Examining the Implementation of Conditional Financial Incentives Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework to Improve HIV Outcomes among Persons Living with HIV (PLWH) in Louisiana.

Economic strengthening interventions are needed to support HIV outcomes among persons living with HIV (PLWH). The Baton Rouge Positive Pathway Study (BRPPS), a mixed method implementation science study, was conducted to assess key RE-AIM components tied to the provision of conditional financial incentives among PLWH in Baton Rouge, Louisiana. Seven hundred and eighty-one (781) PLWH enrolled at four HIV clinic sites were included in the final analyses. Participants completed an initial baseline survey, viral load test, and were contacted at 6 and 12 months (±1 month) post-enrollment for follow-up labs to monitor viral load levels. Participants received up to USD140 in conditional financial incentives. The primary analyses assessed whether participation in the BRPPS was associated with an increase in the proportion of participants who were: (a) engaged in care, (b) retained in care and (c) virally suppressed at baseline to 6 and 12 months post-baseline. We constructed a longitudinal regression model where participant-level outcomes at times t0 (baseline) and t1 (6- or 12-month follow-up) were modeled as a function of time. A secondary analysis was conducted using single-level regression to examine which baseline characteristics were associated with the outcomes of interest at 12-month follow-up. Cost analyses were also conducted with three of the participating clinics. Most participants identified as Black/African American (89%). Fewer than half of participants reported that they were unemployed or made less than USD5000 annually (43%). Over time, the proportion of participants engaged in care and retained in care significantly increased (70% to 93% and 32% to 64%, p < 0.00). However, the proportion of virally suppressed participants decreased over time (59% to 34%, p < 0.00). Implementation costs across the three sites ranged from USD17,198.05 to USD396,910.00 and were associated with between 0.37 and 1.34 HIV transmissions averted at each site. Study findings provide promising evidence to suggest that conditional financial incentives could help support engagement and retention in HIV care for a high need and at risk for falling out of HIV care population.

Cost and Cost-Effectiveness of Incentives for Viral Suppression in People Living with HIV.

Only 63% of people living with HIV in the United States are achieving viral suppression. Structural and social barriers limit adherence to antiretroviral therapy which furthers the HIV epidemic while increasing health care costs. This study calculated the cost and cost-effectiveness of a contingency management intervention with cash incentives. People with HIV and detectable viral loads were randomized to usual care or an incentive group. Individuals could earn up to $3650 per year if they achieved and maintained an undetectable viral load. The average 1-year intervention cost, including incentives, was $4105 per patient. The average health care costs were $27,189 per patient in usual care and $35,853 per patient in the incentive group. We estimated a cost of $28,888 per quality-adjusted life-year (QALY) gained, which is well below accepted cost-per-QALY thresholds. Contingency management with cash incentives is a cost-effective intervention for significantly increasing viral suppression.

COVID-19 vaccine intentions in the United States, a social-ecological framework.

BACKGROUND: COVID-19 vaccine hesitancy is a major obstacle for pandemic mitigation. As vaccine hesitancy occurs along multiple dimensions, we used a social-ecological framework to guide the examination of COVID-19 vaccine intentions. METHODS: Using an online survey in the US conducted in July 2020, we examined intentions to obtain a COVID-19 vaccine, once available. 592 respondents provided data, including measures of demographics, vaccine history, social norms, perceived risk, and trust in sources of COVID-19 information. Bivariate and multivariate multinomial models were used to compare respondents who intended to be vaccinated against COVID-19 to respondents who did not intend or were ambivalent about COVID-19 vaccination. RESULTS: Only 59.1% of the sample reported that they intended to obtain a COVID-19 vaccine. In the multivariate multinomial model, those respondents who did not intend to be vaccinated, as compared to those who did, had significantly lower levels of trust in the CDC as a source of COVID-19 information (aOR = 0.29, CI = 0.17-0.50), reported lower social norms of COVID-19 preventive behaviors (aOR = 0.67, CI 0.51-0.88), scored higher on COVID-19 Skepticism (aOR = 1.44, CI = 1.28-1.61), identified as more politically conservative (aOR = 1.23, CI = 1.05-1.45), were less likely to have obtained a flu vaccine in the prior year (aOR = 0.21, CI = 0.11-0.39), were less likely to be female (aOR = 0.51, CI = 0.29-0.87), and were much more likely to be Black compared to White (aOR = 10.70, CI = 4.09-28.1). A highly similar pattern was observed among those who were ambivalent about receiving a COVID-19 vaccine compared to those who intended to receive one. CONCLUSION: The results of this study suggest several avenues for COVID-19 vaccine promotion campaigns, including social network diffusion strategies and cross-partisan messaging, to promote vaccine trust. The racial and gender differences in vaccine intentions also suggest the need to tailor campaigns based on gender and race.

