An Interactive Modeling Tool for Projecting the Health and Direct Medical Cost Impact of Changes in the Sexually Transmitted Diseases Prevention Program Budgets.

CONTEXT: Estimating the return on investment for public health services, tailored to the state level, is critical for demonstrating their value and making resource allocation decisions. However, many health departments have limited staff capacity and expertise to conduct economic analyses in-house. PROGRAM: We developed a user-friendly, interactive Excel-based spreadsheet model that health departments can use to estimate the impact of increases or decreases in sexually transmitted infection (STI) prevention funding on the incidence and direct medical costs of chlamydia, gonorrhea, syphilis, and STI-attributable HIV infections. Users tailor results to their jurisdictions by entering the size of their population served; the number of annual STI diagnoses; their prior annual funding amount; and their anticipated new funding amount. The interface was developed using human-centered design principles, including focus groups with 15 model users to collect feedback on an earlier model version and a usability study on the prototype with 6 model users to finalize the interface. IMPLEMENTATION: The STI Prevention Allocation Consequences Estimator ("SPACE Monkey 2.0") model will be publicly available as a free downloadable tool. EVALUATION: In the usability testing of the prototype, participants provided overall positive feedback. They appreciated the clear interpretations, outcomes expressed as direct medical costs, functionalities to interact with the output and copy charts into external applications, visualization designs, and accessible information about the model's assumptions and limitations. Participants provided positive responses to a 10-item usability evaluation survey regarding their experiences with the prototype. DISCUSSION: Modeling tools that synthesize literature-based estimates and are developed with human-centered design principles have the potential to make evidence-based estimates of budget changes widely accessible to health departments.

Integrating human-centered design in public health data dashboards: lessons from the development of a data dashboard of sexually transmitted infections in New York State.

OBJECTIVE: The increased availability of public data and accessible visualization technologies enhanced the popularity of public health data dashboards and broadened their audience from professionals to the general public. However, many dashboards have not achieved their full potential due to design complexities that are not optimized to users' needs. MATERIAL AND METHODS: We used a 4-step human-centered design approach to develop a data dashboard of sexually transmitted infections for the New York State Department of Health: (1) stakeholder requirements gathering, (2) an expert review of existing data dashboards, (3) a user evaluation of existing data dashboards, and (4) an usability evaluation of the prototype dashboard with an embedded experiment about visualizing missing race and ethnicity data. RESULTS: Step 1 uncovered data limitations and software requirements that informed the platform choice and measures included. Step 2 yielded a checklist of general principles for dashboard design. Step 3 revealed user preferences that influenced the chart types and interactive features. Step 4 uncovered usability problems resulting in features such as prompts, data notes, and displaying imputed values for missing race and ethnicity data. DISCUSSION: Our final design was accepted by program stakeholders. Our modifications to traditional human-centered design methodologies to minimize stakeholders' time burden and collect data virtually enabled project success despite barriers to meeting participants in-person and limited public health agency staff capacity during the COVID-19 pandemic. CONCLUSION: Our human-centered design approach and the final data dashboard architecture could serve as a template for designing public health data dashboards elsewhere.

Who Are the Local Policy Innovators? Cluster Analysis of Municipal Tobacco Control Policies in Massachusetts.

CONTEXT: Tobacco use is a leading cause of preventable death, yet it is challenging to establish public policy to reduce tobacco use. Massachusetts has been a national leader in tobacco control, and its policy-making patterns can be informative to the country. OBJECTIVE: To identify factors associated with the adoption of tobacco policy within 351 Massachusetts municipalities. DESIGN: We obtained the 2019 Massachusetts municipality-level tobacco control policy information from Massachusetts' Tobacco Automated Fact Sheet Information system and compiled it with data from American Community Survey, Massachusetts Municipal Association, and Massachusetts state government's Web sites. We used k -means clustering method to identify statistical clustering patterns and hotspot analysis (Getis-Ord Gi*) and Local Indicators of Spatial Association to identify geographic clustering patterns. We then performed multinomial logistic regression to identify factors associated with policy clusters. SETTING: Massachusetts. PARTICIPANTS: Three hundred fifty-one municipalities in Massachusetts. MAIN OUTCOME MEASURE: Policy clusters-groups of municipalities with similar tobacco control policy behaviors. RESULTS: Based on the k -means analyses, we identified 3 clusters in Massachusetts municipal tobacco control policy behaviors: 54% (N = 191) of municipalities were "Policy Leaders" with a high adoption rate of the 6 tobacco control policies; 18% (N = 63) were "Peer-Influenced Actors" focused on tobacco purchase restrictions for individuals younger than 21 years; and 28% (N = 97) were "Policy Non-Actors," with no tobacco control policies in place. Policy Leaders were geographically clustered in larger cities and the MetroWest region. Policy Non-Actors were clustered in rural areas of Western and Central Massachusetts. Larger municipal population size, higher municipal tax income, and higher percentages of residents voting Democratic were associated with higher policy adoption activities. CONCLUSIONS: Local variation in the adoption of tobacco policies may exacerbate inequities in tobacco use and population health. Opportunities remain to implement additional tobacco control regulations at the local level to promote public health.

