A Call for PrEP Discussions With Black Women-Be a Gardener.

This Viewpoint discusses the importance of proactively discussing preexposure prophylaxis (PrEP) with Black cisgender women.

Years Since Diagnosis Among People Living With Diagnosed HIV in New York City.

Antiretroviral treatment has greatly improved the survival of people living with diagnosed HIV (PLWDH), but little information is available on the time since diagnosis among them. Using New York City HIV surveillance data, we described the trend in the number of years since diagnosis among PLWDH during 2010-2019 and reported the mean, median, and interquartile range (IQR) of years since diagnosis among PLWDH in New York City in 2019, overall and by gender, race and ethnicity, and transmission risk. The median number of years since diagnosis among PLWDH in New York City increased from 10.5 years (IQR, 6.3-15.6) in 2010 to 16.3 years (IQR, 8.9-22.1) in 2019. By gender, transgender people had the shortest time since diagnosis, with a median of 11.4 years (IQR, 5.6-17.9), compared with men (median = 15.2 years; IQR, 8.1-21.6) and women (median, 18.5 years; IQR, 12.0-23.0). By race and ethnicity, non-Hispanic White people had been living with the diagnosis for the longest time (median = 17.4 years; IQR, 9.5-23.5), and Asian/Pacific Islander people had been living with the diagnosis for the shortest time (median = 10.1 years; IQR, 4.7-17.0). With an expected and continuing increase in the number of years since HIV diagnosis among PLWDH, programs that provide treatment and support services will need to be expanded, updated, and improved.

Pre-exposure Prophylaxis (PrEP) Initiation Among Black and Latina Cisgender Women Receiving HIV Prevention Care Coordination Services in New York City.

Black and Latina cisgender women are disproportionately impacted by HIV in the US. Although PrEP is effective at preventing HIV infection, uptake in this population remains low. The aim of the study was to examine sociodemographic, behavioral, clinical, and psychosocial factors associated with PrEP initiation (defined as receiving a PrEP prescription) among 565 cisgender women enrolled in an HIV prevention services coordination program in NYC from January 2017 to December 2019 who met HIV risk criteria for PrEP. Of these, 26% initiated PrEP. Latina women were significantly more likely than white women to have initiated PrEP (Latina: 29.7%; Black: 26.1%; White: 16.3%; Other: 7.4%). PrEP initiation was significantly associated with PrEP awareness, an annual income < $20,000, being unstably housed, receiving benefits navigation services, and reporting non-injection drug use and/or a recent sexual relationship with an HIV-positive partner. The relatively low rate of PrEP initiation we observed suggests the need to increase PrEP access and uptake among women, particularly Black and Latina women who continue to be disproportionately at risk for HIV.

Public Health Detailing to Promote HIV Pre- and Postexposure Prophylaxis Among Women's Healthcare Providers in New York City.

INTRODUCTION: Equitable access to HIV pre- and postexposure prophylaxis for women is essential to ending the HIV epidemic. Providers' lack of knowledge and comfort in discussing and prescribing pre-exposure prophylaxis to women persist as barriers. METHODS: From May to November 2019, the New York City Health Department conducted its first public health detailing campaigns among women's healthcare providers to promote pre- and postexposure prophylaxis and the associated best practices. Over 2 campaigns (10 weeks each), trained Health Department representatives visited providers for 1-on-1 visits at select practices to promote key messages. Representatives distributed an Action Kit that addressed knowledge gaps and practice needs on providing pre-exposure prophylaxis and postexposure prophylaxis to cisgender and transgender women. Providers completed an assessment at the beginning of initial and follow-up visits, used to compare responses across visits. Statistically significant changes were evaluated by generalized linear models of bivariate outcomes, adjusted for nonindependence of providers at the same practice. RESULTS: Representatives visited 1,348 providers specializing in primary care (47%), women's health (30%), adolescent health (7%), infectious disease (4%), and other (12%) at 860 sites; 1,097 providers received initial and follow-up visits. Provider report of ever prescribing pre-exposure prophylaxis increased by 12% (n=119 providers); increases were reported in measures of taking sexual history, asking about partners' HIV status, providing postexposure prophylaxis, recognizing pre-exposure prophylaxis's effectiveness, and discussing and referring for pre-exposure prophylaxis. CONCLUSIONS: After public health detailing, women's healthcare providers report increased adoption of recommended practices that promote pre- and postexposure prophylaxis uptake and sexual wellness among women. Detailing may be adaptable to other regions and contexts to reach providers.

