Examining the Intrapersonal, Interpersonal and Community Level Correlates of Access to Medical Care Among Women Employed by Sex Work in Southern Uganda: A cross-sectional Analysis of the Kyaterekera Study.

Women employed by sex work (WESW) experience significant gaps in accessing necessary healthcare services, leading to unmet health needs. Yet, there is a dearth of literature on the barriers to medical care access among WESW in Uganda. We used data from the Kyaterekera baseline to examine the correlates of access to medical care among WESW, defined as the ability of individuals to obtain the necessary healthcare services they require in a timely, affordable, and equitable manner. The Kyaterekera study recruited 542 WESW aged 18-58 years from Southern Uganda. We conducted a multilevel linear regression model to determine the intrapersonal (age, education level, marital status, HIV knowledge, and asset ownership), interpersonal (family cohesion and domestic violence attitudes), and community (community satisfaction, sex work stigma and distance to health facility) level correlates of access to medical care among WESW. Intrapersonal and interpersonal factors were associated with access to medical care among WESW. There was no significant association between community level factors and access to medical care. WESW with secondary education (ß = 0.928, 95% CI = 0.007, 1.849) were associated with increased access to medical care. WESW with high asset ownership (ß = -1.154, 95% CI= -1.903, -0.405), high family cohesion (ß = -0.069, 95% CI= -0.106, -0.031), and high domestic violence attitudes (ß = -0.253, 95% CI= -0.438, -0.068) were associated with decreased access to medical care. The findings emphasize the critical need for targeted family strengthening interventions to enhance family support for WESW and address domestic violence.

Understanding why racial/ethnic inequities along the HIV care continuum persist in the United States: a qualitative exploration of systemic barriers from the perspectives of African American/Black and Latino persons living with HIV.

BACKGROUND: Racial/ethnic inequities along the HIV care continuum persist in the United States despite substantial federal investment. Numerous studies highlight individual and social-level impediments in HIV, but fewer foreground systemic barriers. The present qualitative study sought to uncover and describe systemic barriers to the HIV care continuum from the perspectives of African American/Black and Latino persons living with HIV (PLWH) with unsuppressed HIV viral load, including how barriers operated and their effects. METHODS: Participants were African American/Black and Latino PLWH with unsuppressed HIV viral load (N = 41). They were purposively sampled for maximum variability on key indices from a larger study. They engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed. Data were analyzed using directed content analysis. RESULTS: Participants were 49 years old, on average (SD = 9), 76% were assigned male sex at birth, 83% were African American/Black and 17% Latino, 34% were sexual minorities (i.e., non-heterosexual), and 22% were transgender/gender-nonbinary. All had indications of chronic poverty. Participants had been diagnosed with HIV 19 years prior to the study, on average (SD = 9). The majority (76%) had taken HIV medication in the six weeks before enrollment, but at levels insufficient to reach HIV viral suppression. Findings underscored a primary theme describing chronic poverty as a fundamental cause of poor engagement. Related subthemes were: negative aspects of congregate versus private housing settings (e.g., triggering substance use and social isolation); generally positive experiences with health care providers, although structural and cultural competency appeared insufficient and managing health care systems was difficult; pharmacies illegally purchased HIV medication from PLWH; and COVID-19 exacerbated barriers. Participants described mitigation strategies and evidenced resilience. CONCLUSIONS: To reduce racial/ethnic inequities and end the HIV epidemic, it is necessary to understand African American/Black and Latino PLWH's perspectives on the systemic impediments they experience throughout the HIV care continuum. This study uncovers and describes a number of salient barriers and how they operate, including unexpected findings regarding drug diversion and negative aspects of congregate housing. There is growing awareness that systemic racism is a core determinant of systemic barriers to HIV care continuum engagement. Findings are interpreted in this context.

"I expected little, although I learned a lot": perceived benefits of participating in HIV risk reduction sessions among women engaged in sex work in Uganda.

