Utilizing PRISM and RE-AIM to implement and evaluate the Rural Telementoring Training Center (RTTC) for health care workforce development in rural communities.

Introduction: Amid rural health worker shortages and hospital closures, it is imperative to build and maintain the local workforce. Telementoring (TM) or technology-enabled mentoring, is a tool for improving health care quality and access by increasing workforce capacity and support. The national Rural Telementoring Training Center (RTTC) was developed to compile and disseminate TM best practices by delivering free training, tools, and technical assistance to support the implementation, sustainability, and evaluation of new and current TM programs for rural health workers. This paper details how the Practical, Robust Implementation and Sustainability Model (PRISM) was used to understand the context that shaped implementation as well as how Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) was concurrently applied to frame outcomes. Methods: The RTTC has three implementation strategies: outreach, training and technical assistance (TTA), and a Quality Measure Toolkit. Ongoing periodic reflections with the RTTC team, informed by PRISM, were collected, as were RE-AIM outcomes. Central to this design was the continuous review of incoming data in team meetings to inform programmatic changes by identifying challenges and applying modifications to strategies in real time. Results: Major implementation changes discussed during reflections included providing timely and relevant messaging through various platforms, streamlining and customizing a TTA approach, and offering different options for accessing the Toolkit. The outreach strategy resulted in high Reach across the US, with over 300 organizations contacted. The effectiveness of the RTTC was demonstrated by counts of people engaging with outreach (ex. over 8,300 impressions on LinkedIn), the website (over 6,400 views), and e-bursts (33% open rate). Moreover, there were 32 TTA requests and 70 people accessing the Toolkit. Adoption was demonstrated by 27 people participating in TTA and 14 individuals utilizing the Toolkit. Discussion: The integration of PRISM and RE-AIM frameworks promoted a holistic implementation and evaluation plan. Using PRISM, the RTTC team was able to reflect on the implementation strategies through the lens of contextual factors and make rapid programmatic changes within team meetings. That process resulted in outcomes framed by RE-AIM. The integration of two frameworks in tandem provided an adaptive and comprehensive approach to implementing a large-scale, national program.

Mitigating the HIV and Viral Hepatitis Workforce Crisis Through Development of an HIV/Hepatitis C Coinfection Mobile Application.

A decline in the HIV workforce has led to a crisis of insufficient expertise to manage people with HIV (PWH), roughly a quarter of whom are coinfected with hepatitis C. Task shifting to nonspecialist providers can contribute to solving the HIV workforce shortage problem, but nonspecialist providers require sufficient training and support to acquire and retain the necessary knowledge and skills. Digital tools including mobile applications (apps) and telementoring which utilizes telecommunication technology for education and skill acquisition can be used for professional development. Described is the development and dissemination of a mobile app specifically for providers managing HIV/HCV coinfection in the United States. The app, through provider professional development, facilitates access to curative HCV treatment in PWH, encourages integration of HCV care into primary care and contributes to national goals to eliminate HIV and viral hepatitis by 2030.

Qualitative Evaluation of a Program to Integrate Hepatitis C Care Into HIV Care Inclusive of Task Shifting to Nonspecialist Providers.

The treatment and cure of hepatitis C (HCV) in people with HIV is particularly important as progression of their liver disease is quicker compared with those who have HCV monoinfection. Innovative approaches are needed to maximize access to curative HCV treatment. Integration of HCV care into HIV primary care with education and support of nonspecialist providers via telementoring offers a solution to specialist workforce shortages. Using focus group qualitative methodology, health care workers' perspectives regarding this approach, particularly with the Extension for Community Healthcare Outcomes (ECHO) telementoring model, were obtained and are described. Successful integration of HCV care into HIV primary care has demonstrated benefits to patients, including allowing them to remain in their medical home for care. Factors beyond disease that influence their health and wellbeing must also be considered.

Accessing Care During the COVID-19 Pandemic Using Telemedicine: Perspectives From People With HIV.