Modeling the Potential Impact of Missing Race and Ethnicity Data in Infectious Disease Surveillance Systems on Disparity Measures: Scenario Analysis of Different Imputation Strategies.

BACKGROUND: Monitoring progress toward population health equity goals requires developing robust disparity indicators. However, surveillance data gaps that result in undercounting racial and ethnic minority groups might influence the observed disparity measures. OBJECTIVE: This study aimed to assess the impact of missing race and ethnicity data in surveillance systems on disparity measures. METHODS: We explored variations in missing race and ethnicity information in reported annual chlamydia and gonorrhea diagnoses in the United States from 2007 to 2018 by state, year, reported sex, and infection. For diagnoses with incomplete demographic information in 2018, we estimated disparity measures (relative rate ratio and rate difference) with 5 imputation scenarios compared with the base case (no adjustments). The 5 scenarios used the racial and ethnic distribution of chlamydia or gonorrhea diagnoses in the same state, chlamydia or gonorrhea diagnoses in neighboring states, chlamydia or gonorrhea diagnoses within the geographic region, HIV diagnoses, and syphilis diagnoses. RESULTS: In 2018, a total of 31.93% (560,551/1,755,510) of chlamydia and 22.11% (128,790/582,475) of gonorrhea diagnoses had missing race and ethnicity information. Missingness differed by infection type but not by reported sex. Missing race and ethnicity information varied widely across states and times (range across state-years: from 0.0% to 96.2%). The rate ratio remained similar in the imputation scenarios, although the rate difference differed nationally and in some states. CONCLUSIONS: We found that missing race and ethnicity information affects measured disparities, which is important to consider when interpreting disparity metrics. Addressing missing information in surveillance systems requires system-level solutions, such as collecting more complete laboratory data, improving the linkage of data systems, and designing more efficient data collection procedures. As a short-term solution, local public health agencies can adapt these imputation scenarios to their aggregate data to adjust surveillance data for use in population indicators of health equity.

Development of a usability checklist for public health dashboards to identify violations of usability principles.

OBJECTIVE: To develop a usability checklist for public health dashboards. MATERIALS AND METHODS: This study systematically evaluated all publicly available dashboards for sexually transmitted infections on state health department websites in the United States (N = 13). A set of 11 principles derived from the information visualization literature were used to identify usability problems that violate critical usability principles: spatial organization, information coding, consistency, removal of extraneous ink, recognition rather than recall, minimal action, dataset reduction, flexibility to user experience, understandability of contents, scientific integrity, and readability. Three user groups were considered for public health dashboards: public health practitioners, academic researchers, and the general public. Six reviewers with usability knowledge and diverse domain expertise examined the dashboards using a rubric based on the 11 principles. Data analysis included quantitative analysis of experts' usability scores and qualitative synthesis of their textual comments. RESULTS: The dashboards had varying levels of complexity, and the usability scores were dependent on the dashboards' complexity. Overall, understandability of contents, flexibility, and scientific integrity were the areas with the most major usability problems. The usability problems informed a checklist to improve performance in the 11 areas. DISCUSSION: The varying complexity of the dashboards suggests a diversity of target audiences. However, the identified usability problems suggest that dashboards' effectiveness for different groups of users was limited. CONCLUSIONS: The usability of public health data dashboards can be improved to accommodate different user groups. This checklist can guide the development of future public health dashboards to engage diverse audiences.

The Setting-Intervention Fit of Nine Evidence-Based Interventions for Substance Use Disorders Within HIV Service Organizations Across the United States: Results of a National Stakeholder-Engaged Real-Time Delphi Study.