BACKGROUND: The global HIV burden remains a public health concern. Women engaged in sex work (WESW) are at higher risk of acquiring HIV compared to the general adult population. Uganda reports high rates of HIV prevalence among WESW. While WESW in Uganda have long been the subject of surveillance studies, they have not been targeted by theory-informed HIV prevention intervention approaches. In this study, we explored the perceived benefits of an evidence-based HIV risk reduction intervention that was implemented as part of a combination intervention tested in a clinical trial in Uganda. METHODS: As part of a larger randomized clinical trial, we conducted semi-structured in-depth interviews with 20 WESW selected using a stratified purposive sampling. All interviews were conducted in Luganda, language spoken in the study area, and audio-recorded. They were transcribed verbatim and translated to English. Thematic analysis was used to analyze the data. RESULTS: WESW's narratives focused on: (1) condom use; (2) alcohol/drug consumption; (3) PrEP use; (4) "handling" customers; and (5) "massaging" customers. WESW agreed that male condom was one of the important learning points for them and planned to continue using them while female condoms were received with mixed reactions. Many women appreciated receiving information about the risks of consuming alcohol and drugs, and discussed how they reduced/ eliminated their consumption. PrEP information was appreciated though identified by fewer WESW. Handling a client was discussed as a helpful strategy for safer sex through improved ability to convince customers to use condoms or avoiding sex. Massaging was also beneficial to avoid penetrative sex, but similar to female condom, massaging also yielded mixed perceptions. CONCLUSION: WESW found the intervention beneficial and described ways in which it improved their ability to engage in safer sex and stay healthy. The fact that WESW identified other strategies beyond condom use as helpful underlines the importance of adopting a comprehensive approach to behavioral interventions targeting HIV prevention even when combined with other interventions. Additionally, WESW's narratives suggest that incorporating the tenets of social cognitive theory and harm reduction approaches in HIV prevention among this population can result in risk behavior change.

Using the multiphase optimization strategy (MOST) framework to optimize an intervention to increase COVID-19 testing for Black and Latino/Hispanic frontline essential workers: A study protocol.

BACKGROUND: Among those at highest risk for COVID-19 exposure is the large population of frontline essential workers in occupations such food service, retail, personal care, and in-home health services, among whom Black and Latino/Hispanic persons are over-represented. For those not vaccinated and at risk for exposure to COVID-19, including frontline essential workers, regular (approximately weekly) COVID-19 testing is recommended. However, Black and Latino/Hispanic frontline essential workers in these occupations experience serious impediments to COVID-19 testing at individual/attitudinal- (e.g., lack of knowledge of guidelines), social- (e.g., social norms), and structural-levels of influence (e.g., poor access), and rates of testing for COVID-19 are insufficient. METHODS/DESIGN: The proposed community-engaged study uses the multiphase optimization strategy (MOST) framework and an efficient factorial design to test four candidate behavioral intervention components informed by an integrated conceptual model that combines critical race theory, harm reduction, and self-determination theory. They are A) motivational interview counseling, B) text messaging grounded in behavioral economics, C) peer education, and D) access to testing (via navigation to an appointment vs. a self-test kit). All participants receive health education on COVID-19. The specific aims are to: identify which components contribute meaningfully to improvement in the primary outcome, COVID-19 testing confirmed with documentary evidence, with the most effective combination of components comprising an "optimized" intervention that strategically balances effectiveness against affordability, scalability, and efficiency (Aim 1); identify mediators and moderators of the effects of components (Aim 2); and use a mixed-methods approach to explore relationships among COVID-19 testing and vaccination (Aim 3). Participants will be N = 448 Black and Latino/Hispanic frontline essential workers not tested for COVID-19 in the past six months and not fully vaccinated for COVID-19, randomly assigned to one of 16 intervention conditions, and assessed at 6- and 12-weeks post-baseline. Last, N = 50 participants will engage in qualitative in-depth interviews. DISCUSSION: This optimization trial is designed to yield an effective, affordable, and efficient behavioral intervention that can be rapidly scaled in community settings. Further, it will advance the literature on intervention approaches for social inequities such as those evident in the COVID-19 pandemic. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05139927 ; Registered on 11/29/2021. Protocol version 1.0. May 2, 2022, Version 1.0.

