Status-Neutral Interventions to Support Health Equity for Black Sexual Minority Men.

PURPOSE OF REVIEW: Status-neutral care, a person-centered approach to healthcare not predicated on HIV serostatus, may improve health equity among Black sexual minority men (BSMM). We reviewed current status-neutral, HIV, and Pre-Exposure Prophylaxis (PrEP) interventions, and coded each for social-ecological focus and use of six approaches: (1) person-centered, (2) anti-stigma, (3) social support, (4) the social determinants of health (SDOH), (5) community engagement, and (6) multi-sectoral partnerships. RECENT FINDINGS: We reviewed 25 studies, of which 3 were status-neutral. Nineteen studies utilized person-centered approaches, with several employing BSMM peers. For SDOH, financial incentives and reducing clinic-level barriers to care improved cascade outcomes. Direct text messaging, anti-stigma, social support, community-engagement, and multi-sectoral partnerships also improved outcomes in some studies. Few status-neutral programs exist and additional research is needed to identify key intervention components and mechanisms of influence. Programs targeting SDOH and multiple social-ecological levels offer promise for providing holistic care to BSMM, while addressing HIV prevention and treatment and health equity.

Conceptualizing the Effects of Continuous Traumatic Violence on HIV Continuum of Care Outcomes for Young Black Men Who Have Sex with Men in the United States.

The United States (US) is on track to achieve the 90-90-90 targets set forth by UNAIDS and the National HIV/AIDS strategy, yet significant racial disparities in HIV care outcomes remain, particularly for young Black men who have sex with men (YBMSM). Research has demonstrated that various types of violence are key aspects of syndemics that contribute to disparities in HIV risk. However, little research has looked collectively at cumulative violent experiences and how those might affect HIV treatment and care outcomes. Drawing on extant literature and theoretical underpinnings of syndemics, we provide a conceptual model that highlights how continuous traumatic violence experienced by YBMSM may affect HIV outcomes and contribute to racial disparities in HIV outcomes. The findings of this focused review suggest a need for research on how continuous exposure to various types of violence influence HIV prevention and treatment outcomes for young Black MSM.

Impact of COVID-19 pandemic on HIV viremia: a single-center cohort study in northern Italy.

BACKGROUND: Brescia Province, northern Italy, was one of the worst epicenters of the COVID-19 pandemic. The division of infectious diseases of ASST (Azienda Socio Sanitaria Territoriale) Spedali Civili Hospital of Brescia had to face a great number of inpatients with severe COVID-19 infection and to ensure the continuum of care for almost 4000 outpatients with HIV infection actively followed by us. In a recent manuscript we described the impact of the pandemic on continuum of care in our HIV cohort expressed as number of missed visits, number of new HIV diagnosis, drop in ART (antiretroviral therapy) dispensation and number of hospitalized HIV patients due to SARS-CoV-2 infection. In this short communication, we completed the previous article with data of HIV plasmatic viremia of the same cohort before and during pandemic. METHODS: We considered all HIV-patients in stable ART for at least 6 months and with at least 1 available HIV viremia in the time window March 01-November 30, 2019, and another group of HIV patients with the same two requisites but in different time windows of the COVID-19 period (March 01-May 31, 2020, and June 01-November 30, 2020). For patients with positive viremia (PV) during COVID-19 period, we reported also the values of viral load (VL) just before and after PV. RESULTS: the percentage of patients with PV during COVID-19 period was lower than the previous year (2.8% vs 7%). Only 1% of our outpatients surely suffered from pandemic in term of loss of previous viral suppression. CONCLUSIONS: Our efforts to limit the impact of pandemic on our HIV outpatients were effective to ensure HIV continuum of care.

Characterizing the Human Immunodeficiency Virus Care Continuum Among Transgender Women and Cisgender Women and Men in Clinical Care: A Retrospective Time-series Analysis.

