A qualitative study evaluating COVID-19 vaccine hesitancy among individuals living in Mississippi.

Background: COVID-19 vaccination rates are lower in the Southern United States compared to other regions. This study investigated COVID-19 vaccination hesitancy in Mississippi (MS) to identify preferences that may boost MS vaccination strategies in areas with poor vaccine uptake. Methods: Qualitative interviews were completed between April 2021 and January 2022 with staff and patients at four Federally Qualified Health Centers in MS. Interviews included the following COVID-19 vaccine topics: willingness to be vaccinated, barriers and facilitators, and methods for providing vaccine information. Data were organized with NVivo software and analyzed using reflexive thematic analysis. Results: Fifteen clinic staff and 49 patients were interviewed. Barriers to vaccine uptake included a lack of knowledge and understanding of how the vaccine worked, distrust of the government, fear of side effects, and social pressure to stay unvaccinated. Vaccination facilitators included its widespread accessibility, a desire to protect themselves and vulnerable populations, and a previous unpleasant COVID-19 illness experience. Participants stated that vaccine information should be provided by health organizations and familiar, respected community members. Conclusions: Results identified barriers to vaccination, such as mistrust of the government and healthcare system, and facilitators like vaccination advocacy originating from congregations and religious leaders. These findings can inform future COVID-19 vaccination efforts to increase overall immunization rates in MS. Future research in other locations could further assess commonalities and differences in the barriers and facilitators to vaccination.

Social, Structural, Behavioral, and Clinical Barriers Influencing Pre-exposure Prophylaxis (PrEP) Use Among Young Black Men Who Have Sex with Men in the South: A Qualitative Update to a 2016 Study.

Antiretroviral pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV. Despite its promise, PrEP use is low, especially among young Black men who have sex with men (YBMSM). The prevalence of HIV in Mississippi (MS) is among the highest in the United States, with the bulk of new infections occurring amongst YBMSM living in Jackson, MS. We recruited 20 PrEP-eligible YBMSM and 10 clinic staff from MS health clinics between October 2021 and April 2022. Data were collected remotely using in-depth interviews and a brief survey, which lasted approximately 45-60 min. Interview content included PrEP knowledge/experiences, HIV risk perception, and PrEP use barriers and facilitators. Qualitative data were coded then organized using NVivo. Using thematic analysis methodology, data were assessed for current barriers to PrEP use. An array of barriers were identified by participants. Barriers included structural factors (cost of PrEP, lack of discreet clinics, time commitment, competing interests); social factors (unaware of HIV risk, stigma and homophobia, fear that partners would find out about PrEP use, not knowing anyone on PrEP); behavioral factors (sexual risk factors, denial, less priority for prevention vs treatment); and clinical factors (misunderstood side effects, fear PrEP won't work). Significant barriers to PrEP use among YBMSM stem from structural, social, behavioral, and clinical factors. These results will inform intervention efforts tailored to mitigate barriers and improve PrEP uptake among YBMSM in the southern United States.

Considerations for PrEP Implementation at Federally Qualified Health Centers in Mississippi: Perspectives From Staff and Patients.

Pre-exposure prophylaxis (PrEP) uptake remains low in the southeastern United States ("the South"), likely owing to overlapping structural barriers, including the lack of nearby PrEP providers. Federally qualified health centers (FQHCs) are potential sites through which to expand PrEP availability in the South, and telemedicine is promising for these services. This study investigated considerations for PrEP implementation at FQHCs and the use of telemedicine through qualitative interviews with 19 FQHC staff and 17 PrEP-eligible patients in Mississippi. Results indicated that existing infrastructure and policies at FQHCs can support PrEP implementation and that additional needed resources include more education for providers and strategies to advertise PrEP services. Findings suggest that using telemedicine for PrEP can address some regional implementation barriers (e.g., transportation problems and confidentiality concerns) but may present new ones (e.g., concerns about patients performing home HIV/STI testing procedures). Results can inform future PrEP implementation efforts in the South.