The COVID-19 pandemic has resulted in a steep increase in telemedicine implementation and use. Data are lacking on telemedicine use in marginalized and underserved groups including people with HIV (PWH). The Ryan White HIV/AIDS Program (RWHAP) is the largest single provider of HIV care in the United States (U.S.) and the southern part of the country remains the epicenter of the HIV epidemic. This study recruited PWH from RWHAP clinics across South Texas. To ascertain their perspectives on utilizing telemedicine for HIV care during the COVID-19 pandemic, a survey instrument derived from validated instruments was used. Descriptive statistics were used for client characteristics, quality of telemedicine care, and COVID-19 impact. Wilcoxon Rank Sum and Kruskal-Wallis tests were assessed associations of telemedicine care quality and COVID-19 impact between client groups. Among 246 eligible PWH, 122 clients completed the survey with a response rate of 50%. Clients were predominantly Hispanic males. Significant differences in perception of telemedicine care and the impact of COVID-19 by gender, age, language, and race/ethnicity were observed. Older PWHIV used telemedicine more than younger clients (p = .01). English speakers indicated more impact of the COVID-19 pandemic on daily life than Spanish speakers (p = .02). Worry about the pandemic was most evident among non-Hispanic Black and Hispanic PWH (p = .03). Overall, telemedicine was found to be a favorable and acceptable mechanism of HIV care delivery by PWH in a Southern state during the COVID-19 pandemic.

Hepatitis C Knowledge, Attitudes, and Perceptions Among People With HIV in South Texas.

Direct-acting antivirals are overwhelmingly effective in curing hepatitis C (HCV). Barriers to HCV treatment exist for those co-infected with both HIV and HCV. Southern states represent the epicenter of the HIV epidemic in the United States. This study assessed HCV knowledge, attitudes, and perceptions in 318 co-infected individuals attending Ryan White HIV/AIDS Program (RWHAP) clinics in three South Texas cities. Two groups were compared, those tested for HCV and aware of their results (Group 1) and those uncertain if they were tested or tested and unaware of their results (Group 2). HCV knowledge was poor overall. Group 1 had a significantly higher mean HCV knowledge score than Group 2 by t-test (48.6 vs. 38.8; p < .01), but not by multivariable linear regression (p=.14). Factors predictive of greater HCV knowledge included self-identification as lesbian, gay, bisexual, transgender, queer and post high school educational attainment. Significantly more in Group 1 compared with Group 2 agreed that HCV medications would keep a person healthier for longer. Spanish speakers were more likely to disagree with a statement that people of color receive the same treatment for hepatitis C as white people. Study limitations identified include poor generalizability to people with HIV (PWH) receiving care in non-RWHAP settings and rural communities. Despite limitations, this study augments the paucity of information about knowledge, attitudes, and perceptions of HCV in PWH and can inform interventions to combat barriers to HCV treatment and to maximize opportunities for HCV screening, diagnosis, and linkage to curative care.

Evaluating the Effectiveness of the AIDS Education and Training Center (AETC) National Human Immunodeficiency Virus/Hepatitis C Virus (HCV) Curriculum.

BACKGROUND: People with human immunodeficiency virus (PWHIV) who have hepatitis C virus (HCV) coinfection are at a higher risk of progression of liver disease than the general population. Direct acting antivirals provide a therapeutic option for HCV cure, however access to HCV specific care for PWHIV can be challenging. A paucity of specialist providers is a barrier to this care. OBJECTIVES: This study aims to assess knowledge gained about HIV/HCV coinfection among health care providers. METHODS: AIDS Education Training Centers (AETC) have developed a modular national HIV/HCV coinfection curriculum consisting of a free selfdirected online curriculum to educate health care providers, including nonspecialist providers, involved in the care of PWHIV on HCV care and management. The effectiveness of this curriculum was evaluated with pre and post module assessment completion by learners compared with a paired t-test. RESULTS: 716 people received links to the curriculum and 277 modules were completed by 221 unique individuals. 86% completed one module, 9% complete 2 modules, and the remaining 5% completed between 3 and all 6 modules. There were statistically significant increases in knowledge in the epidemiology module.

Pre-Exposure Prophylaxis (PrEP) for HIV Infection in Cisgender and Transgender Women in the U.S.: A Narrative Review of the Literature.

Using a socioecological approach, this review describes the peer-reviewed literature on oral pre-exposure prophylaxis (PrEP) among both cisgender (cis women) and transgender women (trans women) in the U.S. A search of the PubMed database and HIV-related conference abstracts generated over 2,200 articles and abstracts. Of these, 103 fulfilled review inclusion criteria. Most of the existing research presents findings on individual-level factors associated with PrEP use such as willingness and perceived barriers. There was far less investigation of factors related to PrEP at more distal ecological levels. Though trans women are at greater risk of HIV infection than cisgender women, less is known about this population group with respect to PrEP despite their inclusion in many major clinical trials. Further, the literature is characterized by a persistent conflation of sex and gender which makes it difficult to accurately assess the reviewed research on HIV prevention and PrEP apart from risk group. Informed by these findings, we highlight specific opportunities to improve access to PrEP and reduce socioecological barriers to PrEP care engagement for cisgender and transgender women.