BACKGROUND: Prior studies suggest that transgender women (TW) with human immunodeficiency virus (HIV) are less likely to be virally suppressed than cisgender women (CW) and cisgender men (CM). However, prior data are limited by small sample sizes and cross-sectional designs. We sought to characterize the HIV care continuum comparing TW to CW and CM in the United States and Canada. METHODS: We analyzed annual HIV care continuum outcomes by gender status from January 2001 through December 2015 among adults (aged ≥18 years) in 15 clinical cohorts. Outcomes were retention in care and viral suppression. RESULTS: The study population included TW (n = 396), CW (n = 14 094), and CM (n = 101 667). TW had lower proportions retained in care than CW and CM (P < .01). Estimates of retention in care were consistently lower in TW, with little change over time within each group. TW and CW had similar proportions virally suppressed over time (TW, 36% in 2001 and 80% in 2015; CW, 35% in 2001 and 83% in 2015) and were lower than CM (41% in 2001 and 87% in 2015). These differences did not reach statistical significance after adjusting for age, race, HIV risk group, and cohort. CONCLUSIONS: TW experience challenges with retention in HIV care. However, TW who are engaged in care achieve viral suppression that is comparable to that of CW and CM of similar age, race, and HIV risk group. Further research is needed to understand care engagement disparities.

Interprofessional Collaboration Improves the Odds of Educating Patients About PrEP over Time.

BACKGROUND: Low levels of pre-exposure prophylaxis (PrEP) uptake continue among the most vulnerable (e.g., men who have sex with men) for HIV exposure in the USA. Providers of social and public health services ("psychosocial providers") can help improve this situation by educating patients about PrEP before linking them to primary care providers (PCPs). OBJECTIVE: To identify predictors of psychosocial providers offering PrEP education to patients vulnerable to HIV infection by determining the frequency with which psychosocial providers offer PrEP education to patients. DESIGN: Longitudinal overview of PrEP implementation in New York City. PARTICIPANTS: Psychosocial providers of HIV prevention and adjunct treatment services, such as medication adherence counseling in 34 community settings. MAIN MEASURES: Longitudinal survey data collected in 2014-2016 (baseline) and 2015-2017 (1-year follow-up) from a 5-year longitudinal repeated measures study. Logistic regression modeling tested associations between baseline psychosocial provider-level and organization-level characteristics and frequency of PrEP education at baseline and 1-year follow-up. KEY RESULTS: Out of 245 participants, the number of psychosocial providers offering PrEP education at least once in the past 6 months increased significantly from baseline (n = 127, 51.8%) to 1-year follow-up (n = 161, 65.7%). Participants with higher odds of offering PrEP education at baseline and at one1-year follow-up were more likely to have reported high levels of interprofessional collaboration (IPC) and were also more likely to have received formal HIV prevention training. CONCLUSIONS: Both IPC and HIV training are predictive of PrEP education, and this association was maintained over time. We recommend expanding educational outreach efforts to psychosocial providers to further improve PrEP education and also training in interprofessional collaboration. This is an important first step toward linking patients to PCPs who prescribe PrEP and may help improve PrEP uptake.

A Scoping Review of Employment and HIV.

Employment is a social determinant of health that is important for understanding health behaviors, health outcomes and HIV transmission among people living with HIV. This study is a scoping review of the literature that addresses (a) the relationship between employment and the HIV continuum of care, (b) determinants of employment among PLWH and (c) experiences with employment. We searched two databases, PubMed and Embase, and identified a total of 5622 articles that were subjected to title and abstract review. Of these, 5387 were excluded, leaving 235 articles for full-text review. A total of 66 articles met inclusion criteria and were included in the study. The literature suggests that employment status is positively associated with HIV testing, linkage to HIV care, retention in HIV care, and HIV medication adherence. Guided by a social-ecological framework, we identified determinants of employment at the individual, interpersonal, organizational, community, and policy levels that are amenable to public health intervention. Experiences with employment, including barriers, facilitators, advantages, disadvantages, and needs, provide additional insight for future research and programs.

Consequences of the COVID-19 pandemic on the continuum of care in a cohort of people living with HIV followed in a single center of Northern Italy.