Protocol of a randomized controlled trial to test the effects of client-centered Representative Payee Services on antiretroviral therapy adherence among marginalized people living with HIV.

BACKGROUND: Client-Centered Representative Payee (CCRP) is an intervention modifying implementation of a current policy of the US Social Security Administration, which appoints organizations to serve as financial payees on behalf of vulnerable individuals receiving Social Security benefits. By ensuring beneficiaries' bills are paid while supporting their self-determination, this structural intervention may mitigate the effects of economic disadvantage to improve housing and financial stability, enabling self-efficacy for health outcomes and improved antiretroviral therapy adherence. This randomized controlled trial will test the impact of CCRP on marginalized people living with HIV (PLWH). We hypothesize that helping participants to pay their rent and other bills on time will improve housing stability and decrease financial stress. METHODS: PLWH (n = 160) receiving services at community-based organizations will be randomly assigned to the CCRP intervention or the standard of care for 12 months. Fifty additional participants will be enrolled into a non-randomized ("choice") study allowing participant selection of the CCRP intervention or control. The primary outcome is HIV medication adherence, assessed via the CASE adherence index, viral load, and CD4 counts. Self-assessment data for ART adherence, housing instability, self-efficacy for health behaviors, financial stress, and retention in care will be collected at baseline, 3, 6, and 12 months. Viral load, CD4, and appointment adherence data will be collected at baseline, 6, 12, 18, and 24 months from medical records. Outcomes will be compared by treatment group in the randomized trial, in the non-randomized cohort, and in the combined cohort. Qualitative data will be collected from study participants, eligible non-participants, and providers to explore underlying mechanisms of adherence, subjective responses to the intervention, and implementation barriers and facilitators. DISCUSSION: The aim of this study is to determine if CCRP improves health outcomes for vulnerable PLWH. Study outcomes may provide information about supports needed to help economically fragile PLWH improve health outcomes and ultimately improve HIV health disparities. In addition, findings may help to refine service delivery including the provision of representative payee to this often-marginalized population. This protocol was prospectively registered on May 22, 2018 with ClinicalTrials.gov (NCT03561103) .

A Scoping Review of Employment and HIV.

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

HIV and employment among Black men who have sex with men in Baltimore.

Employment status is a key social determinant of health, and many populations in the United States that are impacted by HIV have unequal access to education and employment opportunities which contributes to HIV-related disparities. Black men who have sex with men (BMSM) are one of the groups most heavily burdened by HIV. With improved health outcomes associated with advancements in HIV treatment, research suggests that more people living with HIV want to work. This study describes employment among BMSM living in Baltimore, assesses differences in employment by HIV status and assesses predictors of full-time employment among BMSM. The study found that BMSM have limited access to full-time employment and that this disparity is even more pronounced among BMSM living with HIV. Men living with HIV were less likely to be employed full-time compared to men not living with HIV controlling for education and social contextual factors (OR 0.40 95% CI (0.22-0.73)). HIV will most likely have important implications for employment patterns and trajectories of BMSM over the life course. Additional research is needed among BMSM living with HIV to understand work histories and experiences, facilitating factors, and the impact of various work experiences on the health and wellbeing.

A Cost and Cost-Threshold Analysis of Implementation of an Evidence-Based Intervention for HIV-Serodiscordant Couples.

To address gaps in the cost literature by estimating the cost of delivering an evidence-based HIV risk reduction intervention for HIV-serodiscordant, heterosexual, African American couples (Eban II) and calculating the cost-effective thresholds at three participating sites. The cost, cost-saving, and cost-effectiveness thresholds for Eban II were calculated using standard methods. The analytic time period was from July 1 to September 31, 2014. Total costs for 3 months of program implementation were from $13,747 to $25,937, with societal costs ranging from $5632 to $17,008 and program costs ranging from $8115 to $14,122. The costs per participant were from $1621 to $2160; the cost per session (per participant) ranged from $147 to $196. Sites had achievable cost-saving thresholds, which were all less than one for the 3-month costing timeframe.

I Don't Want the Tray to Tip: Experiences of Peer Evaluators in a Multisite HIV Retention in Care Study.

