Preexposure Prophylaxis Uptake Among Spanish-Speaking Transgender Women: A Randomized Controlled Trial in North and South Carolina, 2019-2022.

Objectives. To evaluate Chicas Creando Acceso a la Salud (Girls Creating Access to Health; ChiCAS), a Spanish-language, small-group intervention designed to increase preexposure prophylaxis (PrEP) use, consistent condom use, and medically supervised gender-affirming hormone therapy use among Spanish-speaking transgender Latinas who have sex with men. Methods. Participants were 144 HIV-negative Spanish-speaking transgender Latinas, aged 18 to 59 years, living in North and South Carolina. From July 2019 to July 2021, we screened, recruited, and randomized them to the 2-session ChiCAS intervention or the delayed-intervention waitlist control. Participants completed assessments at baseline and 6-month follow-up. Follow-up retention was 94.4%. Results. At follow-up, relative to control participants, ChiCAS participants reported increased PrEP use (adjusted odds ratio [AOR] = 4.64; 95% confidence interval [CI] = 1.57, 13.7; P < .006). However, ChiCAS participants did not report increased use of condoms or medically supervised gender-affirming hormone therapy. ChiCAS participants reported increases in knowledge of HIV (P < .001), sexually transmitted infections (P < .001), and gender-affirming hormone therapy (P = .01); PrEP awareness (P < .001), knowledge (P < .001), and readiness (P < .001); condom use skills (P < .001); and community attachment (P < .001). Conclusions. The ChiCAS intervention was efficacious in increasing PrEP use among Spanish-speaking, transgender Latinas in this trial. (Am J Public Health. 2024;114(1):68-78. https://doi.org/10.2105/AJPH.2023.307444).

Cost Analysis of the Positive Health Check Intervention to Suppress HIV Viral Load and Retain Patients in HIV Clinical Care.

CONTEXT: Digital video-based behavioral interventions are effective tools for improving HIV care and treatment outcomes. OBJECTIVE: To assess the costs of the Positive Health Check (PHC) intervention delivered in HIV primary care settings. DESIGN, SETTING, AND INTERVENTION: The PHC study was a randomized trial evaluating the effectiveness of a highly tailored, interactive video-counseling intervention delivered in 4 HIV care clinics in the United States in improving viral suppression and retention in care. Eligible patients were randomized to either the PHC intervention or the control arm. Control arm participants received standard of care (SOC), and intervention arm participants received SOC plus PHC. The intervention was delivered on computer tablets in the clinic waiting rooms. The PHC intervention improved viral suppression among male participants. A microcosting approach was used to assess the program costs, including labor hours, materials and supplies, equipment, and office overhead. PARTICIPANTS: Persons with HIV infection, receiving care in participating clinics. MAIN OUTCOME MEASURES: The primary outcome was the number of patients virally suppressed, defined as having fewer than 200 copies/mL by the end of their 12-month follow-up. RESULTS: A total of 397 (range across sites [range], 95-102) participants were enrolled in the PHC intervention arm, of whom 368 participants (range, 82-98) had viral load data at baseline and were included in the viral load analyses. Of those, 210 (range, 41-63) patients were virally suppressed at the end of their 12-month follow-up visit. The overall annual program cost was $402 274 (range, $65 581-$124 629). We estimated the average program cost per patient at $1013 (range, $649-$1259) and the cost per patient virally suppressed at $1916 (range, $1041-$3040). Recruitment and outreach costs accounted for 30% of PHC program costs. CONCLUSIONS: The costs of this interactive video-counseling intervention are comparable with other retention in care or reengagement interventions.

Positive Health Check intervention tool usage during a feasibility pilot in HIV primary care clinics.

