Program Director Reports of COVID-19 Lockdown-Driven Service Changes in Community-Based STI Clinics and Syringe Services Programs in the Southeastern U.S.

The COVID-19 pandemic strained the U.S. health care system, posing logistical challenges for community-based programs. This study surveyed 11 program directors in sexually transmitted infection (STI) clinics and syringe services programs (SSPs) that served people who use substances and are at risk for HIV in five southeastern U.S. states. Brief survey questions asked about programs' use of in-person and telehealth services. Results indicated widespread reduction of in-person services and concomitant adoption of telehealth services. In STI clinics, telehealth replaced in-person visits for all but urgent treatment of active symptoms. In SSPs, in-person contact continued or increased from pre-pandemic volumes. In both programs, the most salient telehealth use barrier was limited device or internet access and limited technological ease. Services were sustained through innovative adaptations. This snapshot of response to the early COVID-19 lockdown phase offers actionable guidance about service preparedness for future public health catastrophes in community-based programs serving vulnerable populations.

PrEP for people who use opioids: A NIDA clinical trials network survey study in Southern U.S. cities where HIV incidence is high.

BACKGROUND: People who use opioids (PWUO) are at increased risk for HIV. Pre-exposure prophylaxis (PrEP) is effective but underutilized as HIV prevention among PWUO. This study examined predictors of willingness to take daily oral PrEP and long-acting injectable (LAI) PrEP among PWUO across eight Southern urban cities with high HIV incidence. METHODS: HIV-negative PWUO (N = 308) seeking services in community-based programs participated in this cross-sectional survey study. Measures included demographics, sexual risk behavior, substance use frequency, and awareness of and willingness to take oral and injectable PrEP. Data were analyzed using mixed-effects models. RESULTS: Willingness to take daily oral and LAI PrEP was moderately high (69.16% and 62.02%, respectively). Half had heard of PrEP, but only 4% had ever taken it. Only education and condomless vaginal sex predicted willingness to take oral PrEP. Only education predicted willingness to take LAI PrEP. Polysubstance use was prevalent, with substantial proportions of PWUO reporting frequent use of injection drugs (opioids or stimulants, 79.5%), non-injection opioids (73.3%), non-injection stimulants (71.1%), cannabis (62.6%), and hazardous drinking (29.6%). About 20% reported past-year condomless anal sex, and one-third reported past-year condomless vaginal sex. CONCLUSIONS: PWUO in this study were amenable to PrEP, particularly in light of education and condomless vaginal sex. Careful consideration for matching PrEP messaging to the PWUO audience is needed. PrEP promotion should expand beyond men who have sex with men to include groups such as these predominantly heterosexual, polysubstance-using PWUO with HIV risk who were open to both formulations of PrEP.

Dosage of booster phone calls following an SBIRT intervention in the emergency department for reducing substance use.

Brief Interventions (BIs) for problematic drug use in general medical settings, including in Emergency Departments (EDs), have shown disappointing results compared to those that target problematic alcohol use. Telephone booster calls may augment the impact of a BI delivered in the ED. The current study uses data from the National Drug Abuse Treatment Clinical Trials Network (CTN) Protocol 0047, "Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED)", a multisite randomized clinical trial conducted in six EDs in the U.S. We examine dose effects of telephone boosters (0, 1, or 2 calls completed) with non-treatment seeking patients who we randomized to the BI-Booster condition and who endorsed problematic drug use during their ED visit (N = 427). We assessed primary outcomes at 3-, 6-, and 12-month follow-ups, which included past month use of the primary drug of choice, use of any drug, and heavy drinking. There were no significant differences among those completing 0, 1, or 2 booster calls on any of the three main outcomes at 3-, 6-, and 12-months post-BI in the ED. Patients who were older were significantly more likely to complete booster calls. Taken together, these findings raise questions about the clinical utility of booster phone calls following screening and BIs targeting heterogeneous drug use in the ED.

Disparities by age in depressive symptoms and substance use among men who have sex with men living with HIV.

