Which Features of Telehealth in HIV Care Are Most Important? A Mixed-Methods Study With HIV Care Providers and People Living With HIV in South Carolina.

ABSTRACT: Telehealth was rapidly implemented in HIV care during COVID-19 yet remains understudied. To assess the importance of telehealth features, we conducted a mixed-methods study with HIV care providers and people living with HIV. Qualitative interviews and ranking exercises revealed heterogeneity in preference-relevant features of telehealth in HIV care.

Disparities in Telehealth Use in HIV Care During the COVID-19 Pandemic: Study Findings from South Carolina.

Background: Telehealth was adopted to maintain HIV care continuity during the COVID-19 pandemic; however, its use was unequally distributed. This study examined variation in HIV care visit patterns and whether telehealth use was associated with viral suppression. Methods: Electronic health record (EHR) data from a large HIV clinic in South Carolina was analyzed using multivariable logistic regression to characterize variation in telehealth use, having a viral load (VL) test, and viral suppression in 2022. Results: EHR data from 2,375 people living with HIV (PWH) between March 2021 and March 2023 showed telehealth use among 4.8% of PWH. PWH who are 50+ years and non-Hispanic Black had lower odds of telehealth use (odds ratio [OR] 0.59, 95% confidence interval [CI 0.40-0.86]; OR 0.58, 95% CI [0.37-0.92] respectively). Telehealth use was not associated with viral suppression and VL testing. Conclusion: Telehealth disparities in HIV care affected older and non-Hispanic Black PWH, requiring tailored strategies to promote telehealth among them.

The Future of Telehealth in Human Immunodeficiency Virus Care: A Qualitative Study of Patient and Provider Perspectives in South Carolina.

To ensure care continuity during the COVID-19 pandemic, telehealth has been widely implemented in human immunodeficiency virus (HIV) care. However, participation in and benefits from telehealth were unequal. This study aims to assess the willingness of people living with HIV (PWH) and HIV care providers to use telehealth and perceptions of the future role of telehealth. In-depth interviews with 18 PWH and 10 HIV care providers from South Carolina assessed their willingness to use telehealth, their perspectives on the future of telehealth in HIV care, and recommendations to improve telehealth. Interviews were analyzed using thematic analysis. Most PWH were female (61%), Black/African American (67%), and non-Hispanic (78%). Most PWH (61%) and all providers had used telehealth for HIV care. Most PWH and all providers reported being willing to use or (re-)consider telehealth HIV care services in the future. Providers suggested that telehealth is most suitable for routine HIV care encounters and for established, clinically stable, generally healthy PWH. Attitudes toward telehealth were heterogeneous, with most interviewees valuing telehealth similarly or superior to in-person care, yet >20% perceiving it less valuable. Recommendations to improve telehealth included multilevel strategies to address challenges across four domains: technology, the virtual nature of telehealth, administrative processes, and the sociodemographic profile of PWH. Telehealth in HIV care is here to stay; however, it may not yet be suitable for all PWH and all care encounters. Decision processes related to telehealth versus in-person care need to involve providers and PWH. Existing telehealth options require multilevel adjustments addressing persistent challenges.

Beyond coverage: Rural-urban disparities in the timeliness of childhood vaccinations in Tanzania.

BACKGROUND: Timely vaccination maximizes efficacy for preventing infectious diseases. In the absence of national vaccination registries, representative sample survey data hold vital information on vaccination coverage and timeliness. This study characterizes vaccination coverage and timeliness in Tanzania and provides an analytic template to inform contextually relevant interventions and evaluate immunization programs. METHODS: Cross-sectional data on 6,092 children under age 3 from the 2015-16 Tanzania Demographic and Health Survey were used to examine coverage and timeliness for 14 vaccine doses recommended in the first year of life. The Kaplan-Meier method was used to model time to vaccination. Cox proportional hazard models were used to examine factors associated with timely vaccination. RESULTS: Substantial rural-urban disparities in vaccination coverage and timeliness were observed for all vaccines. Across 14 recommended doses, documented coverage ranged from 52 % to 79 %. Median vaccination delays lasted up to 35 days; gaps were larger among rural than urban children and for later doses in vaccine series. Among rural children, median delays exceeded 35 days for the 3rd doses of the polio, pentavalent, and pneumococcal vaccines. Median delays among urban children were < 21 days for all doses. Among rural and urban children, lower maternal education and delivery at home were associated with increased risk of delayed vaccination. In rural settings, less household wealth and greater distance to a health facility were also associated with increased risk of delayed vaccination. DISCUSSION: This study highlights persistent gaps in uptake and timeliness of childhood vaccinations in Tanzania and substantial rural-urban disparities. While the results provide an informative situation assessment and outline strategies for identifying unvaccinated children, a national electronic registry is critical for comprehensive assessments of the performance of vaccination programs. The timeliness measure employed in this study-the amount of time children are un- or undervaccinated-may serve as a sensitive performance metric for these programs.