INTRODUCTION: During the COVID-19 pandemic, hospitals faced increasing pressure, where people living with HIV risked to either acquire SARS-CoV-2 and to interrupt the HIV continuum of care. METHODS: This is a retrospective, observational study. We compared the numbers of medical visits performed, antiretroviral drugs dispensed and the number of new HIV diagnosis and of hospitalizations in a cohort of people living with HIV (PLWH) followed by the Spedali Civili of Brescia between the bimester of the COVID-19 pandemic peak and the bimester of October-November 2019. Data were retrieved from administrative files and from paper and electronic clinical charts. Categorical variables were described using frequencies and percentages, while continuous variables were described using mean, median, and interquartile range (IQR) values. Means for continuous variables were compared using Student's t-tests and the Mann-Whitney test. Proportions for categorical variables were compared using the χ2 test. RESULTS: As of December 31st, 2019, a total of 3875 PLWH were followed in our clinic. Mean age was 51.4 ± 13 years old, where 28% were females and 18.8% non-Italian. Overall, 98.9% were on ART (n = 3834), 93% were viro-suppressed. A total of 1217 and 1162 patients had their visit scheduled at our out-patient HIV clinic during the two bimesters of 2019 and 2020, respectively. Comparing the two periods, we observed a raise of missed visits from 5 to 8% (p < 0.01), a reduction in the number of new HIV diagnosis from 6.4 in 2019 to 2.5 per month in 2020 (p = 0.01), a drop in ART dispensation and an increase of hospitalized HIV patients due to COVID-19. ART regimens including protease inhibitors (PIs) had a smaller average drop than ART not including PIs (16.6 vs 21.6%, p < 0.05). Whether this may be due to the perception of a possible efficacy of PIs on COVID19 is not known. CONCLUSIONS: Our experience highlights the importance of a resilient healthcare system and the need to implement new strategies in order to guarantee the continuum of HIV care even in the context of emergency.

Interprofessional collaboration associated with frequency of life-saving links to HIV continuum of care services in the urban environment of Newark, New Jersey.

BACKGROUND: HIV continuum of care has been used as a strategy to reduce HIV transmission rates, with timely engagement in HIV testing being the first and most critical step. This study examines interprofessional-collaboration (IPC) after controlling for agency/ provider demographics, provider training and self-efficacy as a significant predictor of how frequently HIV service providers link their clients to HIV testing. METHODS: Multilevel binary logistic regression analysis was conducted to examine the effects of IPC on links to HIV testing while controlling for demographic and agency information, provider training, and standardized measures of providers' feelings, attitudes, and opinions about IPC. Cross-sectional data from 142 providers in 13 agencies offering treatment and prevention services for HIV and substance-use disorders were collected via a survey. RESULTS: Those who scored higher on the IPC scale reported significantly higher rates of linkages to HIV testing. Compared to the null model (i.e., no predictor model), the final multilevel binary logistic regression model showed a significantly improved likelihood of linkage to HIV testing by 11.4%, p. < .05. The final model correctly classified 90.2% of links to HIV testing. Providers in agencies with smaller budgets and in agencies offering substance use disorder services were more likely to link clients to HIV testing. Younger providers who received HIV training were also more likely to link clients to HIV testing. CONCLUSIONS: Findings suggest IPC training as a potential strategy to improve linkages to HIV testing for clients at risk for HIV infection. Future research is recommended to identify specific areas of IPC that might have differential effects on links to HIV testing.

Predicting Retention in HIV Primary Care: Is There a Missed Visits Continuum Based on Patient Characteristics?

Missing 3 + scheduled HIV primary care visits over a 1-year period increases mortality risk for people living with HIV (PLWH). We used electronic health data from PLWH (≥ 18 years old) at a southeastern US HIV clinic in 2016 to examine differences across patient-level characteristics and number of missed visits (1-2 vs. 0, 3 + vs. 0, 3 + vs. 1-2). In multivariable multinomial logistic regression analyses, poverty, lack of Ryan White HIV/AIDS Program support services, being uninsured, not having a high school degree, and being younger were significantly associated with 1-2 or 3 + missed visits (vs. 0 missed). Only poverty remained predictive of missing 3 + versus 1-2 visits (RR = 2.70, 95% CI 1.49-4.88). Patients at risk for missing 3 + visits present similar characteristics to patients who miss 1-2 visits. Interventions aimed at poverty reduction and increased access to education, health insurance, and support services may improve retention and, therefore, decrease mortality risk.

Connecting Corrections and HIV Care: Building a Care Coordination Program for Recently Incarcerated Persons Living with HIV in Virginia.