The aim of this study was to assess the association between age, depressive symptoms, and substance use among men who have sex with men (MSM) living with HIV. Baseline data were obtained from 337 MSM living with HIV. Linear and logistic regression models were used to determine the association between age and depressive symptoms and substance use. MSM aged 35-49 had higher depressive symptoms than MSM 50 and older (B = 3.53; 95% CI: 0.33, 6.72); MSM aged 25-34 and MSM 35-49 had higher substance use than MSM 50 and older (B = 2.66; 95% CI: 0.77, 4.54; and B = 1.68; 95% CI: 0.22, 3.14, respectively). MSM aged 35-49 were more likely to be at risk for clinical depression than MSM 50 and older (OR = 1.84; 95% CI: 1.06, 3.22); MSM aged 18-24 and MSM 35-49 were less likely and more likely to have substance abuse than MSM 50 and older (OR = 0.29; 95% CI: 0.09, 0.91; and OR = 1.83; 95% CI: 1.02, 3.29, respectively). Interventions addressing depressive symptoms and substance use tailored to individuals in different age groups should account for varying needs at different stages of life.

Effects of a Decision-Making Intervention to Help Decide Whether to Disclose HIV-Positive Status to Family Members on Well-Being and Sexual Behavior.

An HIV diagnosis is often followed by uncertainty, questions over next steps, and concerns over how to share the diagnosis with others. The goal of the current study was to investigate the effects of an intervention designed to help people living with HIV decide whether or not they want to disclose their status to family members (i.e., decision-making process rather than actual disclosure) and the subsequent decision on their well-being and sexual behavior. Additionally, differences in outcomes among men who have sex with men (MSM), heterosexual men (HSM), and women were examined. A total of 346 women and men living in the Southeastern part of the United States. Participated in the study, which consisted of a baseline assessment, followed by randomization into either the disclosure intervention or attention control case management group. Both treatments consisted of seven sessions over a 12-month period. Results from repeated measures ANOVA indicated that although there was no significant intervention effect, participants in both groups reported some improvements in well-being and decreases in risky sexual behavior. However, no consistent differences in outcomes emerged among MSM, HSM, and women. Assisting with the disclosure decision-making process and reducing HIV transmission risk should continue to be an essential focus in future research endeavors and for frontline professionals dedicated to HIV-related care and prevention.

Ways of coping and perceived HIV-related stigma among people living with HIV: moderation by sex and sexual orientation.

Perceived HIV-related stigma continues to persist among people living with HIV and coping strategies are crucial to overall health. Coping may be associated with perceived HIV-related stigma. However, research examining differences by sex and sexual orientation is lacking. Therefore, the aims of the study were to assess the association between ways of coping and perceived HIV-related stigma, and to examine the relationship by sex and sexual orientation. Data were obtained from 346 individuals (191 men and 155 women) living with HIV. Multiple linear regression models showed that overall, distancing, and attack/escape avoidance coping were positively associated with perceived HIV-related stigma among the overall population, among men who have sex with men (MSM), and among women overall and heterosexual women. Among men overall, distancing and attack/escape avoidance coping were positively associated with perceived HIV-related stigma. Among women who have sex with women (WSW), attack/escape avoidance coping was positively associated with perceived HIV-related stigma. Effect sizes indicated small effects for overall coping and medium to large effects for distancing and attack/escape avoidance coping. Interventions focused on reducing perceived HIV-related stigma among populations living with HIV should address distancing and attack/escape avoidance strategies especially among women, regardless of sexual orientation, and MSM.

Ways of coping and HIV disclosure among people living with HIV: mediation of decision self-efficacy and moderation by sex.