Considerations for the Design of Pre-exposure Prophylaxis (PrEP) Interventions for Women: Lessons Learned from the Implementation of a Novel PrEP Intervention.

Pre-exposure prophylaxis (PrEP) uptake among women in the United States has been low. To increase uptake, we developed a peer outreach and navigation PrEP intervention. Semi-structured qualitative interviews with 32 cisgender women and 3 transgender women were conducted to assess the intervention. We used a thematic approach to identify barriers to, and facilitators of the intervention. Facilitators included interest in PrEP, offer of health and social services, the intervention's women-focused approach, and peer outreach and navigation. Barriers were perceived HIV risk, concerns about medication side effects or interactions, housing insecurity and travel, co-occurring health-related conditions, and caregiving responsibilities. We recommend that future interventions consider packaging PrEP in local community settings, such as syringe exchange programs; include services such as food and housing assistance; use peers to recruit and educate women; integrate a culturally appropriate women's focus; and consider providing same-day PrEP.

Coronavirus Disease 2019 (COVID-19) Infection Among People With Human Immunodeficiency Virus in New York City: A Population-Level Analysis of Linked Surveillance Data.

BACKGROUND: New York City (NYC) was hard-hit by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and is also home to a large population of people with human immunodeficiency virus (PWH). METHODS: We matched laboratory-confirmed coronavirus disease 2019 (COVID-19) case and death data reported to the NYC Health Department as of 2 June 2020 against the NYC HIV surveillance registry. We describe and compare the characteristics and COVID-19-related outcomes of PWH diagnosed with COVID-19 with all NYC PWH and with all New Yorkers diagnosed with COVID-19. RESULTS: Through 2 June, 204 583 NYC COVID-19 cases were reported. The registry match identified 2410 PWH with diagnosed COVID-19 eligible for analysis (1.06% of all COVID-19 cases). Compared with all NYC PWH and all New Yorkers diagnosed with COVID-19, a higher proportion of PWH with COVID-19 were older, male, Black, or Latino, and living in high-poverty neighborhoods. At least 1 underlying condition was reported for 58.9% of PWH with COVID-19. Compared with all NYC COVID-19 cases, a higher proportion of PWH with COVID-19 experienced hospitalization, intensive care unit admission, and/or death; most PWH who experienced poor COVID-19-related outcomes had CD4 <500 cells/µL. CONCLUSIONS: Given NYC HIV prevalence is 1.5%, PWH were not overrepresented among COVID-19 cases. However, compared with NYC COVID-19 cases overall, a greater proportion of PWH had adverse COVID-19-related outcomes, perhaps because of a higher prevalence of factors associated with poor COVID-19 outcomes. Given the pandemic's exacerbating effects on health inequities, HIV public health and clinical communities must strengthen services and support for people living with and affected by HIV.

A Pilot Study to Evaluate a Novel Pre-exposure Prophylaxis Peer Outreach and Navigation Intervention for Women at High Risk for HIV Infection.

Pre-exposure prophylaxis (PrEP) uptake remains woefully low among U.S. women at high risk for HIV acquisition. We evaluated a pilot intervention which involved Peers providing brief PrEP education and counseling at mobile syringe exchange sites and at sex worker and syringe exchange drop-in centers followed by navigation to PrEP care. Peers recruited English-proficient, self-identified women (i.e., cisgender and transgender women and persons with other transfeminine identities) over a 3-month period and delivered the intervention to 52 HIV-negative/status unknown participants. Thirty-eight participants (73.1%) reported PrEP interest, 27 (51.9%) accepted the offer of a PrEP appointment, 13 (25.0%) scheduled a PrEP appointment, 3 (5.8%) attended an initial PrEP appointment, and none were prescribed PrEP. We found a gap between PrEP interest and connecting women to PrEP care. Further study is needed to understand this gap, including exploring innovative approaches to delivering PrEP care to women at highest risk for HIV.