Positive Health Check (PHC), an interactive, web-based intervention, provides tailored behavioral health messages to support people with HIV in their HIV care. Users interact with a virtual doctor and based on responses to tailoring questions, PHC delivers relevant content modules addressing treatment initiation, medication adherence, retention in care, sexual risk reduction, mother-to-child transmission, and injection drug use. During a one-month feasibility pilot of PHC, patients in four HIV primary care clinics were invited to use PHC and tool usage metrics were collected and assessed. Descriptive analyses were conducted to characterize how the tool was used based on behavioral risk scenarios presented.Ninety-seven patients accessed PHC as part of the pilot, with 68 (70.1%) completing the intervention on average in 15 min. Out of 85 patients who viewed behavioral tips and commitments, 66 (77.7%) selected at least one tip to practice and 41 (48.2%) made at least one commitment to ask their provider a question. Patients spent the most time with adherence and sexual risk reduction content. The high level of tool engagement suggests that PHC was acceptable to patients regardless of length of time since diagnosis. PHC can be completed within a single visit and is a promising tool for PWH.

Adapting a Group-Level PrEP Promotion Intervention Trial for Transgender Latinas During the COVID-19 Pandemic.

The COVID-19 pandemic has profoundly affected the conduct of community-based and community-engaged research. Prior to the pandemic, our community-based participatory research partnership was testing ChiCAS, an in-person, group-level behavioral intervention designed to promote uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised gender-affirming hormone therapy among Spanish-speaking transgender Latinas. However, the pandemic required adaptations to ensure the safe conduct of the ChiCAS intervention trial. In this article, we describe adaptations to the trial within five domains. Transgender women are disproportionately affected by HIV, and it is essential to find ways to continue research designed to support their health within the context of the COVID-19 pandemic and future infectious disease outbreaks, epidemics, and pandemics. These adaptations offer guidance for ongoing and future community-based and community-engaged research during the COVID-19 pandemic and/or potential subsequent outbreaks (e.g., monkeypox), epidemics, and pandemics, particularly within under-served marginalized and minoritized communities.

Effectiveness of an Interactive, Highly Tailored "Video Doctor" Intervention to Suppress Viral Load and Retain Patients With HIV in Clinical Care: A Randomized Clinical Trial.

BACKGROUND: To determine whether Positive Health Check, a highly tailored video doctor intervention, can improve viral suppression and retention in care. SETTING: Four clinics that deliver HIV primary care. METHODS: A hybrid type 1 effectiveness-implementation randomized trial design was used to test study hypotheses. Participants (N = 799) who were not virally suppressed, were new to care, or had fallen out of care were randomly assigned to receive Positive Health Check or the standard of care alone. The primary endpoint was viral load suppression, and the secondary endpoint was retention in care, both assessed at 12 months, using an intention-to-treat approach. A priori subgroup analyses based on sex assigned at birth and race were examined as well. RESULTS: There were no statistically significant differences between Positive Health Check (N = 397) and standard of care (N = 402) for either endpoint. However, statistically significant group differences were identified from a priori subgroup analyses. Male participants receiving Positive Health Check were more likely to achieve suppression at 12 months than male participants receiving standard of care adjusted risk ratio [aRR] [95% confidence interval (CI)] = 1.14 (1.00 to 1.29), P = 0.046}. For retention in care, there was a statistically significant lower risk for a 6-month visit gap in the Positive Health Check arm for the youngest participants, 18-29 years old [aRR (95% CI) = 0.55 (0.33 to 0.92), P = 0.024] and the oldest participants, 60-81 years old [aRR (95% CI) = 0.49 (0.30 to 0.81), P = 0.006]. CONCLUSIONS: Positive Health Check may help male participants with HIV achieve viral suppression, and younger and older patients consistently attend HIV care. REGISTRY NAME: Positive Health Check Evaluation Trial. Trial ID: 1U18PS004967-01. URL: https://clinicaltrials.gov/ct2/show/NCT03292913.

HIV Testing Before and During the COVID-19 Pandemic - United States, 2019-2020.