Incarcerated individuals are disproportionately affected by HIV and often experience risk factors associated with poor maintenance of HIV care upon release. Therefore, the transition period from incarceration to the community is a particularly critical time for persons living with HIV to ensure continuity of care and treatment. By building relationships with Department of Corrections staff and community partners, the Virginia Department of Health developed a program to link recently incarcerated persons living with HIV to care and treatment immediately upon release from correctional facilities across Virginia. Findings show that clients served by the program have better outcomes along the HIV continuum of care than the overall population living with HIV in Virginia. This paper describes the development, implementation and health outcomes of the Care Coordination program for recently incarcerated persons living with HIV in Virginia.

Enhancing value and lowering costs of care: a qualitative exploration of a randomized linkage to care intervention in South Africa.

While interventions to improve HIV linkage and retention in care exist, none have demonstrated results sufficient to reach UNAIDS 90-90-90 goals. We explored values and costs of seeking clinical care through testing three strategies to improve linkage to care: Point of care CD4 testing alone (POC-CD4), POC-CD4 combined with transportation support and combined with care facilitation. We conducted in-depth interviews with participants and transcribed audio-recordings of care facilitation sessions. Participants described values and costs enhanced or addressed by the three interventions. Psychosocial support provided through the care facilitation intervention appeared salient. Participants named other values and costs of seeking care unrelated to the intervention, such as encouragement from healthcare workers and aversion to lifelong treatment. Combined with the quantitative results of this trial, these findings may point to why the care facilitation arm was successful but not the POC-CD4 only or transportation arms. It also provides guidance for future interventions.

The relationship between adverse neighborhood socioeconomic context and HIV continuum of care outcomes in a diverse HIV clinic cohort in the Southern United States.

Retention in care and viral suppression are critical to delaying HIV progression and reducing transmission. Neighborhood socioeconomic context (NSEC) may affect HIV care receipt. We therefore assessed NSEC's impact on retention and viral suppression in a diverse HIV clinical cohort. HIV-positive adults with ≥1 visit at the Vanderbilt Comprehensive Care Clinic and 5-digit ZIP code tabulation area (ZCTA) information between 2008 and 2012 contributed. NSEC z-score indices used neighborhood-level socioeconomic indicators for poverty, education, labor-force participation, proportion of males, median age, and proportion of residents of black race by ZCTA. Retention was defined as ≥2 HIV care visits per calendar year, >90 days apart. Viral suppression was defined as an HIV-1 RNA <200 copies/mL at last measurement per calendar year. Modified Poisson regression was used to estimate risk ratios (RR) and 95% confidence intervals (CI). Among 2272 and 2541 adults included for retention and viral suppression analyses, respectively, median age and CD4 count at enrollment were approximately 38 (1st and 3rd quartile: 30, 44) years and 351 (176, 540) cells/µL, respectively, while 24% were female, and 39% were black. Across 243 ZCTAs, median NSEC z-score was 0.09 (-0.66, 0.48). Overall, 79% of person-time contributed was retained and 74% was virally suppressed. In adjusted models, NSEC was not associated with retention, though being in the 4th vs. 1st NSEC quartile was associated with lack of viral suppression (RR = 0.88; 95% CI: 0.80-0.97). Residing in the most adverse NSEC was associated with lack of viral suppression. Future studies are needed to confirm this finding.

Care cascade structural intervention versus standard of care in the diagnosis and treatment of HIV in China: a cluster-randomized controlled trial protocol.

BACKGROUND: The high rate of attrition along the care cascade of infection with human immunodeficiency virus (HIV) results in lost opportunities to provide timely antiretroviral therapy (ART) and to prevent unnecessarily high mortality. This study aims to assess the effectiveness of a structural intervention, the one-stop ("One4All") strategy that streamlines China's HIV care cascade with the intent to improve testing completeness, ART initiation, viral suppression, and mortality. METHOD: A two-arm, cluster-randomized controlled trial was implemented in twelve county hospitals in Guangxi China to test the effectiveness of the One4All strategy (intervention arm) compared to the current standard of care (SOC; control arm). The twelve study hospitals were selected for homogeneity and allocated one-to-one to the intervention and control arms. All patients screening HIV positive in study hospitals were enrolled. Target study enrollment was 180 participants per arm, 30 participants per hospital. Basic demographic information was collected as well as HIV risk behavior and route of infection. In intervention hospitals, patients then went on to receive point-of-care CD4 testing and in-parallel viral load (VL) testing whereas patients in control hospitals progressed through the usual SOC cascade. The primary outcome measure was testing completeness within 30 days of positive initial HIV screening result. Testing completeness was defined as receipt of all tests, test results, and post-test counseling. The secondary outcome measure was ART initiation (receipt of first ART prescriptions) within 90 days of positive initial HIV screening result. Tertiary outcome measures were viral suppression (≤200 copies/mL) and all-cause mortality at 12 months. DISCUSSION: We expect that this first-ever, cluster-randomized controlled trial of a bundle of interventions intended to streamline the HIV care cascade in China (the One4All strategy) will provide strong evidence for the benefit of accelerating diagnosis, thorough clinical assessment, and ART initiation via an optimized HIV care cascade. We furthermore anticipate that this evidence will be valuable to policymakers looking to elevate China's overall HIV/AIDS response to meet the UNAIDS 90-90-90 targets and the broader, global goal of eradication of the HIV/AIDS epidemic. TRIAL REGISTRATION: ClinicalTrials.gov # NCT02084316 . (Registered on March 7, 2014).