Demonstrating the Feasibility of an Economic Empowerment and Health Promotion Intervention among Low-Income Women Affected by HIV in New York City.

Women of color in the U.S. face systematic exclusion from the labor market, work protections, and employer-based benefits. Women's economic vulnerability increases their susceptibility to health-related issues, including HIV transmission and substance use, which are work-restricting disabilities, by constraining their capacity to effectively reduce risk. The Women's Economic Empowerment pilot examined the feasibility of a structural intervention, implemented at a neighborhood agency, combining both health promotion and economic empowerment components as a pathway to accessing an urban job market for low-income women with work-restricting disabilities, including living with HIV. Ten women clients from a partner agency in New York completed four health promotion sessions, six financial literacy sessions, and a concurrent opportunity to match savings; some also followed with up to 24 vocational rehabilitation sessions. Interviews captured self-reported data on health promotion and financial outcomes at pre-/post-intervention and 3-month follow-up. Qualitative analysis of recorded group sessions and field notes demonstrate that women express improved HVI/STI knowledge and problem-solving strategies for risk reduction, a shared optimism for the future due to group participation, enhanced social support through relationship-building, a heightened sense of empowerment regarding financial decision making, and a desire to re-engage in the labor force. Findings suggest an empowering approach to re-engage women impacted by poverty, unemployment, and disabilities, including living with HIV, into the workforce may be implemented in a community setting.

Economic Abuse and Care-seeking Practices for HIV and Financial Support Services in Women Employed by Sex Work: A Cross-Sectional Baseline Assessment of a Clinical Trial Cohort in Uganda.

Economic hardship is a driver of entry into sex work, which is associated with high HIV risk. Yet, little is known about economic abuse in women employed by sex work (WESW) and its relationship to uptake of HIV prevention and financial support services. This study used cross-sectional baseline data from a multisite, longitudinal clinical trial that tests the efficacy of adding economic empowerment to traditional HIV risk reduction education on HIV incidence in 542 WESW. Mixed effects logistic and linear regressions were used to examine associations in reported economic abuse by demographic characteristics, sexual behaviors, HIV care-seeking, and financial care-seeking. Mean age was 31.4 years. Most WESW were unmarried (74%) and had less than primary school education (64%). 48% had savings, and 72% had debt. 93% reported at least one economic abuse incident. Common incidents included being forced to ask for money (80%), having financial information kept from them (61%), and being forced to disclose how money was spent (56%). WESW also reported partners/relatives spending money needed for bills (45%), not paying bills (38%), threatening them to quit their job(s) (38%), and using physical violence when earning income (24%). Married/partnered WESW (OR = 2.68, 95% CI:1.60-4.48), those with debt (OR = 1.70, 95% CI:1.04-2.77), and those with sex-work bosses (OR = 1.90, 95% CI:1.07-3.38) had higher economic abuse. Condomless sex (ß = +4.43, p < .05) was higher among WESW experiencing economic abuse, who also had lower odds of initiating PrEP (OR = .39, 95% CI:.17-.89). WESW experiencing economic abuse were also more likely to ask for cash among relatives (OR = 2.36, 95% CI:1.13-4.94) or banks (OR = 2.12, 95% CI:1.11-4.03). The high prevalence of HIV and economic abuse in WESW underscores the importance of integrating financial empowerment in HIV risk reduction interventions for WESW, including education about economic abuse and strategies to address it. Programs focusing on violence against women should also consider economic barriers to accessing HIV prevention services.

A virtual pilot optimization trial for African American/Black and Latino persons with non-suppressed HIV viral load grounded in motivational interviewing and behavioral economics.