HIV testing is a core strategy for the Ending the HIV Epidemic in the U.S. (EHE) initiative, which has the aim of reducing new HIV infections by at least 90% by 2030.* During 2016-2017, jurisdictions with the highest HIV diagnosis rates were those with higher prevalences of HIV testing; past-year HIV testing was higher among persons who reported recent HIV risk behaviors compared with those who did not report these risks (1). During 2020-2021, the COVID-19 pandemic disrupted health care delivery, including HIV testing in part because many persons avoided services to comply with COVID-19 risk mitigation efforts (2). In addition, public health departments redirected some sexual health services to COVID-19-related activities.† CDC analyzed data from four national data collection systems to assess the numbers of HIV tests performed and HIV infections diagnosed in the United States in the years before (2019) and during (2020) the COVID-19 pandemic. In 2020, HIV diagnoses reported to CDC decreased by 17% compared with those reported in 2019. This decrease was preceded by decreases in HIV testing during the same period, particularly among priority populations including Black or African American (Black) gay men, Hispanic or Latino (Hispanic) gay men, bisexual men, other men who have sex with men (MSM), and transgender persons in CDC-funded jurisdictions. To compensate for testing and diagnoses missed during the COVID-19 pandemic and to accelerate the EHE initiative, CDC encourages partnerships among federal organizations, state and local health departments, community-based organizations, and health care systems to increase access to HIV testing services, including strategies such as self-testing and routine opt-out screening in health care settings.

A Longitudinal Mixed-Methods Examination of Positive Health Check: Implementation Results From a Type 1 Effectiveness-Implementation Hybrid Trial.

BACKGROUND: Positive Health Check is an evidence-based video doctor intervention developed for improving the medication adherence, retention in care, and viral load suppression of people with HIV receiving clinical care. SETTING: Four HIV primary care clinics within the United States. METHODS: As part of a type 1 hybrid trial, a mixed-methods approach was used to longitudinally assess the following 3 key implementation constructs over a 23-month period: innovation-values fit (ie, the extent to which staff perceive innovation use will foster the fulfillment of their values), organizational readiness for change (ie, the extent to which organizational members are psychologically and behaviorally prepared to implement organizational change), and implementation climate (ie, the extent to which implementation is expected, supported, and rewarded). Quantitative mixed-effects regression analyses were conducted to assess changes over time in these constructs. Qualitative analyses were integrated to help provide validation and understanding. RESULTS: Innovation-values fit and organizational readiness for change were found to be high and relatively stable. However, significant curvilinear change over time was found for implementation climate. Based on the qualitative data, implementation climate declined toward the end of implementation because of decreased engagement from clinic champions and differences in priorities between research and clinic staff. CONCLUSIONS: The Positive Health Check intervention was found to fit within HIV primary care service settings, but there were some logistical challenges that needed to be addressed. Additionally, even within the context of an effectiveness trial, significant and nonlinear change in implementation climate should be expected over time.

HIV Testing Program Activities and Challenges in Four U.S. Urban Areas.

The national "Ending the HIV Epidemic: A Plan for America" supports expanded testing in jurisdictions and groups with disproportionate HIV burden. Public health planners benefit from learning HIV testing service (HTS) strengths, challenges, and innovations. We conducted semistructured interviews with 120 HTS staff from local health departments, community-based organizations, and community members in Houston, Texas; Miami, Florida; New Orleans, Louisiana; and Washington, DC. We coded interview transcripts using qualitative methods to identify themes. Program strengths include HIV testing integration with other client services; prioritized testing and tailored incentives; multiple advertising methods; and partnerships among HTS providers. Challenges include stigma, fear, and disparities; funding requirements that create competition between providers; and service accessibility, unnecessary repeat testing, and insufficient innovation. The four jurisdictions addressed some, but not all, of these challenges. Cross-jurisdictional collaboration, together with state and federal partners plus program data may help identify additional strategies for strengthening HTS.

Evaluating Locally Developed Interventions to Promote PrEP Among Racially/Ethnically Diverse Transgender Women in the United States: A Unique CDC Initiative.