BACKGROUND: Given substance use disorders (SUDs) among people with HIV are highly prevalent, integrating SUD services within HIV service settings is needed to help end the HIV epidemic. In this study, we assessed the setting-intervention fit (SIF) of 9 evidence-based SUD interventions: acamprosate, disulfiram, oral naltrexone, injectable naltrexone, oral buprenorphine, injectable buprenorphine, contingency management, motivational interviewing, and cognitive behavioral therapy (CBT). SETTING: Clinical and nonclinical HIV service organizations (HSOs) in the United States. METHODS: In May 2020, a stakeholder-engaged real-time Delphi was completed with 202 HSOs. HSO respondents rated the extent to which each SUD intervention was fundable, implementable, retainable, sustainable, scalable, and timely for their HSO, and these 6 items were summed into an SIF score (possible range of 0-18). RESULTS: Motivational interviewing had the highest average SIF score (11.42), with SIF scores above the midpoint (9.5) for clinical (11.51) and nonclinical HSOs (11.36). For nonclinical HSOs, none of the other interventions were above the midpoint. For clinical HSOs, the average SIF scores were above the midpoint for CBT (10.97) and oral buprenorphine (9.51). Multivariate regression analyses, which controlled for characteristics of the HSO respondent, revealed geographic region of the United States and whether the HSO currently offered any substance use services as 2 of the best predictors of SIF scores. CONCLUSIONS: Notwithstanding the need to improve the SIF for the other evidence-based SUD interventions, motivational interviewing, CBT, and oral buprenorphine are currently the evidence-based SUD interventions with greatest perceived fit for integration within HSOs in the United States.

Variation in Patterns of Racial and Ethnic Disparities in Primary and Secondary Syphilis Diagnosis Rates Among Heterosexually Active Women by Region and Age Group in the United States.

BACKGROUND: Syphilis rates have increased substantially over the past decade. Women are an important population because of negative sequalae and adverse maternal outcomes including congenital syphilis. We assessed whether racial and ethnic disparities in primary and secondary (P&S) syphilis among heterosexually active women differ by region and age group. METHODS: We synthesized 4 national surveys to estimate numbers of heterosexually active women in the United States from 2014 to 2018 by region, race and ethnicity, and age group (18-24, 25-29, 30-44, and ≥45 years). We calculated annual P&S syphilis diagnosis rates, assessing disparities with rate differences and rate ratios comparing White, Hispanic, and Black heterosexually active women. RESULTS: Nationally, annual rates were 6.42 and 2.20 times as high among Black and Hispanic than among White heterosexually active women (10.99, 3.77, and 1.71 per 100,000, respectively). Younger women experienced a disproportionate burden of P&S syphilis and the highest disparities. Regionally, the Northeast had the highest Black-White and Hispanic-White disparities using a relative disparity measure (relative rate), and the West had the highest disparities using an absolute disparity measure (rate difference). CONCLUSIONS: To meet the racial and ethnic disparity goals of the Sexually Transmitted Infections National Strategic Plan, tailored local interventions that address the social and structural factors associated with disparities are needed for different age groups.

The Prevalence and Negative Impacts of Substance Use Disorders among People with HIV in the United States: A Real-Time Delphi Survey of Key Stakeholders.

Although HIV and substance use disorders (SUDs) constitute a health syndemic, no research to date has examined the perceived negative impacts of different SUDs for people with HIV (PWH). In May 2019, 643 stakeholders in the U.S., representing clients of AIDS service organizations (ASOs), ASO staff, and HIV/AIDS Planning Council members, participated in an innovative Stakeholder-Engaged Real-Time Delphi (SE-RTD) survey focused on the prevalence and individual-level negative impact of five SUDs for PWH. The SE-RTD method has advantages over conventional survey methods by efficiently sharing information, thereby reducing the likelihood that between-group differences are simply due to lack of information, knowledge, and/or understanding. The population-level negative impacts were calculated by weighting each SUD's individual-level negative impact on indicators of the HIV Care Continuum and other important areas of life by the perceived prevalence of each SUD. Overall, we found these SUDs to have the greatest population-level negative impact scores (possible range 0-24): alcohol use disorder (population-level negative impact = 6.9; perceived prevalence = 41.9%), methamphetamine use disorder (population-level negative impact = 6.5; perceived prevalence = 3.2%), and opioid use disorder (population-level negative impact = 6.4; perceived prevalence = 34.6%). Beyond further demonstration of the need to better integrate SUD services within HIV settings, our findings may help inform how finite funding is allocated for addressing the HIV-SUD syndemic within the U.S. Based on our findings, such future efforts should prioritize the integration of evidence-based treatments that help address use disorders for alcohol, methamphetamine, and opioids.