The Relationship Between Discrimination and Missed HIV Care Appointments Among Women Living with HIV.

Receiving regular HIV care is crucial for maintaining good health among persons with HIV. However, racial and gender disparities in HIV care receipt exist. Discrimination and its impact may vary by race/ethnicity and gender, contributing to disparities. Data from 1578 women in the Women's Interagency HIV Study ascertained from 10/1/2012 to 9/30/2016 were used to: (1) estimate the relationship between discrimination and missing any scheduled HIV care appointments and (2) assess whether this relationship is effect measure modified by race/ethnicity. Self-reported measures captured discrimination and the primary outcome of missing any HIV care appointments in the last 6 months. Log-binomial models accounting for measured sources of confounding and selection bias were fit. For the primary outcome analyses, women experiencing discrimination typically had a higher prevalence of missing an HIV care appointment. Moreover, there was no statistically significant evidence for effect measure modification by race/ethnicity. Interventions to minimize discrimination or its impact may improve HIV care engagement among women.

Undocumented African Immigrants' Experiences of HIV Testing and Linkage to Care.

In the United States, undocumented African immigrants living with HIV enter care late, potentially leading to adverse individual and population health outcomes, yet little is known about the specific experiences of HIV diagnosis and linkage to care among this population. We conducted individual, semi-structured interviews with adults who were undocumented African immigrants living with HIV in New York City. Interviews explored perspectives regarding individual, social, institutional, and societal barriers and facilitators of HIV testing and linkage to care. Of 14 participants from 9 different African countries, 9 were women and the median age was 44 years (interquartile range: 42-50). Participants described fear of discovery by immigration authorities as a substantial barrier to HIV testing and linking to initial medical appointments. Actual and perceived structural barriers to both testing and care linkage included difficulty obtaining health insurance and a belief that undocumented immigrants are ineligible for any health services. Participants also expressed reluctance to be tested because of HIV-related stigma within the immigrant communities that they heavily relied on. After diagnosis, however, participants overwhelmingly described a positive role of health and social service providers in facilitating linkage to HIV care. Concerns about immigration status and HIV-related stigma are significant barriers to HIV testing and linkage to care among undocumented African immigrants. Multilevel efforts to reduce stigma and increase awareness of available services could enhance rates of HIV testing and care linkage in this population.

Pathways to HIV Pre-exposure Prophylaxis Among Women Prescribed PrEP at an Urban Sexual Health Clinic.

Little is known about real-world facilitators of and barriers to pre-exposure prophylaxis (PrEP) uptake among women prescribed PrEP. We sought to characterize the pathway to PrEP uptake and continuation in women prescribed PrEP at an urban sexual health-focused clinic. We conducted semi-structured individual interviews with 14 women from October 2016 to May 2017. Using grounded theory and the constant comparative method, we found that self-perceived HIV risk, learning about PrEP through trusted sources, having positive interactions with PrEP providers, and insurance coverage were facilitators of PrEP uptake and continuation. Concerns about PrEP safety, misinformation about PrEP eligibility and appropriateness, lack of insurance coverage, and pharmacy impediments were key barriers. The confluence of these issues led to PrEP rumination, a process of ongoing deliberation about the benefits and risks of PrEP. These findings provide important insights about how to increase PrEP uptake among women at high risk of HIV infection.

A Cross-sectional Survey of Internal Medicine Resident Knowledge, Attitudes, Behaviors, and Experiences Regarding Pre-Exposure Prophylaxis for HIV Infection.