In the United States, transgender women are disproportionately affected by HIV. However, few evidence-based prevention interventions exist for this key population. We describe two promising, locally developed interventions that are currently being implemented and evaluated through the Centers for Disease Control and Prevention Combination HIV Prevention for Transgender Women Project: (a) ChiCAS, designed to promote the uptake of pre-exposure prophylaxis (PrEP), condom use, and medically supervised hormone therapy among Spanish-speaking transgender Latinas, and (b) TransLife Care, designed to address the structural drivers of HIV risk through access to housing, employment, legal services, and medical services, including HIV preventive care (e.g., PrEP use) among racially/ethnically diverse urban transgender women. If the evaluation trials determine that these interventions are effective, they will be among the first such interventions for use with transgender women incorporating PrEP, thereby contributing to the evidence-based resources that may be used to reduce HIV risk among this population.

STEPS to Care: Translating an Evidence-Informed HIV Care Coordination Program Into a Field-Tested Online Practice Improvement Toolkit.

Increasing care engagement is essential to meet HIV prevention goals and achieve viral suppression. It is difficult, however, for agencies to establish the systems and practice improvements required to ensure coordinated care, especially for clients with complex health needs. We describe the theory-driven, field-informed transfer process used to translate key components of the evidence-informed Ryan White Part A New York City Care Coordination Program into an online practice improvement toolkit, STEPS to Care (StC), with the potential to support broader dissemination. Informed by analyses of qualitative and quantitative data collected from eight agencies, we describe our four phases: (1) review of StC strategies and key elements, (2) translation into a three-part toolkit: Care Team Coordination, Patient Navigation, and HIV Self-Management, (3) pilot testing, and (4) toolkit refinement for national dissemination. Lessons learned can guide the translation of evidence-informed strategies to online environments, a needed step to achieve wide-scale implemention.

Tracking linkage to care in an anonymous HIV testing context: A field assessment in Mozambique.

RATIONALE: Effective human immunodeficiency virus (HIV) prevention requires a coordinated continuum of services to foster early diagnosis and treatment. Early linkage to care (LTC) is critical, yet programmes differ in strategies to monitor LTC. METHODS: In 2014, we visited 23 HIV testing and care service delivery points in Mozambique to assess programme strategies for monitoring LTC. We interviewed key informants, reviewed forms, and matched records across service points to identify successful models and challenges. RESULTS: Forms most useful for tracking LTC included individual identifiers, eg, patient name, unique identifier (ie, National Health Identification Number [NID]), sex, and date of birth. The majority (67%) of records matched occurred in the presence of a unique NID. Key informants described challenges related to processes, staffing, and communication between service delivery points to confirm LTC. CONCLUSIONS: While tracking clients from HIV testing to care is possible, programmes with insufficient tracking procedures are likely to underreport LTC. Adoption of additional patient identifiers in testing registers and standardized protocols may improve LTC programme monitoring and reduce underreporting.

Increasing partner HIV testing and linkage to care in TB settings: findings from an implementation study in Pwani, Tanzania.

Couples HIV testing for tuberculosis (TB) patients and their partners may be an effective means to identify HIV-positive persons and strengthen linkage to HIV care. We evaluated an intervention to increase HIV testing and linkage to care (LTC) of newly diagnosed persons and re-linkage for TB/HIV patients in Pwani, Tanzania. In 2014, 12 TB settings within two regional clusters participated; each cluster included ≥1 referral hospital, health center, and directly observed therapy center. Three months after introducing tools to record HIV service delivery, TB clinic staff and peer education volunteers in Cluster 1 received training on HIV partner testing and linkage/re-linkage, and staff in the second cluster received training 3 months thereafter. Twelve months after tools were introduced, clinic records were abstracted to assess changes in couples HIV testing, LTC, and re-linkage. Staff interviews assessed the feasibility and acceptability of the service delivery model. HIV prevalence was high among TB patients during the study period (44.9%; 508/1132), as well as among others who received HIV testing (19.8%; 253/1288). Compared to pre-implementation, couples HIV testing increased in both clusters from 1.8% to 35.2%. Documented LTC increased (from 5.7% to 50.0%) following the introduction of the tools. Additional increases in LTC (from 57.9% to 79.3%) and re-linkage (from 32.9% to 53.7%) followed Cluster 1 training, but no additional increases after Cluster 2 training. Staff perceived little burden associated with service delivery. This study demonstrated a feasible, low-burden approach to expand couples HIV testing and linkage of HIV-positive persons to care. TB settings in sub-Saharan Africa serve populations at disproportionate risk for HIV infection and should be considered key venues to expand access to effective HIV prevention strategies for both patients and their partners. HIV services in TB settings should include HIV testing, condom distribution, and linkage to appropriate additional services.