Knowledge and Acceptability of Human Papillomavirus Vaccination and Text Message Reminders for Adolescents in Urban Emergency Departments: A Pilot Study.

PURPOSE: Cervical, oropharyngeal and anogenital cancers are vaccine-preventable diseases, but human papillomavirus (HPV) vaccination coverage in the US remains poor overall with regional variations in vaccination rates. We explore the acceptability by adolescents and their parents of HPV vaccination and text message reminders in the non-traditional setting of the emergency department (ED). PATIENTS AND METHODS: The modified validated Carolina HPV Attitudes and Beliefs Scale (CHIAS) survey was administered at two urban EDs to adolescents aged 13-18 years and their parents. Demographic information was collected for each participating adolescent. Recruitment occurred with consecutive eligible participants on the ED census list approached within 4-hour blocks from 8am to 8pm. RESULTS: Ninety-six adolescents completed the survey. The mean adolescent and parental knowledge scores were 63% (SD=29.7) and 60% (SD=22.1), respectively. The higher the HPV knowledge score among both adolescents and parents, the more likely they were to accept HPV vaccine in ED. Among the 10 cases where the parents disagreed to the HPV vaccine and the adolescents agreed to the HPV vaccine, the mean knowledge score among parents disagreeing was 47 compared to 62 among the remaining parents (p=0.04). Sixty-seven percent of adolescents and 68% of parents were agreeable to the adolescent receiving vaccination in the ED (kappa = 0.24). Seventy-five percent of adolescents and 71% of parents reported being agreeable to receiving text reminders for HPV vaccines (kappa = 0.20). Adolescent agreement with receiving a text message reminder corresponded with an increased willingness to be vaccinated (OR=3.21, 95% CI=1.07-9.57, p-value=0.0368). Sexually active adolescents were older (mean age, 17 years) than those who reported no sexual activity (mean age, 15 years) (p<0.0001). CONCLUSION: Increased knowledge about HPV influences vaccine acceptance. Parents and adolescents may disagree in accepting HPV vaccination. A majority of adolescents and their parents were agreeable to receiving HPV vaccination in the ED and subsequent text message reminders. The ED should be explored further as a non-traditional healthcare setting for HPV vaccination of adolescents.

Knowledge about Hepatitis C Virus Infection and Acceptability of Testing in the 1945-1965 Birth Cohort (Baby Boomers) Presenting to a Large Urban Emergency Department: A Pilot Study.

BACKGROUND: Hepatitis C virus (HCV) is responsible for the most common chronic bloodborne infection in the United States. The Centers for Disease Control (CDC) recently recommended screening all patients born between 1945-1965 (baby boomers) at least once for HCV infection. New York State has since mandated screening of baby boomers for HCV in nearly all patient care settings and encouraged it in the emergency department (ED). OBJECTIVES: This pilot study aimed to ascertain acceptability of an HCV screening test among the 1945-1965 birth cohort presenting to the ED in advance of a study investigating the prevalence of HCV infection in this birth cohort in the ED setting. METHODS: We conducted a cross-sectional study of health knowledge about HCV and government recommendations regarding HCV testing using a convenience sample of baby boomers in an ED in a large public hospital in the New York metropolitan area. Surveys were administered via a series of semistructured interviews. RESULTS: There were 81 patient participants. Fifty-two percent of patients were born outside of the United States, 69% had a high school diploma level of education or lower, and 37% were unemployed. Patients demonstrated misconceptions about HCV transmission and curability and poor knowledge about the necessity of testing in their age cohort. Knowledge that "HCV can cause the liver to stop working" was significantly associated with acceptance of testing. CONCLUSIONS: Baby boomers showed limited knowledge about the necessity of HCV screening in their age group, but testing for HCV infection in the ED was acceptable for the majority.

Hepatitis C virus infection in the 1945-1965 birth cohort (baby boomers) in a large urban ED.