BACKGROUND: Pre-exposure prophylaxis (PrEP) for HIV is effective, yet many providers continue to lack knowledge and comfort in providing this intervention. It remains unclear whether internal medicine (IM) residents receive appropriate training in PrEP care and if this affects their future practices. OBJECTIVE: We sought to evaluate the relationship between current IM residents' prior PrEP training and knowledge, comfort, and practice regarding the provision of PrEP. DESIGN AND PARTICIPANTS: We created an online survey to assess IM residents' knowledge, attitudes, and behaviors related to PrEP. The survey was distributed among five IM programs across the USA. KEY RESULTS: We had a 35% response rate. Of 229 respondents, 96% (n = 220) had heard of PrEP but only 25% (n = 51) had received prior training and 11% (n = 24) had prescribed PrEP. Compared with those without, those with prior training reported good to excellent knowledge scores regarding PrEP (80% versus 33%, p < 0.001), more frequent prescribing (28% versus 7%, p = 0.001), and higher comfort levels with evaluating risk for HIV, educating patients, and monitoring aspects of PrEP (75% versus 26%, 56% versus 16%, and 47% versus 8%, respectively; all p values < 0.0001). While only 25% (n = 51) had received prior training, 75% (n = 103) of respondents reported that training all providers at their continuity clinic sites would improve implementation. CONCLUSIONS: We found that prior training was associated with higher levels of self-reported PrEP knowledge, comfort, and prescribing behaviors. Given the significant need for PrEP, IM residents should be trained to achieve adequate knowledge and comfort levels to prescribe it. This study demonstrates that providing appropriate PrEP training for IM residents may lead to an increase in the pool of graduating IM residents prescribing PrEP.

Brief Report: PrEP Eligibility Among At-Risk Women in the Southern United States: Associated Factors, Awareness, and Acceptability.

BACKGROUND: Among women in the United States, non-Latina black women in the South have disproportionately high rates of new HIV infections but low use of pre-exposure prophylaxis (PrEP). Effective strategies to identify factors associated with PrEP eligibility could facilitate improved screening, offering, and uptake of PrEP among US women at risk of HIV. SETTING AND METHODS: We applied 2014 CDC criteria for PrEP use to at-risk HIV-negative women enrolled in the Southern US sites (Atlanta, Chapel Hill, Birmingham/Jackson, Miami) of the Women's Interagency HIV Study from 2014 to 2015 to estimate PrEP eligibility and assess PrEP knowledge and acceptability. Factors associated with PrEP eligibility were assessed using multivariable models. RESULTS: Among 225 women, 72 (32%) were PrEP-eligible; the most common PrEP indicator was condomless sex. The majority of PrEP-eligible women (88%) reported willingness to consider PrEP. Only 24 (11%) PrEP-eligible women had previously heard of PrEP, and only 1 reported previous use. Education level less than high school [adjusted odds ratio (aOR) 2.56; 95% confidence interval (CI): 1.22 to 5.37], history of sexual violence (aOR 4.52; 95% CI: 1.52 to 17.76), and medium to high self-perception of HIV risk (aOR 6.76; 95% CI: 3.26 to 14.05) were significantly associated with PrEP eligibility in adjusted models. CONCLUSIONS: Extremely low PrEP awareness and use despite a high proportion of eligibility and acceptability signify a critical need to enhance PrEP education and delivery for women in this region. Supplementing CDC eligibility criteria with questions about history of sexual violence and HIV risk self-assessment may enhance PrEP screening and uptake among US women.

PrEP in the Real World: Predictors of 6-Month Retention in a Diverse Urban Cohort.

The effectiveness of HIV pre-exposure prophylaxis (PrEP) depends on adherence, which requires retention in PrEP care. We sought to examine factors associated with six-month retention in PrEP care among individuals prescribed PrEP between 2011 and 2015 in a large, academic health system in the Bronx, New York. We used multivariable logistic regression to identify factors independently associated with six-month retention. Among 107 patients, retention at 6 months was 42%. In the multivariable analysis, heterosexual individuals were less likely to be retained in PrEP care at 6 months, but individuals who received prescriptions from attending physicians were more likely to be retained in care. Larger prospective studies are needed to better evaluate the individual and health system factors associated with long-term engagement in PrEP care.

Missed Opportunities for HIV Prevention: Individuals Who HIV Seroconverted Despite Accessing Healthcare.