Building Capacity for Data-Driven Decision Making in African HIV Testing Programs: Field Perspectives on Data Use Workshops.

Strategic, high quality HIV testing services (HTS) delivery is an essential step towards reaching the end of AIDS by 2030. We conducted HTS Data Use workshops in five African countries to increase data use for strategic program decision-making. Feedback was collected on the extent to which workshop skills and tools were applied in practice and to identify future capacity-building needs. We later conducted six semistructured phone interviews with workshop planning teams and sent a web-based survey to 92 past participants. The HTS Data Use workshops provided accessible tools that were readily learned by most respondents. While most respondents reported increased confidence in interpreting data and frequency of using such tools over time, planning team representatives indicated ongoing needs for more automated tools that can function across data systems. To achieve ambitious global HIV/AIDS targets, national decision makers may continue to seek tools and skill-building opportunities to monitor programs and identify opportunities to refine strategies.

Occupational exposure to bloodborne pathogens among health care workers in Botswana: Reporting and utilization of postexposure prophylaxis.

BACKGROUND: This study assessed reporting behavior and satisfaction with postexposure prophylaxis (PEP) systems among health care workers (HCWs) at risk for occupational bloodborne pathogen exposure (BPE) in 3 public hospitals in Botswana. METHODS: A cross-sectional survey among HCWs provided information on perceptions, attitudes, and experiences with occupational exposures, reporting, and postexposure care. HCWs potentially in contact with blood or body fluids were surveyed using audio computer-assisted self-interview. RESULTS: Between August 2012 and April 2013, 1,624 HCWs completed the survey; most were women (72%), and almost half (48%) were nurses. Sixty-seven percent of them had ever received training related to BPE management; 62% perceived themselves to be at high risk for BPE. Among the 426 HCWs who were exposed to sharps injuries or splashes in the last 6 months, 160 (37%) reported the exposure. Of these, 111 of the 160 (69%) received PEP, and 79 of the 111 (71%) completed their medication. Whereas >92% of the total HCWs had ever been tested for HIV, only 557 (37%) were tested in their own health facility. Most HCWs (87%, n = 1,406) reported they would be interested in testing themselves. Of HCWs who reported an exposure, less than half (49%, n = 78) were satisfied with existing reporting systems. CONCLUSIONS: Underreporting of occupational exposures and dissatisfaction with PEP management is common among HCWs. Improved PEP management strategies and regular monitoring are needed.

Shifting Resources and Focus to Meet the Goals of the National HIV/AIDS Strategy: The Enhanced Comprehensive HIV Prevention Planning Project, 2010-2013.

In September 2010, CDC launched the Enhanced Comprehensive HIV Prevention Planning (ECHPP) project to shift HIV-related activities to meet goals of the 2010 National HIV/AIDS Strategy (NHAS). Twelve health departments in cities with high AIDS burden participated. These 12 grantees submitted plans detailing jurisdiction-level goals, strategies, and objectives for HIV prevention and care activities. We reviewed plans to identify themes in the planning process and initial implementation. Planning themes included data integration, broad engagement of partners, and resource allocation modeling. Implementation themes included organizational change, building partnerships, enhancing data use, developing protocols and policies, and providing training and technical assistance for new and expanded activities. Pilot programs also allowed grantees to assess the feasibility of large-scale implementation. These findings indicate that health departments in areas hardest hit by HIV are shifting their HIV prevention and care programs to increase local impact. Examples from ECHPP will be of interest to other health departments as they work toward meeting the NHAS goals.

Reporting and case management of occupational exposures to blood-borne pathogens among healthcare workers in three healthcare facilities in Tanzania.

