A Qualitative Study of Barriers and Facilitators of PrEP Uptake Among Women in Substance Use Treatment and Syringe Service Programs.

PrEP is an HIV prevention option that could benefit substance-involved women, a high-risk population with low PrEP uptake. Little is known about their interest in PrEP. This qualitative study used in-depth interviews to examine PrEP willingness, barriers, and facilitators among 16 women in outpatient psychosocial substance use treatment, methadone, and/or harm reduction/syringe programs in NYC. All expressed willingness to use PrEP, but only during periods of perceived risk. Women perceived themselves to be at high risk for HIV when engaging in active substance use and/or transactional sex. They perceived themselves to be at low risk and therefore unmotivated to take PrEP when abstinent from these activities. Paradoxically, a major barrier to using PrEP was anticipated interference from substance use and transactional sex, the very same activities that create a perception of risk. Facilitators of PrEP use included perceptions of it as effortless (as opposed to barrier methods during sex) and effective, safe, and accessible. Other barriers included fear of stigma and doubts about adhering daily. Recommendations for best PrEP implementation practices for substance-involved women included tailored and venue-specific PrEP information and messaging, PrEP discussion with trusted medical providers, and on-site PrEP prescription in substance use treatment and harm reduction programs.

RESUMEN: PrEP es una opción de prevención de VIH que puede beneficiar a las mujeres que consumen sustancias, una población de alto riesgo con baja aceptación de la PrEP, pero poco se sabe de su interés en la PrEP. Este estudio cualitativo utilizó entrevistas para examinar el interés en tomar la PrEP y las barreras y los facilitadores del uso de la PrEP entre 16 mujeres en tratamiento por el uso de sustancias en clínicas ambulatorias, clínicas metadonas, o programas de reducción de daños en la ciudad de Nueva York, Estados Unidos. Todas las participantes expresaron su disposición a usar PrEP, pero solo durante períodos de riesgo percibido (por ejemplo, tiempos de uso de sustancias activas y/o sexo transaccional). Paradójicamente, una barrera importante para el uso de PrEP fue la interferencia anticipada por el uso de sustancias y el sexo transaccional, las mismas actividades que crean una percepción de riesgo. Los facilitadores incluyeron percepciones de PrEP como sin esfuerzo durante las relaciones sexuales, efectiva, segura, y accesible. Otras barreras incluyeron el miedo del estigma y dudas sobre la adherencia diaria. Las recomendaciones para las mejores prácticas de implementar la PrEP para mujeres que consumen sustancias incluyeron información y mensajes de PrEP personalizados y específicos del lugar, discusión de PrEP con proveedores médicos confiables, y prescripción de PrEP en el sitio en programas de tratamiento y reducción de daños por uso de sustancias.

Nurturing Practitioner-Researcher Partnerships to Improve Adoption and Delivery of Research-Based Social and Public Health Services Worldwide.

Research-based practices-psychosocial, behavioral, and public health interventions-have been demonstrated to be effective and often cost-saving treatments, but they can take up to two decades to reach practitioners within the health and human services workforce worldwide. Practitioners often rely on anecdotal evidence and their "practice wisdom" rather than on research, and may thus unintentionally provide less effective or ineffective services. Worldwide, community engagement in research is recommended, particularly in low-resource contexts. However, practitioner involvement has not been adequately explored in its own right as an innovative community-engaged practice that requires a tailored approach. The involvement of practitioners in research has been shown to improve their use of research-based interventions, and thus the quality of care and client outcomes. Nevertheless, the literature is lacking specificity about when and how (that is, using which tasks and procedures) to nurture and develop practitioner⁻researcher partnerships. This paper offers theoretical and empirical evidence on practitioner⁻researcher partnerships as an innovation with potential to enhance each phase of the research cycle and improve services, using data from the United States, Brazil, and Spain. Recommendations for partnership development and sustainability are offered, and a case is made for involving practitioners in research in order to advance social justice by amplifying the local relevance of research, increasing the likelihood of dissemination to community settings, and securing the sustainability of research-based interventions in practice settings.

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

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

Can TasP Approaches Be Implemented in Correctional Settings?: A review of HIV testing and linkage to community HIV treatment programs.

High rates of HIV in correctional populations makes evaluation of programs that increase HIV testing in correctional settings and linkage to HIV treatment upon release, and understanding key implementation issues of these programs, essential to reducing new HIV infection. We conducted a systematic search for studies of outcomes or implementation issues of programs that promote HIV testing or that promote linkage to community HIV treatment post-release. Thirty-five articles met inclusion criteria: nine HIV testing initiatives and four linkage programs. HIV testing uptake rates were between 22% and 98% and rates of linkage to community treatment were between 79% and 84%. Findings suggest that some programs may be effective at reducing HIV transmission within the communities to which inmates return. However, attention to implementation factors, such as organizational culture and staff collaborations, appears critical to the success of these programs. Future research using rigorous design and adequate comparison groups is needed.