Introduction: Virtual and low-touch behavioral interventions are needed for African American/Black and Latino persons living with HIV (PLWH) with barriers to HIV viral suppression, particularly during COVID-19. Guided by the multiphase optimization strategy, we explored three components for PLWH without viral suppression, grounded in motivational interviewing and behavioral economics: (1) motivational interviewing counseling, (2) 21-weeks of automated text messages and quiz questions about HIV management, and (3) financial rewards for viral suppression (lottery prize vs. fixed compensation). Methods: This pilot optimization trial used sequential explanatory mixed methods to explore the components' feasibility, acceptability, and preliminary evidence of effects using an efficient factorial design. The primary outcome was viral suppression. Participants engaged in baseline and two structured follow-up assessments over an 8-month period, and provided laboratory reports to document HIV viral load. A subset engaged in qualitative interviews. We carried out descriptive quantitative analyses. Then, qualitative data were analyzed using directed content analysis. Data integration used the joint display method. Results: Participants (N = 80) were 49 years old, on average (SD = 9), and 75% were assigned male sex at birth. Most (79%) were African American/Black, and the remainder were Latino. Participants were diagnosed with HIV 20 years previously on average (SD = 9). Overall, components were feasible (>80% attended) and acceptability was satisfactory. A total of 39% (26/66) who provided laboratory reports at follow-up evidenced viral suppression. Findings suggested no components were entirely unsuccessful. The lottery prize compared to fixed compensation was the most promising component level. In qualitative analyses, all components were seen as beneficial to individual wellbeing. The lottery prize appeared more interesting and engaging than fixed compensation. However, structural barriers including financial hardship interfered with abilities to reach viral suppression. The integrated analyses yielded areas of convergence and discrepancy and qualitative findings added depth and context to the quantitative results. Conclusions: The virtual and/or low-touch behavioral intervention components tested are acceptable and feasible and show enough potential to warrant refinement and testing in future research, particularly the lottery prize. Results must be interpreted in the context of the COVID-19 pandemic. Trial registration: NCT04518241 (https://clinicaltrials.gov/ct2/show/NCT04518241).

PrEP acceptability and initiation among women engaged in sex work in Uganda: Implications for HIV prevention.

BACKGROUND: Women engaged in sex work (WESW) are disproportionately affected by HIV. In Uganda, HIV prevalence among WESW is estimated at 37%, accounting for 18% of all new infections in the country. WESW experience poverty, gender-based violence, and other issues that reduce their power and limit their ability to negotiate condom use. Female-controlled strategies, including pre-exposure prophylaxis (PrEP), may afford women more transmission protection, but barriers to access and use persist. This cross-sectional study examined baseline PrEP acceptability and initiation among WESW recently enrolled in a randomized clinical trial in Uganda to test the impact of a combination HIV risk reduction and economic empowerment intervention on sexual risk outcomes (clinicaltrials.gov, NCT03583541). METHODS: A total of 542 WESW from 19 high HIV-prevalent geographical areas were enrolled in the Kyaterekera study between June 2019 and March 2020. Women were eligible for the study if they: (1) were age 18 or over; (2) reported engagement in transactional sex (a sex act in exchange for pay) in the past 30 days; and (3) reported engagement in one or more episodes of unprotected sex in the past 30 days. Women completed a baseline assessment, were tested for HIV and other sexually transmitted infections (STIs) at enrollment, and were connected with antiretroviral therapy (ART), STI treatment, or PrEP, based on need and interest. Descriptive statistics examined baseline data on PrEP acceptability and initiation. Independent variables (i.e. years in sex work, recent sexual coercion, perceived HIV and sex work stigmas, harmful alcohol use, barriers to medical care, and social support) were derived from the empirical literature and women's self-report. Bivariate analysis was performed to test associations between main effects of these variables. Using binomial logistic regression, predictive models were evaluated for two distinct outcomes-PrEP acceptability and PrEP initiation/uptake. FINDINGS: At baseline, 59% of women (n = 322) tested HIV negative. Among WESW testing negative, 11% (n = 36) were already PrEP enrolled. Most women reported willingness to use PrEP (n = 317; 91%). Slightly over half of WESW not already on PrEP agreed to initiate PrEP (n = 158; 55%). Logistic regression models demonstrate that acceptability of or willingness to use PrEP was significantly associated with fewer years engaged in sex work (AOR= ·18, 95% CI 0·05-·66, p<·01) and greater perceived social support from family (AOR= 1·39, 95% CI 1·03 -1.88, p<·05). PrEP initiation was negatively associated with greater perceived social support from friends (AOR=·81, 95% CI ·68-0·97, p<·05) and positively associated with higher perceived stigma due to sex work among family members (AOR=2·20, 95% CI 1·15-4·22, p<·05). INTERPRETATION: Despite endorsing PrEP use, many WESW remain reluctant to use it. This gap in prevention practice highlights the heart of a failing PrEP prevention cascade. Findings point to the important role family and friend support may play in destigmatizing sex work and PrEP use for women. Social and structural-level efforts are needed to improve educational messaging and to integrate positive messaging into health promotion campaigns for women and their families, while also working toward decriminalizing sex work. FUNDING: This paper was made possible with funding from United States National Institute of Mental Health (Grant number: R01MH116768).