Individuals living with HIV/AIDS face several stressors and use varying strategies to cope. Disclosure (or nondisclosure) of HIV serostatus is an important consideration among individuals living with HIV. However, studies examining the association between coping and HIV disclosure are lacking, and more research examining potential mediators and moderators is needed. The transactional model of stress and coping and the theory of planned behavior may help in understanding the mediating relationship between coping, decision self-efficacy, and HIV disclosure. Therefore, the aims of this study were to examine the association between coping and HIV disclosure to sexual partners, assess the mediating role of decision self-efficacy, and examine moderation by sex. Baseline data from 262 individuals living with HIV who participated in a disclosure intervention were used for analysis. Descriptive statistics were used to assess sociodemographic characteristics. Principal component analysis was used to operationalize coping. Path analysis was then used to determine the mediating role of decision self-efficacy in the association between overall, adaptive, distancing, and attack/escape avoidance coping and HIV disclosure to sexual partners. After adjusting for age and time since diagnosis, direct associations between coping and decision self-efficacy, and decision self-efficacy and disclosure behavior varied by sex. Among the overall study population, decision self-efficacy mediated the associations between adaptive coping (ß = 0.064, p = 0.003), attack/escape avoidance coping (ß = -0.052, p = 0.009) and disclosure behavior. Disclosure intervention programs geared towards populations living with HIV should include decision self-efficacy and adaptive coping, and attenuate attack/escape avoidance coping.

Decision Readiness to Disclose Human Immunodeficiency Virus-positive Status to Family Members.

BACKGROUND: People living with human immunodeficiency virus (HIV) (PLWH) are faced with the often difficult decision of whether, when, and how to disclose their seropositive status. This study draws on the transtheoretical model of change to examine men and women's decision readiness to disclose their HIV-positive status to family members and to assess predictors (decisional balance and decision self-efficacy) of their decision readiness. METHODS: Cross-sectional data were collected from 346 PLWH-191 males and 155 females. Participants self-reported on their disclosure decision readiness, decisional balance, and decision self-efficacy. Data were analyzed using χ tests, general linear models, and multinomial logistic regression models. RESULTS: Two thirds of PLWH were in the 3 lower stages of decision readiness, with the majority starting to think about disclosure. One third of PLWH were in the 3 higher stages of decision readiness (close to deciding or have made the decision to disclose). Decisional balance and decision self-efficacy predicted decision readiness. Overall, few gender differences emerged. CONCLUSIONS: These findings can help researchers, clinicians, and health care providers to better understand and support PLWH as they move through the decision making process.

Mediating Effects of Depressive Symptoms on Perceived Social Support and HIV Disclosure: Assessing Moderation by Sex.

People living with HIV may decide to disclose their HIV-positive status after considering the benefits and costs. Studies have shown associations between perceived social support, depressive symptoms and HIV disclosure among men and women; however, research assessing the mediating pathway among these variables and the associated disparities by sex are lacking. Therefore, the aims of this study were to determine the association between perceived social support from family and friends and HIV disclosure to sexual partners; assess the mediating effects of depressive symptoms; and examine the disparities by sex. Participants included 147 men and 115 women living with HIV who took part in a disclosure intervention study. Mediation analyses were conducted to determine the direct and indirect associations between perceived social support from family and friends, depressive symptoms, and disclosure behavior. Depressive symptoms mediated the association between perceived social support (from family: ß = 0.103, p = 0.019; and from friends: ß = 0.111, p = 0.009) and HIV disclosure to sexual partners, specifically among women. However, these pathways were not statistically significant among men. Women living with HIV may benefit from two types of interventions: (1) Disclosure to sexual partners interventions, which aim to accentuate perceived social support from family and friends through attenuating depressive symptoms; and (2) Social support interventions, which may increase disclosure to sexual partners via reducing depressive symptoms.

Age and racial disparities in substance use and self-reported viral suppression among men who have sex with men with HIV.

