Impact of social determinants of health on time to antiretroviral therapy initiation and HIV viral undetectability for migrants enrolled in a multidisciplinary HIV clinic with rapid, free, and onsite B/F/TAF: 'The ASAP study'.

OBJECTIVE: Multidisciplinary care with free, rapid, and on-site bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) dispensation may improve health outcomes among migrants living with HIV. However, models for rapid B/F/TAF initiation are not well studied among migrants living with HIV, and an understanding of how social determinants of health (SDH) may affect HIV-related health outcomes for migrants enrolled in such care models is limited. METHODS: Within a 96-week pilot feasibility prospective cohort study at a multidisciplinary HIV clinic, participants received free B/F/TAF rapidly after care linkage. The effects of SDH (i.e., birth region, sexual orientation, living status, education, employment, French proficiency, health coverage, use of a public health facility outside our clinic for free blood tests, and time in Canada) and other covariates (i.e., age, sex) on median time to antiretroviral therapy (ART) initiation and HIV viral undetectability from care linkage were calculated via survival analyses. RESULTS: Thirty-five migrants were enrolled in this study. Median time to ART initiation and HIV undetectability was 5 days (range 0-50) and 57 days (range 5-365), respectively. Those who took significantly longer to initiate ART were aged <35 years, identified as heterosexual, had less than university-level education, or were unemployed. No factor was found to significantly affect time to undetectability. CONCLUSION: Despite the provision of free B/F/TAF, several SDH were linked to delays in ART initiation. However, once initiated and engaged, migrants living with HIV reached HIV undetectability efficiently. Findings provide preliminary support for adopting this care model with migrants living with HIV and suggest that SDH should be considered when designing clinical interventions for more equitable outcomes.

People with HIV at the end-of-life and their next-of-kin/loved ones are willing to participate in interventional HIV cure-related research.

INTRODUCTION: The Last Gift study at the University of California San Diego (UCSD), United States enrolls terminally ill people with HIV (PWH) in HIV cure research. METHODS: From 2017 to 2022, we conducted surveys with Last Gift participants and their next-of-kin/loved ones to evaluate willingness to participate in different types of HIV cure research at the end of life (EOL). We analyzed willingness data descriptively. RESULTS: We surveyed 17 Last Gift participants and 17 next-of-kin/loved ones. More than half of Last Gift participants ( n  = 10; 58.8%) expressed willingness to participate in studies involving totally new treatments or approaches ('first-in-human' studies), a combination of different approaches, the use of unique antibodies, proteins or molecules, or therapeutic vaccines. Under one-quarter of Last Gift participants ( n  = 4; 23.5%) expressed willingness to participate in research involving interventions that may shorten their life expectancy to benefit medical research. Most Last Gift participants and their next-of-kin/loved ones also expressed high acceptance for various types of donations and biopsies at the EOL (e.g. hair donations and skin, lymph node or gut biopsies). DISCUSSION: Knowing whether people would be willing to participate in different types of EOL HIV cure research can help inform the design of future innovative studies. As a research community, we have a duty to design studies with adequate safeguards to preserve the public trust in research and honor PWH's important gift to humanity.

Perceived risks and benefits of enrolling people with HIV at the end of life in cure research in Southern California, United States.

Introduction: Although current antiretroviral therapy allows most people with HIV (PWH) to experience normal longevity with a good quality of life, an HIV cure remains elusive due to HIV reservoir formation within deep tissues. An HIV cure remains highly desirable to the community of PWH. This study reports on the perceived risks and benefits of participation in the Last Gift study, a study aimed at characterizing HIV reservoirs via post-mortem autopsy, among PWH at the end of life (EOL) and their next-of-kin (NOK)/loved ones. Methods: Last Gift participants (PWH with a terminal illness and/or near the end of life) and their NOK/loved ones were surveyed for perceptions of risks, benefits, and meaning for participation in the Last Gift study. Results: The average age of the 17 Last Gift participants was 66.6 years, 3 were females, 1 person identified as Hispanic, and 15 as Caucasian. The average age of the 17 NOK/loved ones was 56.7 years, and relationships to Last Gift participants included partner/spouse, sibling, friend, child, parent, grandparent, and nephew. The only perceived personal risk of the Last Gift among participants was the blood draws (3/17). NOK/loved ones perceived the following risks: blood draws (2/17), physical pain (3/17), worry that something bad will happen (2/17), and unpleasant side effects (1/17). Participants in Last Gift and NOK/loved ones indicated the study had various positive social effects. For both participants and NOK/loved ones, the most frequent perceived personal benefit of the Last Gift was the satisfaction of supporting HIV cure research. Discussion: Participants perceived minimal personal and societal risks and valued the altruistic benefits of participating in the Last Gift study. Last Gift participants and NOK/loved ones were cautious about possible personal risks of EOL HIV cure research but still viewed that the emotional, psychological and societal benefits of participation outweighed potential risks.