Engagement in the HIV Care Continuum among Key Populations in Tijuana, Mexico.

In Tijuana, Mexico, HIV is concentrated in sub-epidemics of key populations: persons who inject drugs (PWID), sex workers (SW), and men who have sex with men (MSM). To date, data on engagement in the HIV care continuum among these key populations, particularly in resource-constrained settings, are sparse. We pooled available epidemiological data from six studies (N = 3368) to examine HIV testing and treatment uptake in these key populations; finding an overall HIV prevalence of 5.7 %. Of the 191 identified HIV-positive persons, only 11.5 % knew their HIV-positive status and 3.7 % were on ART. Observed differences between these HIV-positive key populations suggest PWID (vs. non-PWID) were least likely to have previously tested or initiate HIV care. MSM (vs. non-MSM) were more likely to have previously tested but not more likely to know their HIV-positive status. Of persons aware of their HIV-positive status, SW (vs. non-SW) were more likely to initiate HIV care. Findings suggest engagement of key populations in HIV treatment is far below estimates observed for similarly resource-constrained generalized epidemics in sub-Saharan Africa. These data provide one of the first empirical-snapshots highlighting the extent of HIV treatment disparities in key populations.

Cost and cost threshold analyses for 12 innovative US HIV linkage and retention in care programs.

Out of >1,000,000 people living with HIV in the USA, an estimated 60% were not adequately engaged in medical care in 2011. In response, AIDS United spearheaded 12 HIV linkage and retention in care programs. These programs were supported by the Social Innovation Fund, a White House initiative. Each program reflected the needs of its local population living with HIV. Economic analyses of such programs, such as cost and cost threshold analyses, provide important information for policy-makers and others allocating resources or planning programs. Implementation costs were examined from societal and payer perspectives. This paper presents the results of cost threshold analyses, which provide an estimated number of HIV transmissions that would have to be averted for each program to be considered cost-saving and cost-effective. The methods were adapted from the US Panel on Cost-effectiveness in Health and Medicine. Per client program costs ranged from $1109.45 to $7602.54 from a societal perspective. The cost-saving thresholds ranged from 0.32 to 1.19 infections averted, and the cost-effectiveness thresholds ranged from 0.11 to 0.43 infections averted by the programs. These results suggest that such programs are a sound and efficient investment towards supporting goals set by US HIV policy-makers. Cost-utility data are pending.

The Impact of Alcohol Use and Related Disorders on the HIV Continuum of Care: a Systematic Review : Alcohol and the HIV Continuum of Care.

Alcohol use is highly prevalent globally with numerous negative consequences to human health, including HIV progression, in people living with HIV (PLH). The HIV continuum of care, or treatment cascade, represents a sequence of targets for intervention that can result in viral suppression, which ultimately benefits individuals and society. The extent to which alcohol impacts each step in the cascade, however, has not been systematically examined. International targets for HIV treatment as prevention aim for 90 % of PLH to be diagnosed, 90 % of them to be prescribed with antiretroviral therapy (ART), and 90 % to achieve viral suppression; currently, only 20 % of PLH are virally suppressed. This systematic review, from 2010 through May 2015, found 53 clinical research papers examining the impact of alcohol use on each step of the HIV treatment cascade. These studies were mostly cross-sectional or cohort studies and from all income settings. Most (77 %) found a negative association between alcohol consumption on one or more stages of the treatment cascade. Lack of consistency in measurement, however, reduced the ability to draw consistent conclusions. Nonetheless, the strong negative correlations suggest that problematic alcohol consumption should be targeted, preferably using evidence-based behavioral and pharmacological interventions, to indirectly increase the proportion of PLH achieving viral suppression, to achieve treatment as prevention mandates, and to reduce HIV transmission.