Numerous studies demonstrate the efficacy of peer-delivered interventions to improve HIV prevention and care outcomes, yet few explore the role of peers in evaluation and data collection. We conducted qualitative interviews with providers in a multisite HIV Retention in Care initiative to explore peers' evaluation roles, challenges, and strategies for success. We found peers' responsibilities included data collection, client assessments, and data entry. Their rapport with clients was considered an evaluation asset. However, peers struggled with balancing rigorous evaluation and data collection demands with the needs and comfort of clients. Recommendations for peer-based evaluation include ensuring self-care, streamlining workflow, and involving peers in evaluation development and reporting processes. Additional research is needed to explore the extent to which peers participate in evaluation activities and to ensure rigor in peer-based evaluation. Given that peers are well-positioned to collect client-level data, best practices, standards, and trainings for peer-based evaluation should be developed.

HIV Treatment Cascade by Housing Status at Enrollment: Results from a Retention in Care Cohort.

Though housing instability is linked to poor HIV health outcomes, studies that assess the HIV treatment cascade by housing status are limited. Using data from a multi-site Retention in Care initiative we constructed HIV treatment cascades for participants (n = 463) of five grantee sites. We found no significant differences in viral suppression at follow-up among participants who were unstably housed at enrollment (49%) as compared to those who were stably housed at enrollment (54%). Among participants with available data at 6- or 12-month follow-up, 94% were engaged in care, 90% were retained in, 94% were on ART, and 71% had suppressed viral load. Some site-level differences were noted; at two of the sites participants who were stably housed were more likely to be retained in care and on ART. Overall, findings demonstrated that participants moved successfully through the HIV treatment cascade regardless of housing status at enrollment, suggesting that evidence-based support and services to help people living with HIV/AIDS can help mitigate barriers to engagement in care associated with lack of stable housing.

Cost-Utility of Access to Care, a National HIV Linkage, Re-engagement and Retention in Care Program.

Linkage to HIV medical care and on-going engagement in HIV medical care are vital for ending the HIV epidemic. However, little is known about the cost-utility of HIV linkage, re-engagement and retention (LRC) in care programs. This paper presents the cost-utility analysis of Access to Care, a national HIV LRC program. Using standard methods from the US Panel on Cost-Effectiveness in Health and Medicine, we calculated the cost-utility ratio. Seven Access to Care programs were cost-effective and two were cost-saving. This study adds to a small but growing body of evidence to support the cost-effectiveness of LRC programs.

The Cost and Threshold Analysis of Retention in Care (RiC): A Multi-Site National HIV Care Program.

Persons diagnosed with HIV but not retained in HIV medical care accounted for the majority of HIV transmissions in 2009 in the United States (US). There is an urgent need to implement and disseminate HIV retention in care programs; however little is known about the costs associated with implementing retention in care programs. We assessed the costs and cost-saving thresholds for seven Retention in Care (RiC) programs implemented in the US using standard methods recommended by the US Panel on Cost-effectiveness in Health and Medicine. Data were gathered from accounting and program implementation records, entered into a standardized RiC economic analysis spreadsheet, and standardized to a 12 month time frame. Total program costs for from the societal perspective ranged from $47,919 to $423,913 per year or $146 to $2,752 per participant. Cost-saving thresholds ranged from 0.13 HIV transmissions averted to 1.18 HIV transmission averted per year. We estimated that these cost-saving thresholds could be achieved through 1 to 16 additional person-years of viral suppression. Across a range of program models, retention in care interventions had highly achievable cost-saving thresholds, suggesting that retention in care programs are a judicious use of resources.

A Framework to Inform Strategies to Improve the HIV Care Continuum in Low- and Middle-Income Countries.

Reasons for attrition along the HIV care continuum are well described. However, improving patient engagement in care has been a challenge. New approaches to understanding and responding to reasons for attrition are required. Here, with a focus on low- and middle-income countries, we propose a framework that brings together an explanatory model with social ecological levels. Individual action may be based on a conscious or unconscious balance between perceived value and perceived costs. When the balance between value and cost favors value, engagement in care can be expected. Value and cost may be mediated by levels of the individual, interpersonal interactions, the clinic experience, community, society, and policy. We encourage the use of a framework for developing strategies to improve the care continuum and believe that this framework provides a rigorous approach.

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

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

Barriers and Facilitators to Implementing Access to HIV Care Interventions: A Qualitative Analysis of the Positive Charge Initiative.

Research indicates that less than half of people living with HIV (PLWH) have undetectable levels of virus, despite recent findings that viral load suppression dramatically reduces the transmissibility of HIV. Linkage to HIV care is a crucial initial step, yet we know relatively little about how to effectively implement linkage interventions to reach PLWH who are not in care. AIDS United's initiative, Positive Charge (PC), funded five U.S. sites to develop and implement comprehensive linkage interventions. Evaluation of the initiative included qualitative interviews with management and service staff from each intervention site. Sites experienced barriers and facilitators to implementation on multiple environmental, organization, and personnel levels. Successful strategies included developing early relationships with collaborating partners, finding ways to share key information among agencies, and using evaluation data to build support among leadership staff. Lessons learned will be useful for organizations that develop and implement future interventions targeting hard-to-reach, out-of-care PLWH.