Experiences of Migrant People Living with HIV in a Multidisciplinary HIV Care Setting with Rapid B/F/TAF Initiation and Cost-Covered Treatment: The 'ASAP' Study.

This study aimed to explore the experiences of migrant people living with HIV (MLWH) enrolled in a Montreal-based multidisciplinary HIV care clinic with rapid antiretroviral treatment (ART) initiation and cost-covered ART. Between February 2020 and March 2022, 32 interviews were conducted with 16 MLWH at three time-points (16 after 1 week of ART initiation, 8 after 24 weeks, 8 after 48 weeks). Interviews were analyzed via the Framework Method. Thirty categories were identified, capturing experiences across the HIV care cascade. At diagnosis, most MLWH described "initially experiencing distress". At linkage, almost all MLWH discussed "navigating the health system with difficulty". At treatment initiation, almost all MLWH expressed "being satisfied with treatment", particularly due to a lack of side effects. Regarding care retention, all MLWH noted "facing psychosocial or health-related challenges beyond HIV". Regarding ART adherence, most MLWH expressed "being satisfied with treatment" with emphasis on their taking control of HIV. At viral suppression, MLWH mentioned "finding more peace of mind since becoming undetectable". Regarding their perceived health-related quality of life, most MLWH indicated "being helped by a supportive social network". Efficient, humanizing, and holistic approaches to care in a multidisciplinary setting, coupled with rapid and free ART initiation, seemed to help alleviate patients' concerns, address their bio-psycho-social challenges, encourage their initial and sustained engagement with HIV care and treatment, and ultimately contribute to positive experiences.

Brief Report: It's Time to Embed Health-Related Quality of Life Across all Steps of the HIV Care Cascade.

BACKGROUND: Calls for stakeholders across the global HIV landscape to widely and systematically adopt person-centered care and patient-oriented research approaches have been made by HIV scholars, clinicians, patients, and groups such as the Joint United Nations Programme on HIV/AIDS (UNAIDS). Such calls implicitly acknowledge that the end goal of HIV care, research, and advocacy goes beyond HIV viral suppression or undetectability toward ensuring optimal health-related quality of life (HrQoL) for people living with HIV (PLWH). Indeed, global efforts have focused on keeping people alive yet have failed to ensure that they feel alive. APPROACH: In this brief report, we highlight the progress that has been made toward evolving the HIV care cascade to better represent actual experiences of PLWH, especially those that are most vulnerable and marginalized. We then describe what person-centered care, patient-oriented research, and HrQoL are and why they are important for our current context in HIV. We conclude by sharing 2 propositions for the global HIV community to consider moving forward. CONCLUSIONS: HIV care must not only focus on viral suppression but also better recognize the intersecting and multifaceted challenges faced by PLWH when taking HIV treatment and engaging in care. Evaluating HrQoL at each step of the cascade using validated patient-reported outcome and experience measures would assist in systematically tracking and addressing challenges faced by PLWH. Measures chosen through global consensus may facilitate rigorous comparisons across jurisdictions. Adopting a patient-oriented research paradigm will also be crucial for empowering and meaningfully engaging patients throughout the research process.

Videogame exposure positively associates with selective attention in a cross-sectional sample of young children.

There is growing interest in how exposure to videogames is associated with young children's development. While videogames may displace time from developmentally important activities and have been related to lower reading skills, work in older children and adolescents has suggested that experience with attention-demanding/fast-reaction games positively associates with attention and visuomotor skills. In the current study, we assessed 154 children aged 4-7 years (77 male; mean age 5.38) whose parents reported average daily weekday recreational videogame time, including information about which videogames were played. We investigated associations between videogame exposure and children's sustained, selective, and executive attention skills. We found that videogame time was significantly positively associated only with selective attention. Longitudinal studies are needed to elucidate the directional association between time spent playing recreational videogames and attention skills.