Reasons for using traditional and complementary care by people living with HIV on antiretroviral therapy and association with interrupted care: a mixed methods study in Eswatini.

The use of traditional, complementary, and alternative medicine (TCAM) can lead to delays and interruptions in the HIV continuum of care. This study explores reasons for TCAM use in people living with HIV on antiretroviral therapy (ART) in Eswatini and compares interrupted care between different types of TCAM users. Data were collected using surveys in the MaxART study (a test-and-treat trial) between 2014 and 2017 to assess the exposure, namely visiting a TCAM provider. Additionally, visit dates were retrieved from clinic records to assess the outcome, interrupted care. Open-ended questions were analysed with qualitative content analysis (n = 602) and closed questions with bivariable and multivariable analysis (n = 202). Out of 202 participants, 145 (72%) never used TCAM, 40 (20%) ever used, and 17 (8%) is currently using TCAM (diviners, herbalists, and religious healers). No differences in interrupted care were found comparing never (reference category), past (Odds Ratio: 1.31, 95% confidence interval: 0.63-2.72), and current users (1.34, 0.47-3.77), while adjusting for gender, time since HIV diagnosis, and time on ART. Contextual factors affecting the choice for TCAM were the influence of family, advice from the health facility, and religious beliefs. Individual factors include trust in biomedical care, type of illness, no need for additional care, and practical reasons such as financial means. In conclusion, individual and contextual factors influence the choice for TCAM. Interrupted care does not differ between never, past, and current users.

Leveraging mHealth and Patient Supporters for African Americans' and Latinxs' Engagement in HIV Care (LEAN): Protocol for a Randomized, Controlled, Effectiveness-Implementation Trial.

BACKGROUND: Despite substantial investments in ending the HIV epidemic, disparities in HIV care persist, and there is an urgent need to evaluate novel and scalable approaches to improving HIV care engagement and viral suppression in real-world settings. OBJECTIVE: This paper aims to describe a study protocol for a pragmatic type II hybrid effectiveness-implementation randomized controlled trial comparing existing standard of care clinic HIV linkage, adherence, and retention (LAR) protocols to a mobile health (mHealth)-enhanced linkage, adherence, and retention (mLAR) intervention. METHODS: The study will enroll 450 participants from clinics in Baltimore City. Eligibility criteria include being ≥18 years of age, having a new HIV diagnosis or being HIV-positive and out of care, or being HIV-positive and deemed by clinic staff as someone who could benefit from linkage and retention services. Participants randomized to the intervention receive mHealth-supported patient navigation for 12 months. Participants in the control group receive the referring clinic's standard of care patient support. The primary outcome is HIV virologic suppression at 12 months. A subset of participants will be interviewed at 12 months to learn about their HIV care experiences and, for those in the intervention arm, their experiences with the mLAR intervention. This protocol was developed in collaboration with the Baltimore City Health Department (BCHD) and the Maryland Department of Health (MDH) and with input from a community advisory board. RESULTS: Enrollment began on February 25, 2020. As of August 11, 2022, 411 of the 450 target participants had been enrolled. CONCLUSIONS: Pragmatic implementation science trials designed with input from key stakeholders, including health departments and community members, can help evaluate the evidence for mHealth interventions to reduce HIV health disparities. TRIAL REGISTRATION: ClinicalTrials.gov NCT03934437; https://clinicaltrials.gov/ct2/show/NCT03934437. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42691.

Patient-Reported Outcomes Collection at an Urban HIV Clinic Associated With a Historically Black Medical College in the Southern United States: Qualitative Interview Study Among Patients With HIV.