Association of caregiver attitudes with adolescent HPV vaccination in 13 southern US states.

Background and objectives:  HPV vaccination coverage is lower than that of other adolescent vaccines in the southern US. This study sought to characterize caregiver attitudes associated with adolescent HPV vaccination in the southern US and to inform interventions to promote HPV vaccination. Methods: From December 2019 - January 2020, caregivers of adolescents (ages 9-17 years) living in thirteen southern US states were recruited from a nationally-representative online survey panel. Caregivers (N = 1,105) completed a cross-sectional survey that assessed general adolescent vaccine attitudes as well as those associated with the HPV vaccine and HPV vaccination decision-making. The primary study outcome was adolescents' receipt of at least one dose of the HPV vaccine. Results: Caregivers with vaccinated adolescents had greater positive attitudes towards adolescent vaccines compared to caregivers of unvaccinated adolescents. Top three areas of concern among caregivers were related to vaccine ingredients, perceptions that adolescents receive too many vaccines, and worry about vaccine side effects. In multivariable regression models, positive attitudes towards the HPV vaccine and HPV vaccination decision-making strongly associated with HPV vaccination in addition to general adolescent vaccination attitudes. Caregivers' reported discomfort with discussing the topic of sex was predictive of lower vaccination uptake for older adolescents. Conclusions: Public health messaging in the southern US should be tailored to reduce concerns about vaccine safety and to communicate the importance of timely HPV vaccination. Campaigns that deliver information specific to the HPV vaccine and to support vaccination decision-making may be more effective than those delivering only general adolescent vaccination information at promoting on-time HPV vaccination.

Key stakeholder perspectives on challenges and opportunities for rural HPV vaccination in North and South Carolina.

The objective of this study was to identify factors at the individual, provider, and systems levels that serve as challenges or opportunities for increasing adolescent vaccination-including Human Papillomavirus (HPV) vaccination-in rural communities in the southern United States (US). As part of a broader study to increase HPV vaccine uptake in the southern US, we conducted in-depth interviews with vaccination stakeholders representing public health and education agencies in North Carolina (NC) and South Carolina (SC). Fourteen key stakeholders were recruited using purposive sampling to obtain insights into challenges and solutions to rural-urban disparities in HPV vaccination coverage. Stakeholders were also queried about their experiences and attitudes toward school-based vaccination promotion programs and campaigns. We used a rapid qualitative approach to analyze the data. Stakeholders identified factors at the individual, provider, and systems levels that serve as challenges to vaccination in rural communities. Similar to previous studies, stakeholders mentioned challenges with healthcare access and vaccine-related misconceptions that pose barriers to HPV vaccination for rural residents. Systems-level challenges identified included limited access to high-speed internet in rural areas that may impact providers' ability to interface with state-level digital systems such as the vaccination registry. Stakeholders identified a number of opportunities to increase HPV vaccination coverage, including through school-based health promotion programs. Stakeholders strongly supported school-based programs and approaches to strengthen confidence and demand for HPV vaccination and to help address persistent social determinants and system level factors that pose challenges to HPV vaccination coverage in many rural areas.

Feasibility, Acceptability, and Potential Cost-Effectiveness of a Novel Mobile Phone Intervention to Promote Human Immunodeficiency Virus Testing Within Social Networks in Tanzania.

ABSTRACT: Among 145 individuals surveyed in Tanzania, 42% indicated willingness to test for human immunodeficiency virus in response to a confidential, phone-based text message. On average, participants were likely to provide contact information for 1.5 members of their social networks, suggesting high feasibility and moderate acceptability of a novel mHealth human immunodeficiency virus testing intervention.

Predictors of HPV vaccination in the southern US: A survey of caregivers from 13 states.

BACKGROUND AND OBJECTIVES: Despite a high burden of human papillomavirus (HPV)-attributable cancers, the southern US lags other regions in HPV vaccination coverage. This study sought to characterize and contextualize predictors of HPV vaccination in the southern US. METHODS: From December 2019 - January 2020, parents of adolescents (ages 9-17 years) living in thirteen southern US states were recruited from a nationally-representative online survey panel and completed a cross-sectional survey. The primary study outcome was initiation of HPV vaccination. RESULTS: Of 1105 parents who responded to the survey, most were ≥35 years of age and of female gender. HPV vaccination initiation was reported only among 37.3% of adolescents and was highest at age 12. Cumulative HPV vaccination coverage was highest at age 15 (60%) but lower than coverage for tetanus-diphtheria-acellular pertussis (Tdap, 79.3%) and Meningococcal vaccines (MenACWY, 67.3%). Provider recommendation was strongly associated with higher odds of HPV vaccination (aOR: 49.9, 95 %CI: 23.1-107.5). In alternative predictive models, home/online (vs. public) schooling and parents' working status were associated with lower odds of vaccination; health care visits in the past 12 months and shorter travel times to adolescents' usual health care provider were associated with greater odds of vaccination. CONCLUSIONS: Our findings suggest missed opportunities for HPV vaccination in the southern US and support strengthening provider recommendation for on-time initiation of HPV vaccination among adolescents. Other strategies to increase HPV vaccinations may include encouraging co-administration with other adolescent vaccines, increasing vaccine access, and promoting vaccinations for home/online-school students.