Factors Associated with Providers' Perceptions of Mental Health Care in Santa Luzia's Family Health Strategy, Brazil.

Brazil has a unique mental health care system, characterized by universal coverage delivered by interdisciplinary teams both in the community and in specialized centros de atenção psicossocial (CAPS-psychosocial care centers). Provision of patient-centered mental health care is an important principle of Brazilian mental health care, but this topic has not been well-studied. We analyzed data from a cross-sectional survey of 151 community health workers (CHWs), nurses, and physicians in Santa Luzia, Minas Gerais State, Brazil. Chi-squares, t-tests and multivariate regression analyses examined differences in socio-demographics, caseload, engagement in evidence-based practices (EBPs), and transdisciplinary collaboration between providers who reported providing high levels of patient-centered mental health care and those who did not. In multivariate regression models, components of transdisciplinary collaboration were significantly associated with providers' perceptions of patient-centered mental health care (p < 0.05). CHWs were also significantly more likely to report providing patient-centered care than physicians and nurses. EBP engagement and sociodemographics were not associated with perceptions. Results suggest that training efforts to improve patient-centered mental health care in Brazil could build upon CHWs' skills and focus on transdisciplinary collaboration. Findings may inform practice in other countries with similar health care systems.

Delivery of behavioral HIV prevention services in New York City outpatient substance abuse treatment clinics: providers' perspectives on opportunities and challenges.

Providers (e.g., counselors, physicians) of substance abuse treatment have an opportunity to address HIV. This study identified: (1) providers' HIV prevention practices, (2) barriers, and (3) promoters to offering HIV prevention in substance abuse treatment. Semistructured qualitative interviews with one director, one medical provider, and four counselors, from each of six outpatient clinics (N = 36) were transcribed and coded according to thematic content analysis. Providers' practices included: (1) recommending condoms, (2) explaining HIV transmission, (3) HIV testing, and (4) assessing risk. Barriers included: (1) believing that clients know enough about HIV, (2) believing that clients are not at risk, (3) lacking information, (4) outdated training (i.e., > 5 years ago), (5) HIV stigma, and (6) avoidance. While some providers recommended condoms and HIV testing, many avoided discussing HIV. Our results suggest a need for training to improve understanding of HIV transmission, effective counseling practices, and to build capacity for HIV testing or linkages with HIV service agencies.

Implementation of Brazil's "family health strategy": factors associated with community health workers', nurses', and physicians' delivery of drug use services.

BACKGROUND: Brazil's "family health strategy" (ESF), provides primary care, mostly to individuals in impoverished communities through teams of physicians, nurses, and community health workers (CHWs). ESF workers are called upon to offer drug use services (e.g., referrals, counseling) as drug use represents an urgent public health crisis. New federal initiatives are being implemented to build capacity in this workforce to deliver drug use services, yet little is known about whether ESF workers are providing drug use services already. Guided by social cognitive theory, this study examines factors associated with ESF workers' provision of drug use services. METHODS: Cross-sectional surveys were collected from 262 ESF workers (168 CHWs, 62 nurses, and 32 physicians) in Mesquita, Rio de Janeiro State and Santa Luzia, Minas Gerais State. OUTCOME VARIABLE: provision of drug-use services. PREDICTORS: capacity to engage in evidence-based practice (EBP), resource constraints, peer support, knowledge of EBP, and job title. Logistic regression was used to determine relative influence of each predictor upon the outcome. RESULTS: Thirty-nine percent reported providing drug use services. Younger workers, CHWs, workers with knowledge about EBP and workers that report peer support were more likely to offer drug use services. Workers that reported resource constraints and more capacity to implement EBP were less likely to offer drug use services. CONCLUSION: ESF workers require education in locating, assessing and evaluating the latest research. Mentorship from physicians and peer support through team meetings may enhance workers' delivery of drug use services, across professional disciplines. Educational initiatives aimed at ESF teams should consider these factors as potentially enhancing implementation of drug use services. Building ESF workers' capacity to collaborate across disciplines and to gain access to tools for providing assessment and treatment of drug use issues may improve uptake of new initiatives.

PrEP in substance abuse treatment: a qualitative study of treatment provider perspectives.

