID-19 pandemic has exacerbated health disparities, particularly among at-risk people with opioid use disorder (OUD). We sought to characterize the direct and indirect impacts of COVID-19 on this group to understand how the pandemic has affected this group, this group's public health response to COVID-19, and whether there were differences by race/ethnicity. METHODS: This study recruited its sample from a drug treatment setting in the northeast region of the United States. We surveyed 110 individuals on methadone as treatment for OUD and assessed COVID-19-related impacts on their health behaviors and other indices of social, physical, and mental well-being, including sexual health behaviors, substance use, mental health status, health care access, income, and employment. RESULTS: Our findings highlight overall increases in depression, anxiety, loneliness, and frustration among the sample of people with OUD; the study also observed decreases in financial stability. Significant differences between groups indicated a greater financial burden among racial-ethnic minorities; this subgroup also reported greater direct adverse effects of COVID-19, including being more concerned about contracting COVID-19, not being able to get a COVID-19 test, and knowing someone who had died from COVID-19. A greater proportion of Whites indicated increases in alcohol consumption and non-prescription drug use than did racial-ethnic minorities. CONCLUSIONS: Treatment providers must be vigilant in managing direct and indirect outcomes of COVID-19 among people with OUD. Findings highlight the need to develop culturally competent, differentiated interventions in partnership with community-based organizations to meet the unique challenges that the COVID-19 pandemic presents for people in treatment for OUD.