The use of the brief symptom inventory among youth living with HIV: a scoping review.

The brief symptom inventory (BSI), a 53-item measure that assesses psychological distress, is a popular tool for measuring mental health symptoms among youth living with HIV (YLH) in the United States (US); however, it has been used inconsistently with this population. This scoping review summarizes discrepancies in the use of the BSI to identify opportunities to improve systematism and make recommendations for clinicians and researchers, and highlights correlates of psychological distress among YLH as measured by the BSI. Databases searched included PsycINFO, PubMed, and CENTRAL. Eligible studies that assessed psychological distress using the BSI among YLH, were conducted in the US, and were written in English. Of the 237 articles identified, 57 were selected for inclusion. Studies investigated associations between BSI scores and several variables, including pre- versus post-highly active antiretroviral therapy (ART) era, ART adherence, sexual risk behavior, substance use, stigma, social support, self-efficacy, mode of HIV infection, and sexual orientation. There was variation in BSI elements used as outcome measures, sample age ranges, and reporting of mean scores and cutoff t-scores. 89.5% (n = 51) of studies did not report which BSI norms were used in their data analysis, and 68.4% of studies (n = 39) did not report the cut-off t-score value used. Variability in study objectives restricted this study to a scoping review rather than a meta-analysis. Generalizability to non-US settings is another limitation. More consistency in how the BSI is used among YLH is needed to accurately identify distress among YLH and provide tailored interventions to address their unique challenges.

Acceptability and Comfort Regarding Remotely Delivered PrEP Services in Mississippi.

Despite the prevalence of human immunodeficiency virus (HIV) in Mississippi, access to pre-exposure prophylaxis (PrEP) is mostly limited to urban areas. Remote PrEP care via telemedicine, HIV self-testing, and prescription mail delivery can improve care in underserved communities. This mixed methods study assessed the acceptability and feasibility of using remote PrEP care, compared to alternatives. This consisted of (1) a cross-sectional survey and (2) interviews. PrEP-eligible adults were recruited from community-based organizations across Mississippi while accessing HIV testing between December 2019 and May 2022. Those surveyed (n = 63) indicated the greatest comfort in receiving PrEP via mail delivery (m = 5.14) and telemedicine (m = 4.89) and least comfort at gyms (m = 3.92). Comfort significantly differed between mail delivery and gyms (F = 2.90; P < .01). Those interviewed (n = 26) expressed relatively high comfort with remote PrEP care citing enhanced accessibility, privacy, simplicity, and quality. Remote PrEP services were acceptable and feasible among our sample, thus, should be expanded in Mississippi to address unmet needs.

Development of An Acceptance Based PrEP Intervention (ACTPrEP) to Engage Young Black MSM in the South Utilizing the Adaptome Model of Intervention Adaptation.