Understanding newsworthiness of an emerging pandemic: international newspaper coverage of the H1N1 outbreak.

BACKGROUND AND OBJECTIVES: During an evolving public health crisis, news organizations disseminate information rapidly, much of which is uncertain, dynamic, and difficult to verify. We examine factors related to international news coverage of H1N1 during the first month after the outbreak in late April 2009 and consider the news media's role as an information source during an emerging pandemic. METHODS: Data on H1N1 news were compiled in real time from newspaper websites across twelve countries between April 29, 2009 and May 28, 2009. A news sample was purposively constructed to capture variation in countries' prior experience with avian influenza outbreaks and pandemic preparation efforts. We analyzed the association between H1N1 news volume and four predictor variables: geographic region, prior experience of a novel flu strain (H5N1), existence of a national pandemic plan, and existence of a localized H1N1 outbreak. RESULTS: H1N1 news was initially extensive but declined rapidly (OR = 0.85, P < .001). Pandemic planning did not predict newsworthiness. However, countries with prior avian flu experience had higher news volume (OR = 1.411, P < .05), suggesting that H1N1 newsworthiness was bolstered by past experiences. The proportion of H1N1 news was significantly lower in Europe than elsewhere (OR = 0.388, P < 0.05). Finally, coverage of H1N1 increased after a first in-country case (OR = 1.415, P < .01), interrupting the pattern of coverage decline. CONCLUSIONS: Findings demonstrate the enhanced newsworthiness of localized threats, even during an emerging pandemic. We discuss implications for news media's role in effective public health communication throughout an epidemic given the demonstrated precipitous decline in news interest.

Cost-utility analysis of a female condom promotion program in Washington, DC.

A retrospective economic evaluation of a female condom distribution and education program in Washington, DC. was conducted. Standard methods of cost, threshold and cost-utility analysis were utilized as recommended by the U.S. Panel on cost-effectiveness in health and medicine. The overall cost of the program that distributed 200,000 female condoms and provided educational services was $414,186 (at a total gross cost per condom used during sex of $3.19, including educational services). The number of HIV infections that would have to be averted in order for the program to be cost-saving was 1.13 in the societal perspective and 1.50 in the public sector payor perspective. The cost-effectiveness threshold of HIV infections to be averted was 0.46. Overall, mathematical modeling analyses estimated that the intervention averted approximately 23 HIV infections (even with the uncertainty inherent in this estimate, this value appears to well exceed the necessary thresholds), and the intervention resulted in a substantial net cost savings.

HIV transmission rates from persons living with HIV who are aware and unaware of their infection.

Transmission rate modeling estimated secondary infections from those aware and unaware of their HIV infection. An estimated 49% of transmissions were from the 20% of persons living with HIV unaware of their infection. About eight transmissions would be averted per 100 persons newly aware of their infection; with more infections averted the higher the percentage of persons with viral suppression who can be linked to care. Improving all stages of HIV care would substantially reduce transmission rates.

The epidemiology of nonspecific psychological distress in New York City, 2002 and 2003.

The 30-day prevalence of nonspecific psychological distress (NPD) is 3%, nationwide. Little is known about the prevalence and correlates of NPD in urban areas. This study documents the prevalence of NPD among adults in New York City (NYC) using population-based data from the 2002 and 2003 NYC Community Health Surveys (CHS) and identifies correlates of NPD in this population. We examined two cross-sectional random-digit-dialed telephone surveys of NYC adults (2002: N = 9,764; 2003: N = 9,802). Kessler's K6 scale was used to measure NPD. Age-adjusted 30-day prevalence of NPD declined from 6.4% [95% Confidence Interval (CI): 5.8-7.0] in 2002 to 5.1% [95% CI: 4.5-5.6] in 2003. New Yorkers who were poor, in poor health, chronically unemployed, uninsured, and formerly married had the highest prevalence of NPD. Declines occurred among those who were married, white, recently unemployed, and female. NPD prevalence in NYC is higher than national estimates. A stronger economy and recovery from September 11th attacks may have contributed to the 2003 decline observed among selected subgroups. The excess prevalence of NPD may be associated with substantial economic and societal burden. Research to understand the etiology of this high prevalence and interventions to promote mental health in NYC are indicated.