HIV disproportionately affects men who have sex with men (MSM). Substance use is common among people living with HIV and may affect antiretroviral therapy adherence. Nevertheless, research examining the association between substance use and viral suppression is lacking. The aims of this study were to determine the association between substance use and self-reported viral suppression, and by age and race among MSM living with HIV. Data were obtained from 309 HIV-positive MSM. Logistic regression was used to determine the association between substance use and self-reported viral suppression at baseline, and by age and race. Approximately 67% of participants reported they were virally suppressed. After adjusting for sociodemographics, every increase in substance use score was associated with a 7% decrease in the odds of reporting viral suppression (odds ratio [OR]: 0.93; 95% confidence interval [CI]: 0.89-0.98; p = 0.003). The negative association between substance use and self-reported viral suppression remained statistically significant among MSM aged 25-34 years (OR = 0.89; 95% CI: 0.79-1.00; p = 0.041) and statistically significant for Black MSM (OR = 0.92; 95% CI: 0.86-0.98; p = 0.009). Intervention programs for MSM living with HIV aimed at improving viral suppression should address substance use and consider the differences by age and race.

Relationship between serostatus disclosure and categories of HIV transmission risk in men who have sex with men living with HIV.

In prior studies, the relationship between serostatus disclosure and reduced HIV transmission risk has been mixed. The demonstration of a clear connection may be restricted by three main methodological limitations. This study evaluates the relationship between (1) more refined measures of serostatus disclosure and (2) eight categories of HIV transmission risk (lowest to highest risk) among men who have sex with men (MSM) living with HIV, while (3) considering a number of control variables. Results demonstrate that disclosure is more likely in sexual encounters involving no intercourse or involving protected and unprotected anal intercourse with HIV-positive partners than unprotected insertive anal intercourse with HIV-negative/unknown status partners. Additionally, substance use prior to sexual encounters is less likely in lower risk categories than the highest risk category. Results of this study are important to the design of future studies, prevention, and intervention programs for MSM and to the methods used to evaluate their effectiveness.

Assessment of HIV disclosure and sexual behavior among Black men who have sex with men following a randomized controlled intervention.

Disclosure is important in human immunodeficiency virus (HIV) transmission risk reduction. This randomized controlled intervention assessed changes in and predictors of disclosure and risky sexual behavior among Black men who have sex with men (BMSM) living with HIV in the U.S. BMSM were randomly assigned to either the disclosure intervention or attention control case management group. Predictors of three disclosure types (behavior, beliefs, intentions) and condomless anal intercourse (CAI) included disclosure consequences (rewards and costs), disclosure readiness, and safer sex readiness. Mixed-effect results showed no differences between the groups in any of the outcomes; although disclosure behavior increased over time. Relationships were found between readiness to change and CAI; disclosure consequences and different disclosure types; and disclosure behavior and receptive CAI. When working with BMSM living with HIV, practitioners and prevention specialists should consider the importance of disclosure pertaining to receptive CAI and factors that support overall disclosure and safer sex.

Evaluation of HIV Disclosure Behavior Following a Randomized Controlled Disclosure Intervention for Men Who Have Sex with Men Living with HIV.

Preventing the transmission of HIV, especially among high-risk populations, is a U.S. public health priority. Interventions aimed at easing the burden of HIV disclosure to casual sexual partners among men who have sex with men (MSM) living with HIV are essential in this endeavor. This randomized controlled study evaluated differences in disclosure behavior between a disclosure intervention (DI) and attention control case management (ACCM) group for MSM living with HIV (N = 315) and determinants (self-efficacy, outcome expectancy) of disclosure. Mixed-effects models results showed no significant differences in disclosure behavior between the DI and ACCM groups. Further, disclosure behavior changed in a curvilinear manner over 12 months and benefited from a booster session. Both disclosure self-efficacy and outcome expectancy predicted disclosure behavior. Interventions targeting HIV disclosure among MSM living with HIV should focus on improving perceptions of disclosure self-efficacy and outcome expectancy and include a booster session to facilitate HIV disclosure.

Longitudinal Findings on Changes in and the Link Between HIV-Related Communication, Risky Sexual Behavior, and Relationship Status in Men Who Have Sex With Men Living With HIV.