OBJECTIVES: To examine substance abuse treatment providers' views on engaging clients in Pre-exposure Prophylaxis (PrEP) care and research trials. METHODS: Thirty-six medical and counseling service providers in six New York City outpatient substance abuse treatment programs participated in semi-structured qualitative interviews. Thematic content analysis was conducted by three coders, independently. RESULTS: Providers' perspectives toward PrEP were characterized by six salient themes: 1) Limited PrEP awareness. 2) Ambivalence about PrEP; 3) Perception of multiple challenges to delivery; 4) Uncertainty about clients' ability to be adherent to medication; 5) Concerns about medication safety/side effects; and 6) Perception of multiple barriers to conducting clinical trials. CONCLUSIONS: Despite anticipated challenges, providers supported the introduction of PrEP in outpatient substance abuse treatment. Comprehensive training for providers is needed and should include PrEP eligibility criteria, strategies to support adherence and medication monitoring guidelines. Linkages between substance abuse treatment and primary care and/or enhancement of capacity within clinics to offer PrEP may help facilitate PrEP delivery. When conducting research in outpatient clinics, it is particularly important to protect client confidentiality.

HIV practitioners in Madrid and New York improving inclusion of underrepresented populations in research.

Practitioners have frequent contact with populations underrepresented in scientific research--ethnic/racial groups, sexual minorities and others at risk for poor health and whose low participation in research does not reflect their representation in the general population. Practitioners aspire to partner with researchers to conduct research that benefits underrepresented groups. However, practitioners are often overlooked as a work force that can help erase inclusion disparities. We recruited (n = 282) practitioners (e.g. physicians, social workers, health educators) to examine associations between their attitudes toward research purposes, risks, benefits and confidentiality and their involvement in recruitment, interviewing and intervention facilitation. Participants worked in community-based agencies in Madrid and New York City (NYC), two large and densely populated cities. We used cross-sectional data and two-sample tests to compare attitudes toward research and practitioner involvement in recruiting, interviewing and facilitating interventions. We fit logistic regression models to assess associations between practitioner attitudes toward ethical practices and recruitment, interviewing and facilitating interventions. The likelihood of recruiting, interviewing and facilitating was more pronounced among practitioners agreeing more strongly with ethical research practices. Though Madrid practitioners reported stronger agreement with ethical research practices, NYC practitioners were more involved in recruiting, interviewing and facilitating interventions. Practitioners can be trained to improve attitudes toward ethical practices and increase inclusion of underrepresented populations in research. Funders and researchers are encouraged to offer opportunities for practitioner involvement by supporting research infrastructure development in local agencies. Practices that promise to facilitate inclusion herein may be used in other countries.

Research advisory board members' contributions and expectations in the USA.

This study focuses on the Implementation Community Collaborative Board (I-CCB) to identify members' anticipated contributions to and returns from the I-CCB; examine whether or not members achieved these contributions and returns over time; and explore barriers and facilitators that influenced accomplishments. Longitudinal study with repeated semi-structured in-depth interviews; baseline captured anticipated contributions and returns; 6- and 18-month follow-ups short- and longer-term achievements. We used content analysis to code/reduce text into variables, describe, count and compare categories. Participants anticipated involvement in I-CCB dynamics/governance and in research tasks/procedures. Anticipated returns included social support. Participants exerting influence on I-CCB's research agenda stayed the same over time. Participants conducting research doubled between follow-ups; those writing grant proposals increased by 50%. Participants receiving emotional support remained the same. Challenges: meetings steered by researchers; lack of time; use of jargon. Facilitators: outreaching to community; being affected by HIV; having overlapping identities/roles as researcher, service consumer and/or practitioner. Research partners can maximize facilitators, redress barriers and improve advisory board members' retention. Findings may help optimize the functioning of advisory boards worldwide.

Systematizing planning and formative phases of HIV prevention research: Case studies from Brazil, Mongolia, and Kazakhstan.

OBJECTIVES: International Community Based Participatory Research (CBPR) is vulnerable to contextual, political, and interpersonal issues that may hamper researchers' abilities to develop and sustain partnerships with local communities. This paper responds to a call for systematizing CBPR practices and to the urgent need for frameworks with potential to facilitate partnership-building between researchers and communities in both "developed" and "developing" countries. METHODS: Using three brief case examples, each from a different context, with different partners and varied research questions, we demonstrate how to apply the International Participatory Research Framework (IPRF). RESULTS: IPRF consists of triangulated procedures (steps and actions) that can facilitate known participatory outcomes: 1) community-defined research goals, 2) capacity for further research, and 3) policies and programs grounded in research. CONCLUSIONS: We show how the application of this model is particularly helpful in the planning and formative phases of CBPR. Other partnerships can use this framework in its entirety or aspects thereof, in different contexts. Further evaluation of how this framework can help other international partnerships, studying myriad diseases and conditions, should be a focus of future international CBPR.