Racial and ethnic disparities in HIV diagnoses among heterosexually active persons in the United States nationally and by state, 2018.

BACKGROUND: Despite declining HIV infection rates, persistent racial and ethnic disparities remain. Appropriate calculations of diagnosis rates by HIV transmission category, race and ethnicity, and geography are needed to monitor progress towards reducing systematic disparities in health outcomes. We estimated the number of heterosexually active adults (HAAs) by sex and state to calculate appropriate HIV diagnosis rates and disparity measures within subnational regions. METHODS: The analysis included all HIV diagnoses attributed to heterosexual transmission in 2018 in the United States, in 50 states and the District of Columbia. Logistic regression models estimated the probability of past-year heterosexual activity among adults in three national health surveys, by sex, age group, race and ethnicity, education category, and marital status. Model-based probabilities were applied to estimated counts of HAAs by state, which were synthesized through meta-analysis. HIV diagnoses were overlaid to calculate racial- and ethnic-specific rates, rate differences (RDs), and rate ratios (RRs) among HAAs by sex and state. RESULTS: Nationally, HAA women have a two-fold higher HIV diagnosis rate than HAA men (rate per 100,000 HAAs, women: 6.57; men: 3.09). Compared to White non-Hispanic HAAs, Black HAAs have a 20-fold higher HIV diagnosis rate (RR, men: 21.28, women: 19.55; RD, men: 15.40, women: 31.78) and Hispanic HAAs have a 4-fold higher HIV diagnosis rate (RR, men: 4.68, RD, women: 4.15; RD, men: 2.79, RD, women: 5.39). Disparities were ubiquitous across regions, with >75% of states in each region having Black-to-White RR ≥10. CONCLUSION: The racial and ethnic disparities across regions suggests a system-wide failure particularly with respect to preventing HIV among Black and Hispanic women. Pervasive disparities emphasize the role for coordinated federal responses such as the current Ending the HIV Epidemic (EHE) initiative.

Resilience-Focused HIV Care to Promote Psychological Well-Being During COVID-19 and Other Catastrophes.

The COVID-19 pandemic has adversely affected people with HIV due to disruptions in prevention and care services, economic impacts, and social isolation. These stressors have contributed to worse physical health, HIV treatment outcomes, and psychological wellness. Psychological sequelae associated with COVID-19 threaten the overall well-being of people with HIV and efforts to end the HIV epidemic. Resilience is a known mediator of health disparities and can improve psychological wellness and behavioral health outcomes along the HIV Continuum of Care. Though resilience is often organically developed in individuals as a result of overcoming adversity, it may be fostered through multi-level internal and external resourcing (at psychological, interpersonal, spiritual, and community/neighborhood levels). In this Perspective, resilience-focused HIV care is defined as a model of care in which providers promote optimum health for people with HIV by facilitating multi-level resourcing to buffer the effects of adversity and foster well-being. Adoption of resilience-focused HIV care may help providers better promote well-being among people living with HIV during this time of increased psychological stress and help prepare systems of care for future catastrophes. Informed by the literature, we constructed a set of core principles and considerations for successful adoption and sustainability of resilience-focused HIV care. Our definition of resilience-focused HIV care marks a novel contribution to the knowledge base and responds to the call for a multidimensional definition of resilience as part of HIV research.

Predictors of State-Level Stay-at-Home Orders in the United States and Their Association With Mobility of Residents.