Recruiting and retaining service agencies and public health providers in longitudinal studies: Implications for community-engaged implementation research.

This article addresses a lack of attention in the implementation science literature regarding how to overcome recruitment and retention challenges in longitudinal studies involving large samples of service agencies and health service providers ("providers"). Herein, we provide a case-illustration of procedures that improved recruitment and retention in a longitudinal, mixed-method study-Project Interprofessional Collaboration Implementation-funded by the US National Institute of Mental Health. Project Interprofessional Collaboration Implementation included counselors, program workers, educators, and supervisors. We present a research-engagement model to overcome barriers that included developing a low-burden study, social gatherings to engage stakeholders, protocols to recruit agencies and providers, comprehensive record-keeping, research procedures as incentives to participation, a plan to retain hard-to-reach participants, and strategies for modifying incentives over time. Using our model, we retained 36 agencies over the life of the project. Between baseline (N = 379) and 12-month follow-up (N = 285), we retained 75% of the sample and between the 12- (N = 285) and 24-month follow-ups (N = 256), we retained 90%. For qualitative interviews (between baseline and 12-month follow-up and between 12- and 24-month follow-ups), we retained 100% of the sample (N = 20). We provide a summary of frequency of contacts required to initiate data collection and time required for data collection. The model responded to environmental changes in policy and priorities that would not have been achievable without the expertise of community partners. To recruit and retain large samples longitudinally, researchers must strategically engage community partners. The strategies imbedded in our model can be performed with moderate levels of effort and human resources. Creating opportunities for research partners to participate in all phases of the research cycle is recommended, which can help build research capacity for future research.

Interprofessional Collaboration and On-the-Job Training Improve Access to HIV Testing, HIV Primary Care, and Pre-Exposure Prophylaxis (PrEP).

The HIV Continuum of Care is a global priority, yet vulnerable patients face access/retention challenges. Research is missing on the role social and public health service providers can play to help these patients. Using structural equation modeling, we examined the effects of interprofessional collaboration (IPC) and on-the-job training on the frequency of linkages to HIV testing, HIV primary care, and on pre-exposure prophylaxis (PrEP) psychoeducation. The sample included 285 New York City providers of social and public health services from 34 agencies. Forty-eight percent of providers had not offered PrEP psychoeducation and linked fewer than five patients to HIV testing and primary care per week. However, in multivariate analysis higher IPC was associated with more linkages and frequent psychoeducation. After adjusting for IPC, linkage training was associated with more frequent services. The influence of specific factors highlights areas for interventions and policies to improve access to the HIV Continuum of Care.

Policy Interventions Shaping HIV Prevention: Providers' Active Role in the HIV Continuum of Care.