Modeling the Structure of Partnership Between Researchers and Front-Line Service Providers: Strengthening Collaborative Public Health Research.

Partnerships between HIV researchers and service providers are essential for reducing the gap between research and practice. Community-Based Participatory Research principles guided this cross-sectional study, combining 40 in-depth interviews with surveys of 141 providers in 24 social service agencies in New York City. We generated the Provider-Researcher Partnership Model to account for provider- and agency-level factors' influence on intentions to form partnerships with researchers. Providers preferred "balanced partnerships" in which researchers and providers allocated research tasks and procedures to reflect diverse knowledge/skill sets. An organizational culture that values research can help enhance providers' intentions to partner. Providers' intentions and priorities found in this study may encourage researchers to engage in and policy makers to fund collaborative research.

Optimizing ART adherence: update for HIV treatment and prevention.

Optimal adherence to antiretroviral therapy (ART) is central to achieving viral suppression and positive health outcomes in HIV-infected individuals. Virally suppressed individuals can also reduce the risk of HIV transmission to uninfected partners. Hence, adherence to ART has become both an HIV treatment and an HIV prevention strategy. However, achieving optimal ART adherence can be challenging, especially over the long term. It is increasingly important for clinicians and researchers to be abreast of the most recent developments in the field as new biomedical approaches to treatment emerge and as guidelines for the use of pre-exposure prophylaxis (PrEP) are disseminated to providers serving HIV affected populations. Several reviews have described numerous ART adherence interventions that have been developed and/or tested with the most recent review including literature up to 2012. To augment the literature, we present a review of ART adherence interventions from 2013 to the present. We included peer-reviewed journals as well as abstracts from two key conferences.

Transdisciplinary collaboration and endorsement of pharmacological and psychosocial evidence-based practices by medical and psychosocial substance abuse treatment providers in the United States.

AIMS: To examine the relative contribution of providers' professional affiliation (medical vs. non-medical), involvement in research, and training needs for associations with endorsement of the following evidence-based practices (EBPs): (1) pharmacological - buprenorphine treatment and (2) psychosocial - Cognitive Behavioural Therapy (CBT). METHODS: Secondary analysis from a 2008 survey of a national sample (n = 571) of substance abuse treatment providers (medical, social workers, psychologists and counsellors) affiliated with the United States National Institute on Drug Abuse's National Drug Abuse Treatment Clinical Trials Network. Multivariate linear regression models to analyze cross-sectional survey data. FINDINGS: Results demonstrated that medical providers and providers with previous research involvement more strongly endorsed the effectiveness of buprenorphine over CBT. Compared to medical providers, psychosocial providers more strongly endorsed CBT. There was a positive association between needing training in rapport with patients and endorsement of buprenorphine and a negative association with CBT. There was a positive association between needing training in behavioural management and needs assessment and endorsement of CBT. CONCLUSIONS: Results underscore the importance of providers' involvement in research and the need for training medical and non-medical providers in practice areas that can purposely enhance their use of pharmacological and psychosocial EBPs.

CBPR with service providers: arguing a case for engaging practitioners in all phases of research.

This review synthesizes the literature on CBPR with service providers to identify the benefits to, unique contributions of, and challenges experienced by professional service providers engaged in collaborative research. Service providers benefited by obtaining research-based knowledge to help the communities they serve, gaining research skills, professional relationships, professional development, and new programs. They contributed by informing research aims, designing interventions, conducting recruitment, informing overall study design, and dissemination. Challenges include time, resources, organizational factors, and disconnects between researchers and service providers. Policy and practice implications are explored.

International Participatory Research Framework: triangulating procedures to build health research capacity in Brazil.

This study advances Community-based Participatory Research (CBPR) by presenting a set of triangulated procedures (steps and actions) that can facilitate participatory research in myriad international settings. By using procedural triangulation-the combination of specific steps and actions as the basis for the International Participatory Research Framework (IPRF)-our approach can improve the abilities of researchers and practitioners worldwide to systematize the development of research partnerships. The IPRF comprises four recursive steps: (i) contextualizing the host country; (ii) identifying collaborators in the host country; (iii) seeking advice and endorsement from gatekeepers and (iv) matching partners' expertise, needs and interests. IPRF includes the following sets of recursive participatory actions: (A(1)) becoming familiar with local languages and culture; (A(2)) sharing power, ideas, influence and resources; (A(3)) gathering oral and written information about partners; (A(4)) establishing realistic expectations and (A(5)) resolving personal and professional differences. We show how these steps and actions were used recursively to build a partnership to study the roles of community health workers (CHWs) in Brazil's Family Health Program (PSF). The research conducted using IPRF focused on HIV prevention, and it included nearly 200 CHWs. By using the IPRF, our partnership achieved several participatory outcomes: community-defined research aims, capacity for future research and creation of new policies and programs. We engaged CHWs who requested that we study their training needs, and we engaged CHWs' supervisors who used the data collected to modify CHW training. Data collected from CHWs will form the basis for a grant to test CHW training curricula. Researchers and community partners can now use the IPRF to build partnerships in different international contexts. By triangulating steps and actions, the IPRF advances knowledge about the use of CBPR methods/procedures for international health research.