BACKGROUND: Reducing the risk of HIV transmission among men who have sex with men (MSM) is a national health priority. This study longitudinally examined changes in and the link between HIV-related communication, unprotected anal intercourse (UAI), and relationship status among MSM. METHODS: Data were obtained from 337 MSM living with HIV who participated in a randomized controlled study. Approximately equal percentages of men were randomized to either the disclosure intervention group or the attention control case management group. Repeated measures were collected at 5 time points for 12 months and included health-protective sexual communication (HPSC), HIV disclosure, insertive and receptive UAI, and relationship status. Data were analyzed using mixed-effects models. RESULTS: Independent of the treatment condition, HPSC and HIV disclosure increased over time; insertive UAI showed a curvilinear pattern but no significant decrease over time. Relationship status was related to HIV-related communication and UAI. Greater HPSC was related to less insertive and receptive UAI; disclosure was positively related to insertive UAI. CONCLUSIONS: Based on the findings, prevention programs should continue to focus on improving HIV-related communication among MSM and consider relationship status in prevention messages. Intervention studies are needed to continue to identify and test factors that help reduce risky sexual behaviors.

Prevalence of and Factors Related to Tobacco Ban Implementation in Substance Use Disorder Treatment Programs.

This study examined the prevalence of and factors (psychological climate for change and staff attributes) related to indoor and outdoor tobacco bans for patients, employees, and visitors in U.S. substance use disorder treatment programs. Data were collected from a random sample of 1,026 program administrators. Almost all programs banned tobacco use indoors and around one third banned tobacco use outdoors. When there was no tobacco ban, the majority of programs restricted smoking to designated indoor and/or outdoor areas. Further, all psychological climate for change factors (perceived program support, perceived tobacco culture, and tobacco ban beliefs) but none of the staff attributes (percentage licensed/certified clinicians, percentage clinicians with master's degrees, total staff with education in health-related field) were significantly related to the implementation of comprehensive tobacco bans (both indoors and outdoors).

Substance Use Disorder Counselors' Reports of Tobacco Cessation Services Availability, Implementation, and Tobacco-related Knowledge.

PURPOSE: Adolescence is a prime developmental stage for early tobacco cessation (TC) intervention. This study examined substance use disorder counselors' reports of the availability and implementation of TC services (behavioral treatments and pharmacotherapies) in their treatment programs and the relationship between their tobacco-related knowledge and implementation of TC services. METHODS: Survey data were collected in 2012 from 63 counselors working in 22 adolescent-only treatment programs. Measures included 15 TC behavioral treatments, nine TC pharmacotherapies, and three tobacco-related knowledge scales (morbidity/mortality, modalities and effectiveness, pharmacology). RESULTS: First, nine of the 15 behavioral treatments are reported as being available by more than half of counselors; four of the 15 behavioral treatments are used by counselors with more than half of adolescents. Of the nine pharmacotherapies, availability of the nicotine patch is reported by almost 40%, buproprion by nearly 30%, and clonidine by about 21% of counselors. Pharmacotherapies are used by counselors with very few adolescents. Second, counselors' tobacco-related knowledge varies based on the knowledge scale examined. Third, we only find a significant positive relationship between counselors' implementation of TC behavioral treatments and TC modalities and effectiveness knowledge. DISCUSSION: Findings suggest that more behavioral treatments should be made available in substance use disorder treatment programs considering that they are the main treatment recommendation for adolescents. Counselors should be encouraged to routinely use a wide range of available behavioral treatments. Finally, counselors should be encouraged to expand their knowledge of TC modalities and effectiveness because of the relationship with behavioral treatments implementation.

Factors Linked to Substance Use Disorder Counselors' (Non)Implementation Likelihood of Tobacco Cessation 5 A's, Counseling, and Pharmacotherapy.