Individuals with a negative HIV test before a positive one (seroconverters) may represent missed opportunities for prevention. To inform HIV prevention strategies, we aimed to characterize patients who seroconverted despite accessing care. We identified patients at a large, urban healthcare system who seroconverted between 2009 and 2014. Demographics, visits, and HIV-related variables were extracted from the medical records. We performed descriptive statistics, assessed for trends, and tested for associations according to sex. 220 seroconverters were identified: 45% were female, 87% were non-Hispanic Black or Hispanic, and median number of negative tests prior to diagnosis was 2 (IQR 1-3). Overall, 49% reported heterosexual contact as their risk factor and the proportion with heterosexual risk increased over time (24% in 2009 vs. 56% in 2014, p = 0.03). Compared to men, women were older at the time of diagnosis (35 vs. 26 years old, p < 0.01), had more visits between their latest negative and positive HIV test (4 vs. 2, p < 0.01), and were more likely to be diagnosed in the context of screening (64% vs. 56%, p = 0.05). We identified a population that became HIV-infected despite multiple healthcare encounters and undergoing HIV testing multiple times. Patients were mostly heterosexual and almost half were female. To avoid missed opportunities for those already accessing care, HIV prevention efforts should include strategies tailored to individuals with less frequently recognized risk profiles.

Get+Connected: Development and Pilot Testing of an Intervention to Improve Computer and Internet Attitudes and Internet Use Among Women Living With HIV.

BACKGROUND: For persons living with chronic medical conditions, the Internet can be a powerful tool for health promotion, and allow for immediate access to medical information and social support. However, women living with human immunodeficiency virus (HIV) in the United States face numerous barriers to computer and Internet use. Health behavior change models suggest that the first step towards adopting a new health behavior is to improve attitudes towards that behavior. OBJECTIVE: To develop and pilot test Get+Connected, an intervention to improve computer and Internet attitudes and Internet use among women living with HIV. METHODS: To develop Get+Connected, we reviewed the extant literature, adapted an existing curriculum, and conducted a focus group with HIV-positive women (n=20) at a community-based organization in the Bronx, New York. Get+Connected was comprised of five weekly sessions covering the following topics: basic computer knowledge and skills, identifying reliable health-related websites, setting up and using email and Facebook accounts, and a final review session. We recruited 12 women to participate in pilot testing. At baseline, we collected data about participants' sociodemographic information, clinical characteristics, and technology device ownership and use. At baseline, intervention completion, and three months postintervention, we collected data regarding attitudes towards computers and the Internet (Attitudes Towards Computers and the Internet Questionnaire [ATCIQ]; possible scores range from 5-50) as well as frequency of Internet use (composite measure). To examine changes in ATCIQ scores and Internet use over time, we used generalized estimating equations. We also collected qualitative data during intervention delivery. RESULTS: Among women in our sample, the median age was 56 years (interquartile range=52-63). All participants were black/African American and/or Latina. Seven participants (7/12, 58%) had a high school diploma (or equivalent) or higher degree. Ten participants (10/12, 83%) reported owning a mobile phone, while only one (1/12, 8%) reported owning a computer or tablet. Only one participant (1/12, 8%) reported having ever used the Internet or email. Internet nonusers cited lack of computer/Internet knowledge (6/11, 54%) and lack of access to a computer or similar device (4/11, 36%) as the main barriers to use. Over time, we observed an improvement in attitudes towards computers and the Internet (ATCIQ scores: 33.5 at baseline, 35 at intervention completion, and 36 at three months postintervention; P=.008). No significant increase in Internet use was observed (P=.61). Qualitative findings indicated excitement and enthusiasm for the intervention. CONCLUSIONS: In our sample of urban, technology-inexperienced HIV-positive women, participation in Get+Connected was associated with an improvement in attitudes towards computers and the Internet, but not Internet use. Changing attitudes is the first step in many health behavior change models, indicating that with improved access to computer and Internet resources, frequency of Internet use may also have increased. Future studies should consider addressing issues of access to technology in conjunction with Get+Connected.