BACKGROUND: In sub-Saharan Africa, blood-borne pathogens exposure (BPE) is a serious risk to healthcare workers (HCW). METHODS: We conducted a cross-sectional study assessing BPE among HCW at three public hospitals in Tanzania. From August to November 2012, HCW were surveyed using Audio-Computer Assisted Self-Interview. All HCW at risk for BPE were invited to participate. Factors associated with reporting BPE were identified using logistic regression. FINDINGS: Of the 1102 eligible HCW, 973 (88%) completed the survey. Of these, 690 (71%) were women and 499 (52%) were nurses and nurse assistants. Of the 357 HCW who had a BPE (32%) in the previous 6 months, 120 (34%) reported it. Among these 120 reported exposures, 93 (78%) HCWs reported within 2 h of exposure, 98 (82%) received pre- and post-HIV test counselling, and 70 (58%) were offered post-exposure prophylaxis (PEP). Independent factors associated with reporting BPE were being female (adjusted odds ratio [AOR], 2.0; 95% confidence interval [CI], 1.2-3.5), having ever-received BPE training (AOR, 2.0; 95% CI, 1.2-3.5), knowledge that HCW receive PEP at another facility (AOR, 2.6; 95% CI, 1.5-4.4), low/no perceived risk related to BPE (AOR, 4.2; 95% CI, 1.9-9.4) and HIV testing within the past year (AOR, 2.3; 95% CI, 1.2-4.4). CONCLUSION: These results highlight the importance of appropriate training on the prevention and reporting of occupational exposure to increase acceptance of HIV testing and improve access to PEP after BPE.

Re-Testing and Seroconversion Among HIV Testing and Counseling Clients in Lesotho.

HIV testing and counseling (HTC) is an essential component of comprehensive HIV programs. Retrospective HTC program data from 2006 to 2010 were examined to determine patterns of re-testing and seroconversion in Lesotho. Among 104,662 initially negative clients, 6,777 (6.5%) were re-testers. Predictors of re-testing included being male, age ≥ 25 years, divorced/separated, having more than a high school education, being tested as a couple, testing in the year 2006, testing in the capital city, and awareness of partner's recent testing behavior. Among re-testers who seroconverted (N = 259), predictors included being female and having less than a high school education. There is a critical need for more effectively targeting HIV retesting messages to align with WHO (2010) guidelines and identify persons at highest risk for HIV, to increase timely diagnoses and link persons to appropriate HIV prevention, care, and treatment services.

The experiences, needs, and Internet use of women recently diagnosed with HIV.

Women constitute an increasing proportion of persons diagnosed with HIV in the United States. From September 2007 through June 2008, in-depth interviews were conducted with 20 women diagnosed with HIV in the previous 12 months to explore their experiences immediately following their diagnoses. Most women had at least a high school education (90%) and were African American (45%) or Hispanic (15%). Analysis of transcripts showed that: (a) many women were surprised by the diagnosis because they did not fit the profile of people at high risk for HIV, (b) obtaining social support immediately after an HIV diagnosis was a primary need, and (c) HIV had an impact on a woman's role in her family. We concluded that strategies are urgently needed to identify women at risk for HIV in a timely manner, and addressing the unique experiences and needs of women recently diagnosed with HIV is critical to their well-being.

Addressing poverty and HIV using microenterprise: findings from qualitative research to reduce risk among unemployed or underemployed African American women.

INTRODUCTION: Microenterprise programs are widely used to improve health outcomes among women internationally. However, there is little information on applicability to American women living in poverty. We conducted formative research to identify activities that are viable and attractive, that may produce income to address some proportion of economic need and could be incorporated in the development of a micro-enterprise HIV-prevention intervention to reduce HIV/STD transmission among unemployed or underemployed African American women at risk for HIV. METHODS: Focus groups were convened with young African American women and community leaders in two southern states. Interviews with women participating in the focus groups were also convened. RESULTS: Findings suggest an intervention should incorporate activities to increase self-esteem, enhance employability and job sustainability to decrease financial dependence. This research serves as the foundation for developing a novel approach to HIV prevention in the U.S. that may directly address poverty as a social determinant of health.