Barriers and Facilitators Affecting the HIV Care Cascade for Migrant People Living with HIV in Organization for Economic Co-Operation and Development Countries: A Systematic Mixed Studies Review.

Migrants in countries affiliated with the Organization for Economic Co-operation and Development (OECD) have a higher risk of acquiring HIV, experience delayed HIV diagnosis, and have variable levels of engagement with HIV care and treatment when compared to native-born populations. A systematic mixed studies review was conducted to generate a multilevel understanding of the barriers and facilitators affecting HIV Care Cascade steps for migrant people living with HIV (MLWH) in OECD countries. Medline, Embase, Scopus, CINAHL, and the Cochrane Library were searched on March 25, 2020. Screening, critical appraisal, and analysis were conducted independently by two authors. We used qualitative content analysis and the five-level Socio-Ecological Model (i.e., individual, interpersonal, organizational, community, and policy) to categorize barriers and facilitators. Fifty-nine studies from 17 OECD countries were included. MLWH faced similar barriers and facilitators regardless of their host country, ethnic and geographic origins, or legal status. Most barriers and facilitators were associated with the individual and organizational levels and centered around retention in HIV care and treatment. Adapting clinical environments to better address MLWH's competing needs via multidisciplinary models would address retention issues across OECD countries.

Evaluating Usability in Blended Learning Programs Within Health Professions Education: a Scoping Review.

Knowledge was mapped about how usability has been applied in the evaluation of blended learning programs within health professions education. Across 80 studies, usability was explicitly mentioned once but always indirectly evaluated. A conceptual framework was developed, providing a foundation for future instruments to evaluate usability in this context. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01295-x.

The next three epochs: Health system challenges amidst and beyond the COVID-19 era.

The COVID-19 pandemic has brought to light tremendous gaps and issues faced by health systems globally. Commendable effort has been made to retain continuity of care for non-COVID-19 patients amidst the pandemic, particularly using technology-enhanced models of care. However, these efforts are not sufficient to tackle the impending challenges that health systems around the world will face next: (1) vaccine uptake and hesitancy; (2) a mental health crisis; and (3) post-COVID-19 migration. In this letter to the editor, explanation of why each of these issues is concerning and how each subsequent issue grows in severity is provided. Particular focus on the issue of post-COVID-19 migration is made, as this challenge is quite pressing to health systems but has yet to be explored thoroughly in the literature. Possible strategies for health system planners to consider are provided in this letter. Strategies include involving stakeholders such as patients and clinicians in deliberations and deployment of interventions, focussing efforts on adapting primary health systems, and building on technology-enhanced models of care where possible. By adhering to the recommendations made in this letter, health systems may be able to proactively deal with the identified challenges before they become crises of their own, post COVID-19.

Acceptability of a Patient Portal (Opal) in HIV Clinical Care: A Feasibility Study.

Opal (opalmedapps.com), a patient portal in use at the Cedars Cancer Centre of the McGill University Health Centre (MUHC) (Montreal, Canada), gives cancer patients access to their medical records, collects information on patient-reported outcome measures (PROMs), and has demonstrated patient satisfaction with care. This feasibility study aims to evaluate Opal's potential acceptability in the context of HIV care. People living with HIV (PLWH) and their healthcare providers (HCPs) completed cross-sectional surveys from August 2019 to February 2020 at large HIV centers, including the Chronic Viral Illness Service of the MUHC, and other HIV clinical sites in Montreal and Paris, France. This study comprised 114 PLWH (mean age 48 years old, SD = 12.4), including 74% men, 24% women, and 2% transgender or other; and 31 HCPs (mean age 46.5 years old, SD = 11.4), including 32% men, 65% women, and 3% other. Ownership of smartphones and tablets was high (93% PLWH, 96% HCPs), and participants were willing to use Opal (74% PLWH, 68% HCPs). Participants were interested in most Opal functions and PROMs, particularly PROMs capturing quality of life (89% PLWH, 77% HCPs), experience of healthcare (86% PLWH, 97% HCPs), and HIV self-management (92% PLWH, 97% HCPs). This study suggests Opal has high acceptability and potential usefulness as perceived by PLWH and HCPs.

Correlates of explicit and implicit stigmatizing attitudes of Canadian undergraduate university students toward mental illness: A cross-sectional study.