The U.S. Centers for Disease Control and Prevention (CDC) Diffusion of Effective Behavioral Interventions project has disseminated HIV behavioral interventions (EBIs) across the United States since the 1990s. In 2011, the CDC launched the High-Impact HIV Prevention (HIP) project, providing EBIs plus high-impact services (HIV testing, primary care, and support services). Providers (nurses, social workers, educators) are unable to consistently make linkages; thus, numerous at-risk individuals are not benefitting from HIP. Research on providers' roles in the HIV Continuum of Care-linking clients to HIV testing, primary care, and support services-is lacking. This article helps fill this gap with evidence that providers exposed to EBIs, whose agencies offer EBIs, more frequently link clients to high-impact services. This is based on diffusion of innovations theory, where individuals in social networks influence one another's adoption of innovations. We hypothesize that providers are exposed to EBIs via training, reading and hearing about EBIs, and/or discussing EBIs with colleagues. We used cross-sectional data from 379 providers from 36 agencies in New York City. We used multilevel ordinal logistic regression models to test associations between provider exposure to EBIs (agency provides EBIs) and frequency of linkages to high-impact services. Providers exposed to greater numbers of EBIs more frequently link clients to HIV, hepatitis C (HEP-C), and sexually transmitted infections testing; to primary care; and to drug treatment and mental health services. Providers link clients most frequently to primary care and HIV testing and least frequently to HEP-C testing and syringe exchange. Findings suggest a dose effect, with exposure to more EBIs resulting in more linkages. Findings show a staged, evidence-based prevention approach that includes exposure to EBIs, leading to providers linking clients to high-impact services. There needs to be emphasis on inspiring providers to engage with high-impact services at the elevated levels needed to end the epidemic.

Training in Evidence-Based Practices Increases Likelihood to Integrate Different HIV Prevention Services with Substance-Using Clients.

Providers of social and public health services ("providers") often use HIV prevention strategies with substance-using clients to decrease HIV transmission and infection. This article examines factors that facilitate providers' use of select HIV-prevention strategies. Sample comprises 379 providers from 36 agencies in New York City. OUTCOMES: sexual risk assessments; risk reduction counseling; condom demonstration; and referrals to HIV testing. PREDICTORS: training; job satisfaction; staff collaboration. The authors used multilevel logistic regression and linear multilevel models. HIV prevention training was associated with increased performance of each outcome. The odds of conducting several outcomes were higher for providers trained in evidence-based interventions. Staff collaboration and job satisfaction were associated with provision of multiple outcomes. This study shows training and collaboration/satisfaction as significantly influencing providers to use prevention strategies. Providers ought to be trained in multiple modalities, and agencies ought to prioritize collaborative environments that promote job satisfaction.

Factors That Influence Linkages to HIV Continuum of Care Services: Implications for Multi-Level Interventions.

Worldwide, the human immunodeficiency virus (HIV) continuum of care involves health promotion providers (e.g., social workers and health educators) linking patients to medical personnel who provide HIV testing, primary care, and antiretroviral treatments. Regrettably, these life-saving linkages are not always made consistently and many patients are not retained in care. To design, test and implement effective interventions, we need to first identify key factors that may improve linkage-making. To help close this gap, we used in-depth interviews with 20 providers selected from a sample of 250 participants in a mixed-method longitudinal study conducted in New York City (2012-2017) in order to examine the implementation of HIV services for at-risk populations. Following a sociomedical framework, we identified provider-, interpersonal- and environmental-level factors that influence how providers engage patients in the care continuum by linking them to HIV testing, HIV care, and other support services. These factors occurred in four domains of reference: Providers' Professional Knowledge Base; Providers' Interprofessional Collaboration; Providers' Work-Related Changes; and Best Practices in a Competitive Environment. Of particular importance, our findings show that a competitive environment and a fear of losing patients to other agencies may inhibit providers from engaging in linkage-making. Our results suggest relationships between factors within and across all four domains; we recommend interventions to modify factors in all domains for maximum effect toward improving care continuum linkage-making. Our findings may be applicable in different areas of the globe with high HIV prevalence.