OBJECTIVE: To evaluate predictors of stay-at-home order adoption among US states, as well as associations between order enactment and residents' mobility. DESIGN: We assess associations between state characteristics and adoption timing. We also assess associations between enactment and aggregate state-level measures of residents' mobility (Google COVID-19 Community Mobility Reports). SETTING: The United States. PARTICIPANTS: Adoption population: 50 US states and District of Columbia. Mobility population: state residents using devices with GPS tracking accessible by Google. INTERVENTION AND EXPOSURES: State characteristics: COVID-19 diagnoses per capita, 2016 Trump vote share, Republican governor, Medicaid expansion status, hospital beds per capita, public health funding per capita, state and local tax revenue per capita, median household income, population, percent residents 65 years or older, and percent urban residents. Mobility exposure: indicator of order enactment by March 29, 2020 (date of mobility data collection). MAIN OUTCOME MEASURES: Order adoption timing: days since adoption of first order. Mobility: changes in mobility to 6 locations from February 6 to March 29, 2020. RESULTS: In bivariate models, order adoption was associated with COVID-19 diagnoses (hazard ratio [HR] = 1.01; 95% confidence interval [CI], 1.00 to 1.01), Republican governor (HR = 0.24; 95% CI, 0.13 to 0.44), Medicaid expansion (HR = 2.50; 95% CI, 1.40 to 4.48), and hospital capacity (HR = 0.43; 95% CI, 0.26 to 0.70), consistent with findings in the multivariate models. Order enactment was positively associated with time at home (beta (B) = 1.31; 95% CI, 0.35 to 2.28) and negatively associated with time at retail and recreation (B = -7.17; 95% CI, -10.89 to -3.46) and grocery and pharmacy (B = -8.28; 95% CI, -11.97 to -4.59) locations. Trump vote share was associated with increased mobility for 4 of 6 mobility measures. CONCLUSIONS AND RELEVANCE: While politics influenced order adoption, public health considerations were equally influential. While orders were associated with decreased mobility, political ideology was associated with increased mobility under social distancing policies.

A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018.

OBJECTIVES: In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies. METHODS: We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings. RESULTS: The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed. CONCLUSIONS: Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.

Ending the HIV Epidemic: New York's Quest to Become the First State to Reduce HIV Prevalence.

In 2014, New York State became the first jurisdiction to launch a statewide initiative to end AIDS by reducing the number of persons living with HIV for the first time since effective HIV treatment became available. The Ending the Epidemic (ETE) initiative encompasses (1) identifying and linking undiagnosed persons with HIV to care, (2) retaining persons with HIV in care, and (3) facilitating access to preexposure prophylaxis for persons at risk for acquiring HIV. We used a framework for public health program implementation to describe key characteristics of the ETE initiative, present progress toward 13 ETE target metrics, and identify areas in need of increased programming. We provide evidence suggesting that New York State is on track to end AIDS as an epidemic by the end of 2020. As of 2017, 76% of progress toward our primary ETE target had been achieved. Substantial progress on several additional metrics critical to decreasing HIV prevalence and to improving the health of persons living with HIV had also been achieved. Lessons learned included the following: (1) ETE-based programming should be tailored to each jurisdiction's unique political and social climate, HIV epidemiology, fiscal resources, and network of HIV service providers; (2) key stakeholders should be involved in developing ETE metrics and setting targets; (3) performance-based measurement and timely communication to key stakeholders in real time are essential; and (4) examining trends in HIV prevention and care metrics is important for developing realistic ETE timelines.

Simulating the End of AIDS in New York: Using Participatory Dynamic Modeling to Improve Implementation of the Ending the Epidemic Initiative.

OBJECTIVES: In 2014, the governor of New York announced the Ending the Epidemic (ETE) plan to reduce annual new HIV infections from 3000 to 750, achieve a first-ever decrease in HIV prevalence, and reduce AIDS progression by the end of 2020. The state health department undertook participatory simulation modeling to develop a baseline for comparing epidemic trends and feedback on ETE strategies. METHODS: A dynamic compartmental model projected the individual and combined effects of 3 ETE initiatives: enhanced linkage to and retention in HIV treatment, increased preexposure prophylaxis (PrEP) among men who have sex with men, and expanded housing assistance. Data inputs for model calibration and low-, medium-, and high-implementation scenarios (stakeholders' rollout predictions, and lower and upper bounds) came from surveillance and program data through 2014, the literature, and expert judgment. RESULTS: Without ETE (baseline scenario), new HIV infections would decline but remain >750, and HIV prevalence would continue to increase by 2020. Concurrently implementing the 3 programs would lower annual new HIV infections by 16.0%, 28.1%, and 45.7% compared with baseline in the low-, medium-, and high-implementation scenarios, respectively. In all concurrent implementation scenarios, although annual new HIV infections would remain >750, there would be fewer new HIV infections than deaths, yielding the first-ever decrease in HIV prevalence. PrEP and enhanced linkage and retention would confer the largest population-level changes. CONCLUSIONS: New York State will achieve 1 ETE benchmark under the most realistic (medium) implementation scenario. Findings facilitated framing of ETE goals and underscored the need to prioritize men who have sex with men and maintain ETE's multipronged approach, including other programs not modeled here.