STUDY BACKGROUND: Despite efforts to promote the use of tobacco cessation services (TCS), implementation extensiveness remains limited. This study investigated three factors (cognitive, behavioral, environmental) identified by social cognitive theory as predictors of substance use disorder counselors' likelihood of use versus non-use of tobacco cessation (TC) 5 A's (ask patients about tobacco use, advise to quit, assess willingness to quit, assist in quitting, arrange for follow-up contact), counseling, and pharmacotherapy with their patients who smoke cigarettes. METHODS: Data were collected in 2010 from 942 counselors working in 257 treatment programs that offered TCS. Cognitive factors included perceived job competence and TC attitudes. Behavioral factors encompassed TC-related skills and general training. External factors consisted of TC financial resource availability and coworker TC attitudes. Data were analyzed using logistic regression models with nested data. RESULTS: Approximately 86% of counselors used the 5 A's, 76% used counseling, and 53% used pharmacotherapy. When counselors had greater TC-related skills and greater general training they were more likely to implement the 5 A's. Implementation of counseling was more likely when counselors had more positive attitudes toward TC treatment, greater general training, greater financial resource availability, and when coworkers had more positive attitudes toward TC treatment. Implementation of pharmacotherapy was more likely when counselors had more positive attitudes toward TC treatment, greater general training, and greater financial resource availability. CONCLUSION: Findings indicate that interventions to promote TCS implementation should consider all three factors simultaneously as suggested by social cognitive theory.

Sustained, new, never, and discontinued tobacco cessation services adopters.

This study examined longitudinal adoption patterns of tobacco cessation (TC) counseling and TC pharmacotherapy in substance use disorder treatment programs and baseline predictors (program characteristics and program culture) of these patterns 12-months later. Telephone survey data were collected in 2010 from 685 randomly sampled program administrators working in geographically representative treatment programs across the U.S. Regarding TC counseling, about 41% of programs never adopt, 33% sustain, and 27% change adoption patterns. Concerning TC pharmacotherapy, about 62% of programs never adopt, 19% sustain, and 18% change adoption patterns. The three most consistent predictors of counseling adoption patterns are TC reimbursement, TC financial resource availability, and smoking culture. For TC pharmacotherapy adoption patterns, the most consistent predictors include profit status, TC reimbursement, level of care, TC financial resource availability, and smoking culture. Findings provide insights into program characteristics and program culture as both potential barriers and facilitators of longitudinal TCS adoption.

Relationship between Low-Income Patient Census and Substance Use Disorder Treatment Programs' Availability of Tobacco Cessation Services.

Low income adults with substance use disorders (SUDs) have a high prevalence of tobacco use and often limited access to tobacco cessation treatment. This study examines the relationship between low-income SUD patient census (i.e., percentage of patients whose treatment costs are covered by Medicaid and Federal block grants) and SUD programs' availability of three evidence-based tobacco cessation services: behavioral treatments, system-level support, and pharmacotherapy. Data were collected from a random sample of 1,006 program administrators in 2010. Mixed-effects models results show that the percentage of low-income patients is significantly positively associated with the availability of behavioral treatments and system-level support but not pharmacotherapy. Thus, low-income patients may have similar access to tobacco cessation pharmacotherapy but greater access to behavioral treatments and system-level support. However, the availability of tobacco cessation services is not widespread overall, which may hamper access to extensive services to address low-income SUD patients' high smoking rates.

Understanding counselors' implementation of tobacco cessation services with patients.

This study aimed to understand substance use disorder counselors' implementation of evidence-based tobacco cessation services (TCS) with their patients who smoke. Drawing from an established adoption of innovations framework, we investigated the association between counselors' perceptions of the availability of TCS (both pharmacotherapies and behavioral treatments) in their treatment program and the implementation of TCS (both pharmacotherapies and behavioral treatments) with their patients who smoke and whether this association is moderated by the strength of an organization's climate for implementation and the fit of the innovation with users' values. Data were collected in 2010 from 682 counselors working in 239 treatment programs across the U.S. that offer evidence-based TCS. Mixed-effect models showed that perceived availability of TCS was related with greater TCS implementation. This relationship was moderated by several indicators of climate for implementation but not by the fit of the innovation with users' values.