OBJECTIVE: To assess explicit and implicit attitudes toward mental illness of undergraduate students and explore associated variables. Participants: Year 1-4 undergraduate students from a large Canadian university (n = 382). Methods: Participants completed demographics, the Opening Minds Scale for Healthcare Providers, and an Implicit Association Test. Two-tailed independent and paired-samples t-tests, and ANOVA were performed with significance level at p < .05. Results: About 67.5% self-reported having experienced a mental illness and 31.2% had been diagnosed. Lower explicit stigma was associated with females, those with a history of mental illness diagnosis, and those who have had a close relationship with someone experiencing a mental illness. Faculty of Social Sciences students had significantly lower explicit stigma scores than Faculty of Engineering students. Implicit stigma did not show significant associations with any factors. Conclusions: A high proportion of undergraduate students experience mental illness. Increased exposure and experience were associated with reduced explicit stigma.

Barriers and facilitators associated with steps of the HIV care cascade for migrants in OECD countries: a systematic mixed studies review protocol.

INTRODUCTION: In 2019, the United Nations signalled a substantial rise in the number of international migrants, up to 272 million globally, about half of which move to only 10 countries, including 8 member nations of the Organization for Economic Co-operation and Development (OECD). Migrants in OECD countries are often at higher risk for acquiring HIV and have a higher frequency of delayed HIV diagnosis. The barriers and facilitators that migrant people living with HIV (PLWH) in OECD countries face in relation to HIV care are insufficiently understood. The five-step HIV Care Cascade Continuum (HCCC) is an effective model to identify gaps, barriers and facilitators associated with HIV care. The purpose of this study is to generate a comprehensive, multilevel understanding of barriers and facilitators regarding the five steps of the HCCC model in OECD countries by migration status. METHODS AND ANALYSIS: A systematic mixed studies review using a data-based convergent design will be conducted. Medline, Embase, Scopus, CINAHL and the Cochrane Library will be searched on 25 March 2020. Screening and critical appraisal will be conducted independently by the first author. Authors 3-5 will act as second reviewers, each independently conducting 33% of the screening and appraisal. Quantitative data will be transformed to qualitative data and be synthesised using thematic analysis. The Mixed Methods Appraisal Tool will be used for quality assessment. An advisory committee, composed of four migrant PLWH, will be involved in screening and appraising 5% of articles to build knowledge and experience with systematic reviews. They will also be involved in analysis and dissemination. ETHICS AND DISSEMINATION: Ethics approval was obtained from the McGill University Health Centre (15-188-MUHC, 2016-1697, eReviews 4688). Publications arising from this study will be open-access. PROSPERO REGISTRATION NUMBER: CRD42020172122.

Correction to: The Potential Effect of the Psychiatric Clerkship and Contact-Based Hypothesis on Explicit and Implicit Stigmatizing Attitudes of Canadian Medical Students Towards Mental Illness.

The authors would like to correct the footnote of Table 2.

The Potential Effect of the Psychiatric Clerkship and Contact-Based Hypothesis on Explicit and Implicit Stigmatizing Attitudes of Canadian Medical Students Towards Mental Illness.

OBJECTIVE: The purpose of this study was to assess if having completed a psychiatric clerkship or having increased exposure to mental illness in general was associated with reduced explicit and implicit stigmatizing attitudes towards mental illness in undergraduate medical students. METHODS: A secondary analysis of data specific to medical students from McMaster University was completed. Data were obtained through a cross-sectional survey administered electronically. It consisted of a demographic questionnaire, the Opening Minds Scale for Healthcare Providers (OMS-HC) 12-item survey, and an Implicit Association Test (IAT). The OMS-HC was used as a measure of explicit stigmatizing attitudes, whereas the IAT was used as a measure of implicit bias. All analyses were completed using Stata/IC 15 and were two-tailed with significance defined as p < 0.05. RESULTS: Individuals that self-reported either having had a mental illness or diagnosis by a health care professional had significantly lower levels of explicit stigma. Final-year medical students had significantly lower levels of implicit stigmatizing attitudes than first-year medical students. Neither having completed a psychiatric clerkship nor having a close relationship with someone experiencing a mental illness was significantly associated with the explicit or implicit stigmatizing attitudes of medical students. CONCLUSION: More years in medical school and self-identifying or receiving a diagnosis of mental illness are associated with reduced stigmatizing attitudes, whereas having completed the psychiatric clerkship and having a close relationship with an individual experiencing mental illness were not. This study suggests that the psychiatric clerkship may have limited impact on the stigmatizing attitudes of medical students.