INTRODUCTION: The US Preventive Services Task Force recommends one-time screening of the 1945-1965 birth cohort (baby boomers) for hepatitis C (HCV) infection. New York State legislation mandates screening of baby boomers for HCV in most patient care settings except the emergency department (ED). This cross-sectional study explores baby boomer knowledge of HCV, prevalence of HCV infection, and linkage to care from a large urban ED. METHOD: Patients participated in a researcher-administered structured interview and were offered an HCV screening test. If HCV antibody reactive, a follow-up clinic appointment was made within 6 weeks. Reminder telephone calls were made a week before the appointment. Attendance at the follow-up appointment was considered successful linkage to care. RESULTS: A total of 915 eligible patients were approached between October 21, 2014, and July 13, 2015. A total of 427 patients participated in the structured interview; 383 agreed to an HCV rapid test. Prevalence of HCV antibody reactivity was 7.3%. Four patients were successfully linked to care. General knowledge about HCV was fair. Misconceptions about transmission were apparent. Beliefs that "if someone is infected with HCV they will most likely carry the virus all their lives unless treated" and that "someone with hepatitis can look and feel fine" were significantly associated with agreement to testing. CONCLUSIONS: Better linkage to care is needed to justify HCV screening in the 1945-1965 birth cohort in this particular ED setting. Linkage to care from the ED is challenging but can potentially be improved with specific measures including simplified screening algorithms and supportive resources.

Evaluation of an interferon-gamma release assay in children with suspected tuberculosis in Papua New Guinea.

There are few data from tuberculosis (TB) endemic settings of the performance and outcome predictors of the QuantiFERON-TB Gold in Tube assay (QFT) in children with suspected TB. A prospective cross-sectional study was conducted in Papua New Guinea children with suspected TB evaluated at Port Moresby General Hospital (Port Moresby, Papua New Guinea). Two hundred sixteen children were enrolled including 106 probable TB, 87 possible TB and 23 without TB. Concordance between QFT and tuberculin skin test results was 86% (P < 0.001, κ = 0.70). QFT was significantly more likely to be positive than tuberculin skin test, overall and within the probable or possible TB categories, with no difference in prevalence of positivity between these 2 categories. The role of QFT in supporting the clinical diagnosis of TB in endemic settings, where resources are limited, remains uncertain especially as cost and technical requirements remain considerable.

Development of a clinical algorithm to prioritise HIV testing of hospitalised paediatric patients in a low resource moderate prevalence setting.

OBJECTIVE: To develop a clinical algorithm to identify paediatric patients who should be offered HIV testing in a setting of moderate HIV prevalence and limited resources. METHODS: In a prospective cross-sectional study at Port Moresby General Hospital, Papua New Guinea, carers of inpatients were offered HIV testing and counselling for their children. Recruited children were tested for HIV antibodies and DNA. Standardised clinical information was collected. Multivariate regression analysis was used to ascertain independent predictors of HIV infection and these were used to develop a predictive algorithm. RESULTS: From September 2007 to October 2008, 487 children were enrolled. Overall, 55 (11%) with a median age of 7 months were found to be HIV-infected. In multivariate analysis, independent predictors of HIV infection were: persistent fever (OR = 2.05 (95% CI 1.11 to 4.68)), lymphadenopathy (OR = 2.29 (1.12 to 4.68)), oral candidiasis (OR = 3.94 (2.17 to 7.14)) and being underweight for age (OR = 2.03 (1.03 to 3.99)). The presence of any one of these conditions had a sensitivity of 96% in detecting a child with HIV infection. Using an algorithm based on the presence of at least one of these conditions would result in around 40% of hospitalised children being offered testing. CONCLUSIONS: This clinical algorithm may be a useful screening tool for HIV infection in hospitalised children in situations where it is not feasible to offer universal HIV testing, providing guidance for HIV testing practices for increased identification and management of HIV-infected children in Papua New Guinea.

Attitudes to HIV testing among carers of children admitted to Port Moresby General Hospital, Papua New Guinea.

AIM: To assess the acceptability of voluntary counselling and testing among the carers of children admitted to hospital in Papua New Guinea. METHODS: Forty semistructured interviews were carried out between February and April 2007. RESULTS: All the carers interviewed were women, mostly from Port Moresby. Virtually all of them attended primary school. About half of them attended secondary school but none completed it. Half of them knew an adult or child with HIV. Three quarters of the women interviewed would consent to having a child in their care tested for HIV, and over half of those who had never been tested would agree to be tested themselves. Correct answers to more than half the HIV knowledge questions posed were significantly related to agreement to an HIV test. CONCLUSIONS: This study supports the need for further evaluation of knowledge about HIV/AIDS and opportunities for health promotion in this group of women, particularly in view of the implication for voluntary counselling and testing and prevention of mother-to-child HIV transmission programmes in Papua New Guinea.