BACKGROUND: Black Americans, particularly in the southern United States, are disproportionately affected by the US HIV epidemic. Patient-reported outcome (PRO) data collection can improve patient outcomes and provide oft-overlooked data on mental health, substance use, and patient adherence to antiretroviral therapy. OBJECTIVE: We piloted the use of an electronic tablet to collect PRO data on social and behavioral determinants of health among people with HIV at the Meharry Community Wellness Center, an HIV clinic affiliated with a Historically Black Medical College in Nashville, Tennessee. Our primary objective was to better understand patients' experiences and comfort with using an electronic PRO tool through patient interviews. METHODS: We enrolled 100 people with HIV in care at the Meharry Community Wellness Center consecutively to completely validate PRO tools using the Research Electronic Data Capture platform on a hand-held tablet. Using a purposive sampling strategy, we enrolled 20 of the 100 participants in an in-depth interview (IDI). Interview guide development was grounded in the cognitive-behavioral model, in which thoughts, feelings, and behaviors are interrelated. IDIs were audio recorded, transcribed, deidentified, and formatted for coding. A hierarchical coding system was developed and refined using an inductive-deductive approach. RESULTS: Among the 100 people with HIV enrolled, the median age was 50 (IQR 42-54) years; 89% (n=89) were Black, 60% (n=60) were male, and 82% (n=82) were living below 100% of the federal poverty level in 2016. Five major interview themes emerged: overall experience, question content, sensitive topics, clinic visit impact, and future recommendations. IDI participants felt that the tablet was easy to use and that the question content was meaningful. Question content related to trauma, sexual and drug use behaviors, mental health, stigma, and discrimination elicited uncomfortable or distressing feelings in some participants. Patients expressed a strong desire to be truthful, and most would complete these surveys without compensation at future visits if offered. CONCLUSIONS: The use of an electronic tablet to complete PRO data collection was well received by this cohort of vulnerable persons in HIV care in the southern United States. Despite some discomfort related to question content, our cohort overwhelmingly believed this was a meaningful part of their medical experience and expressed a high desire for truthfulness. Future research will focus on scaling up the implementation and evaluation of PRO data collection in a contextually appropriate manner while obtaining input from providers and staff to ensure that the collected data are both applicable and actionable.

Service delivery challenges in HIV care during the first year of the COVID-19 pandemic: results from a site assessment survey across the global IeDEA consortium.

INTRODUCTION: Interruptions in treatment pose risks for people with HIV (PWH) and threaten progress in ending the HIV epidemic; however, the COVID-19 pandemic's impact on HIV service delivery across diverse settings is not broadly documented. METHODS: From September 2020 to March 2021, the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium surveyed 238 HIV care sites across seven geographic regions to document constraints in HIV service delivery during the first year of the pandemic and strategies for ensuring care continuity for PWH. Descriptive statistics were stratified by national HIV prevalence (<1%, 1-4.9% and ≥5%) and country income levels. RESULTS: Questions about pandemic-related consequences for HIV care were completed by 225 (95%) sites in 42 countries with low (n = 82), medium (n = 86) and high (n = 57) HIV prevalence, including low- (n = 57), lower-middle (n = 79), upper-middle (n = 39) and high- (n = 50) income countries. Most sites reported being subject to pandemic-related restrictions on travel, service provision or other operations (75%), and experiencing negative impacts (76%) on clinic operations, including decreased hours/days, reduced provider availability, clinic reconfiguration for COVID-19 services, record-keeping interruptions and suspension of partner support. Almost all sites in low-prevalence and high-income countries reported increased use of telemedicine (85% and 100%, respectively), compared with less than half of sites in high-prevalence and lower-income settings. Few sites in high-prevalence settings (2%) reported suspending antiretroviral therapy (ART) clinic services, and many reported adopting mitigation strategies to support adherence, including multi-month dispensing of ART (95%) and designating community ART pick-up points (44%). While few sites (5%) reported stockouts of first-line ART regimens, 10-11% reported stockouts of second- and third-line regimens, respectively, primarily in high-prevalence and lower-income settings. Interruptions in HIV viral load (VL) testing included suspension of testing (22%), longer turnaround times (41%) and supply/reagent stockouts (22%), but did not differ across settings. CONCLUSIONS: While many sites in high HIV prevalence settings and lower-income countries reported introducing or expanding measures to support treatment adherence and continuity of care, the COVID-19 pandemic resulted in disruptions to VL testing and ART supply chains that may negatively affect the quality of HIV care in these settings.