K-RIM (Corneal Rim) Angle Surgery Training Model.

PURPOSE: To develop an angle surgery training model for training an array of microincisional glaucoma surgery (MIGS) procedures. METHODS: We describe a method for preparing an angle surgery training model using human cadaveric corneoscleral rims. The model provides realistic tactile tissue simulation and excellent angle visualization requiring bimanual technique. Corneoscleral rims may be used multiple times and are prepared at low cost, allowing for a high volume of practice surgeries. RESULTS: This model allows for practice in bimanual surgical training using the gonioscopy lens for visualize alongside surgical tools. The in vivo surgical conditions and limited tactile feedback are recreated using human cadaveric eyes which nonhuman models fail to provide. Our model is prepared at low cost, with relative ease and also provides appropriate positioning of Schlemm canal and for high volume of practice as the canal can be used in 90-degree segments. CONCLUSIONS: Few angle surgery training models currently exist and none provide these necessary features. The model presented here aims to meet the growing demand for adequate training models required for technically advanced MIGS techniques.

Mental Health Stigma: Explicit and Implicit Attitudes of Canadian Undergraduate Students, Medical School Students, and Psychiatrists.

OBJECTIVES: To compare explicit and implicit stigmatizing attitudes towards mental illness among undergraduate students, medical school students, and psychiatrists, and to assess whether attitudes are associated with education level, exposure to, and personal experience with mental illness. METHODS: Participants from McMaster University were recruited through email. Participants completed a web-based survey consisting of demographics; the Opening Minds Scale for Healthcare Providers (OMS-HC) 12-item survey, which measures explicit stigma; and an Implicit Association Test (IAT), measuring implicit bias toward physical illness (diabetes mellitus) or mental illness (schizophrenia). RESULTS: A total of 538 people participated: undergraduate students ( n = 382), medical school students ( n = 118), and psychiatrists ( n = 38). Psychiatrists had significantly lower explicit and implicit stigma than undergraduate students and medical school students. Having been diagnosed with mental illness or having had a relationship with someone experiencing one was significantly associated with lower explicit stigma. Mean scores on the OMS-HC "disclosure/help-seeking" subscale were higher compared with the "attitudes towards people with mental illness" subscale. There was no correlation between the OMS-HC and IAT. CONCLUSIONS: These findings support the theory that increased education and experience with mental illness are associated with reduced stigma. Attitudes regarding disclosure/help-seeking were more stigmatizing than attitudes towards people with mental illness. The groups identified in this study can potentially benefit from anti-stigma campaigns that focus on reducing specific components of explicit, implicit, public and self-stigma.

Cadaver corneoscleral model for angle surgery training.

PURPOSE: To assess a new training model (Tackdriver) for new-generation microinvasive glaucoma surgeries (MIGS). SETTING: Resident training centers in Canada. DESIGN: Evaluation of technology. METHODS: Human cadaver corneoscleral rims recovered after Descemet-stripping endothelial keratoplasty or not suitable for transplantation were acquired from an eye bank. The tissue was fixated with a single tack through the center of the cornea, which was inverted in a concave fashion. A water-based medical lubricant was used for placement of a goniolens after visualization of the anterior chamber and the trabecular meshwork. Microbypass stent (iStent) insertion and gonioscopy-assisted transluminal trabeculotomy (GATT) were practiced on this model. The model was qualitatively assessed for ease of preparation, accuracy of surgical simulation, and the number and variety of MIGS procedures that can be performed. RESULTS: Efficient high-volume training was performed for microbypass stent insertion using first-generation and second-generation microbypass stents. The GATT procedure was also performed as a final step in a titratable fashion in 90-, 180-, or 270-degree segments or a complete 360-degree treatment. The model simulated bimanual angle surgery with good fidelity. CONCLUSIONS: The training model allowed for high-volume bimanual MIGS training for techniques such as microbypass stent insertion and removal as well as GATT. Preparation was relatively simple, efficient, and cost-effective compared with other models. Inverting the specimen allowed the trainee to practice MIGS techniques independent of the tissue's corneal clarity. Other MIGS techniques and angle training procedures can be adopted to this model.