Examining Associations between Knowledge and Vaccine Uptake Using the Human Papillomavirus Knowledge Questionnaire (HPV-KQ).

Objectives: Understanding the relationship between human papillomavirus (HPV) knowledge and vaccination behavior is important to inform public health interventions, yet few validated HPV knowledge scales exist. This study describes development of the Human Papillomavirus Knowledge Questionnaire (HPV-KQ) and its validation with parents residing in the southern United States (US). Methods: Drawing on previously published measures, we developed the 13-item HPV-KQ and administered the scale via Web-based survey to parents (N=1105) of adolescents ages 9 to 17 years. Dimensionality, internal consistency, model fit, and predictive validity were assessed. Results: The scale was bidimensional. One factor captured general HPV knowledge, and the second factor captured perceptions of gender differences in HPV infection and vaccine recommendations. The 13-item scale and 2-factor solution displayed strong internal consistency and good model fit. Parents of vaccinated adolescents scored higher on the 13-item HPV-KQ (Mean = 8.56) than parents of unvaccinated adolescents (Mean = 6.43) (p < .001). In regression models, controlling for key covariates, parents' performance on the HPV-KQ predicted adolescent HPV vaccination (p < .001). Conclusions: Evaluation indicates the HPV-KQ is a reliable and valid tool for measuring knowledge of HPV and the HPV vaccine among parents residing in the southern US. We recommend further efforts to validate the scale with other populations.

Preferences for transitional HIV care among people living with HIV recently released from prison in Zambia: a discrete choice experiment.

INTRODUCTION: No studies from sub-Saharan Africa have attempted to assess HIV service delivery preferences among incarcerated people living with HIV as they transition from prisons to the community ("releasees"). We conducted a discrete choice experiment (DCE) to characterize releasee preferences for transitional HIV care services in Zambia to inform the development of a differentiated service delivery model to promote HIV care continuity for releasees. METHODS: Between January and October 2019, we enrolled a consecutive sample of 101 releasees from a larger cohort prospectively following 296 releasees from five prisons in Zambia. We administered a DCE eliciting preferences for 12 systematically designed choice scenarios, each presenting three hypothetical transitional care options. Options combined six attributes: (1) clinic type for post-release HIV care; (2) client focus of healthcare workers; (3) transitional care model type; (4) characteristics of transitional care provider; (5) type of transitional care support; and (6) HIV status disclosure support. We analysed DCE choice data using a mixed logit model, with coefficients describing participants' average ("mean") preferences for each option compared to the standard of care and their distributions describing preference variation across participants. RESULTS: Most DCE participants were male (n = 84, 83.2%) and had completed primary school (n = 54, 53.5%), with 29 (28.7%) unemployed at follow-up. Participants had spent an average of 8.2 months in the community prior to the DCE, with 18 (17.8%) reporting an intervening episode of re-incarceration. While we observed significant preference variation across participants (p < 0.001 for most characteristics), releasees were generally averse to clinics run by community-based organizations versus government antiretroviral therapy clinics providing post-release HIV care (mean preference = -0.78, p < 0.001). On average, releasees most preferred livelihood support (mean preference = 1.19, p < 0.001) and HIV care support (mean preference = 1.00, p < 0.001) delivered by support groups involving people living with HIV (mean preference = 1.24, p < 0.001). CONCLUSIONS: We identified preferred characteristics of transitional HIV care that can form the basis for differentiated service delivery models for prison releasees. Such models should offer client-centred care in trusted clinics, provide individualized HIV care support delivered by support groups and/or peer navigators, and strengthen linkages to programs providing livelihood support.

Telehealth for HIV Care Services in South Carolina: Utilization, Barriers, and Promotion Strategies During the COVID-19 Pandemic.