Exploring group dynamics for integrating scientific and experiential knowledge in Community Advisory Boards for HIV research.

To demonstrate how Community Advisory Boards (CABs) can best integrate community perspectives with scientific knowledge and involve community in disseminating HIV knowledge, this paper provides a case study exploring the structure and dynamic process of a "Community Collaborative Board" (CCB). We use the term CCB to emphasize collaboration over advisement. The CCB membership, structure, and dynamics are informed by theory and research. The CCB is affiliated with Columbia University School of Social Work and its original membership included 30 members. CCB was built using six systematized steps meant to engage members in procedural and substantive research roles: (1) engaging membership; (2) developing relationships; (3) exchanging information; (4) negotiation and decision-making; (5) retaining membership; and (6) studying dynamic process. This model requires that all meetings be audio-taped to capture CCB dynamics. Using transcribed meeting data, we have identified group dynamics that help the CCB accomplish its objectives: (1) dialectic process helps exchange of information; (2) mutual support helps members work together despite social and professional differences; and (3) problem solving helps members achieve consensus. These dynamics also help members attain knowledge about HIV treatment and prevention and disseminate HIV-related knowledge. CABs can be purposeful in their use of group dynamics, narrow the knowledge gap between researchers and community partners, prepare members for procedural and substantive research roles, and retain community partners.

Let's talk about sex: helping substance abuse counsellors address HIV prevention with men who have sex with men.

Integrating HIV prevention into substance abuse counselling is recommended to ameliorate the health outcomes of men who have sex with men. However, culture-based countertransferences (CBCs) may hamper this effort. Using a case illustration, this paper will explain the manifestation of CBCs held among substance abuse counsellors and how they hinder counsellors' work with men who have sex with men. The following CBCs will be explored: distancing, topic avoidance, heteronormativity, assumptions and denying client strengths. These CBCs allow counsellors to avoid discussions about sexual practices and curtail HIV prevention counselling, while undermining the counsellor-client relationship. Based on the empirical literature on HIV and substance abuse prevention with men who have sex with men, we provide recommendations to help counsellors overcome CBCs and integrate HIV prevention consistently with men who are in treatment for substance abuse.

Substance abuse treatment providers' involvement in research is associated with willingness to use findings in practice.

Using a national sample (n = 571) of substance abuse treatment providers affiliated with the Clinical Trials Network, we examined the contribution of several factors-demographic, attitudes, and involvement in research-toward providers' willingness to use research findings in practice. The sample included medical staff, social workers, psychologists, and counselors. Using a multiple linear regression model, we examined the impact of involvement in research and willingness to use research findings in practice. Providers involved in research were more willing to use findings in practice (p < .001). Latino/Latinas were less willing (p < .05). Providers with favorable attitudes toward evidence-based practices and whose agencies supported professional growth were more willing to use findings (p < .01). Involvement in research may enhance providers' willingness to use findings in practice and improve quality of services. Results underscore the need for providing opportunities for all providers to engage in substance abuse treatment research, particularly racial/ethnic minority providers.

Male-to-Female Transgender Individuals Building Social Support and Capital From Within a Gender-Focused Network.

The literature on male-to-female transgender (MTF) individuals lists myriad problems such individuals face in their day-to-day lives, including high rates of HIV/AIDS, addiction to drugs, violence, and lack of health care. These problems are exacerbated for ethnic and racial minority MTFs. Support available from their social networks can help MTFs alleviate these problems. This article explores how minority MTFs, specifically in an urban environment, develop supportive social networks defined by their gender and sexual identities. Using principles of community-based participatory research (CBPR), 20 African American and Latina MTFs were recruited at a community-based health care clinic. Their ages ranged from 18 to 53. Data were coded and analyzed following standard procedure for content analysis. The qualitative interviews revealed that participants formed their gender and sexual identities over time, developed gender-focused social networks based in the clinic from which they receive services, and engaged in social capital building and political action. Implications for using CBPR in research with MTFs are discussed.