To ensure continuing HIV care services during the COVID-19 pandemic, telehealth has been recommended and implemented in numerous HIV-related facilities. This study aims to understand telehealth utilization for HIV care services in South Carolina (SC), identify barriers to telehealth during COVID-19, and investigate strategies to facilitate remote HIV care delivery. In-depth interviews with 11 management personnel from 8 HIV-related facilities in SC were analyzed using thematic analysis. Utilizations of telehealth were diverse in delivering medical and non-medical HIV care services. Barriers included technological challenges, digital literacy, client/provider experiences, low socio-economic status of client population, and reimbursement issues. Various strategies were mentioned for promoting telehealth utilization, from client empowerment, provider training to improved organizational readiness. For successful telehealth use during and after COVID-19, it is necessary to continue efforts to promote telehealth and remove barriers to telehealth by implementing inclusive multi-level strategies for non-technologically savvy or disadvantaged populations living with HIV.

Criminalization of Sexual and Gender Minorities and Its Consequences for the HIV Epidemic in Zambia: A Critical Review and Recommendations.

ABSTRACT: To elaborate the negative impacts of sexual and gender minority (SGM)-related legislation for the HIV epidemic in Zambia, we reviewed Zambian legislation that restricts the rights of SGM people and synthesized its consequences. We retrieved legal documents through the National Assembly of Zambia and the Zambia Legal Information Institute and conducted a critical review based on four academic databases following thematic synthesis methodology. Eighteen literature records and six Zambian laws were included in the review. Existing laws criminalize same-sex sexual behavior and restrict same-sex marriage and the adoption of children. Anti-SGM legislation has limited legal protections for SGM people and increased vulnerability of criminal prosecution and HIV exposure, persistent stigma/discrimination, insufficient public health resources, and lessened access to HIV-related services. We recommend enacting legal protections for SGM people, decriminalizing anti-SGM laws, rectifying misinformation to destigmatize SGM people, targeting health care for SGM people, and including SGM people in the national HIV strategy.

Time-Varying Insomnia Symptoms and Incidence of Cognitive Impairment and Dementia among Older US Adults.

There is conflicting evidence regarding the association between insomnia and the onset of mild cognitive impairment (MCI) or dementia. This study aimed to evaluate if time-varying insomnia is associated with the development of MCI and dementia. Data from the Health and Retirement Study (n = 13,833) from 2002 to 2014 were used (59.4% female). The Brief Insomnia Questionnaire was used to identify insomnia symptoms which were compiled in an insomnia severity index, ranging from 0 to 4. In analysis, participants' symptoms could vary from wave-to-wave. Dementia was defined using results from the Health and Retirement Study (HRS) global cognitive assessment tool. Respondents were classified as either having dementia, MCI, or being cognitively healthy. Cox proportional hazards models with time-dependent exposure using the counting process (start-stop time) were used for analysis. For each one-unit increase in the insomnia symptom index, there was a 5-percent greater hazard of MCI (HR = 1.05; 95% CI: 1.04-1.06) and dementia (HR = 1.05; 95% CI: 1.03-1.05), after fully adjusting. Using a nationally representative sample of adults age 51 and older, this study found that time-varying insomnia symptoms are associated with risk of MCI and dementia. This highlights the importance of identifying sleep disturbances and their change over time as potentially important risk factors for MCI and dementia.

Who Wants to Switch? Gauging Patient Interest in Novel Antiretroviral Therapies.

Study participants were asked about their interest in switching to novel drug delivery systems that reduce the dosing frequency of antiretroviral regimens. Across a diverse, treatment-experienced cohort, we describe greatest interest in switching to an oral regimen taken once weekly, followed by injections taken every other month and twice-annual implants.

A Mixed Methods Approach to Understanding Antiretroviral Treatment Preferences: What Do Patients Really Want?

As the number of effective antiretroviral therapy (ART) options increases, there is greater opportunity to involve HIV patients in ART selection. To establish the parameters for a shared ART decision-making process, we sought to identify ART characteristics that are important to patients and understand considerations in ART selection from both patient and provider perspectives. Using a mixed-methods approach, 16 patients and 12 healthcare providers were interviewed, and ranking tasks were conducted with 26 patients to identify ART characteristics that are relevant for shared decision making. Interviews were coded using direct content analysis and complemented by a quantitative analysis of references to specific attributes. Ranking data were analyzed through count analysis. Qualitative analysis of patient interviews identified four major categories of ART characteristics that are pertinent to shared decision making: side effects (14/16 patients), administration characteristics (14/16 patients), dosing (13/16 patients), and long-term effects (12/16 patients). Other considerations included expectations for patient involvement in ART decision making, relationship with provider, and efficacy. The degree of concordance between patients and providers differed across categories. Ranking exercises demonstrated differences in the ways providers and patients prioritize specific side effects and food requirements. Expectations for patient involvement in the selection process also varied greatly among and between patients and providers. We identify specific attributes of ART that are decision-relevant to patients and providers, describe heterogeneity of their relative importance, and note variable perceptions of shared decision making. Individualizing ART will require greater investment in understanding an individual patient's preferences, including her/his desire to participate in shared decision making.