Objectives: HIV disproportionately affects young Black men who have sex with men (YBMSM) in the Southern United States. Pre-exposure prophylaxis (PrEP) is an efficacious, biomedical approach to prevent HIV. While Mississippi (MS) has among the highest rates of new HIV infections, it also ranks among the top three states for unmet PrEP need. Thus, increasing engagement in PrEP care for YBMSM in MS is imperative. A potential method to improve psychological flexibility and promote PrEP uptake, explored by this study, is the incorporation of Acceptance and Commitment Therapy (ACT) into PrEP interventions. ACT is an evidence-based intervention used to treat a wide range of mental and physical illnesses. Methods: Twenty PrEP-eligible YBMSM and ten clinic staff working with YBMSM in MS were surveyed and interviewed between October 2021 and April 2022. The brief survey covered PrEP structural barriers, PrEP stigma, and psychological flexibility. Interview topics included internal experiences related to PrEP, existing health behaviors, PrEP related personal values, and relevant constructs from the Adaptome Model of Intervention Adaptation (service setting, target audience, mode of delivery, and cultural adaptations). Qualitative data were coded based on ACT and the Adaptome model, organized using NVivo, then thematically analyzed. Results: Patients identified side effects, costs, and taking a daily prescription as top barriers to taking PrEP. Staff reported the top barrier to PrEP for clients was concern others would believe they were living with HIV. Levels of psychological flexibility and inflexibility varied widely among participants. The resulting thematic categories derived from the interviews included 1) thoughts, emotions, associations, memories, and sensations (TEAMS) related to PrEP and HIV, 2) general health behaviors (existing coping techniques, views on medication, HIV/PrEP approach and avoidance), 3) values related to PrEP use (relationship values, health values, intimacy values, longevity values), and 4) Adaptome Model adaptations. These results informed the development of a new intervention, ACTPrEP. Conclusions: Interview data organized by the Adaptome Model of Intervention Adaptation determined appropriate ACT-informed intervention components, content, intervention adaptations, and implementation strategies. Interventions informed by ACT that help YBMSM endure short-term discomfort related to PrEP by relating it to their values and long-term health goals are promising for increasing individuals' willingness to initiate and maintain PrEP care.

A Comparison of COVID-19 Vaccine and PrEP Hesitancy Among Individuals Living in Mississippi: A Qualitative Study.

Mississippi (MS) trails behind other states in both pre-exposure prophylaxis (PrEP) and COVID-19 vaccine uptake. This study investigated similarities in willingness to receive the COVID-19 vaccine and use PrEP. Semi-structured interviews were conducted between April 2021 and January 2022 with 15 clinical staff and 49 PrEP-eligible patients living in MS. Reflexive thematic analysis was conducted. Overall, 51% of patients were on PrEP, and 67% received the COVID-19 vaccine. Among PrEP users, 64% had received the vaccine. Participants reported similar hesitations (efficacy, side effects, and no perceived risk) and reasons for use (health autonomy and protecting themselves and others) regarding PrEP and the COVID-19 vaccine. Taking PrEP did not increase the likelihood of getting the COVID-19 vaccine, thus engaging in one prevention behavior does not lead to engaging in other prevention behaviors. However, results indicated commonalities in hesitancy and motivators to utilize both preventive measures. Future prevention and implementation efforts can be informed by these commonalities.

Impact of Homophobia and Racism on Comfort Receiving Pre-exposure Prophylaxis at Various Locations Among Black MSM in Mississippi.

Pre-exposure prophylaxis (PrEP) is underutilized among Black men who have sex with men (BMSM) in the Southern United States. We assessed comfort receiving PrEP at various locations among 65 BMSM. Chi-square and t-tests explored associations between demographics, experienced homophobia and racism, and comfort receiving PrEP. BMSM with greater experienced homophobia were less comfortable at academically affiliated clinics [X2(2, N = 59) = 10.61, p = 0.01], CBOs [X2(3, N = 59) = 10.02, p = 0.02], and STI/HIV clinics [X2(3, N = 59) = 8.63, p = 0.04]. Those with greater experienced racism were more comfortable receiving PrEP by mail [X2(3, N = 61) = 9.40, p = 0.02]. Homophobia and racism influence preferences of BMSM for where and how they receive PREP care. Private modes of PrEP delivery and interventions targeting provider and organizational bias should be explored.

Mapping Implementation Science with Expert Recommendations for Implementing Change (MIS-ERIC): Strategies to Improve PrEP Use among Black Cisgender Women Living in Mississippi.

BACKGROUND: Black women are disproportionately affected by the HIV epidemic. Strategies to increase Black women's use of pre-exposure prophylaxis (PrEP) are needed. METHODS: Interviews were conducted in Mississippi (MS) with Black, cisgender women at risk for HIV, and community healthcare clinic (CHC) staff who work directly with this population. Reflexive thematic analysis was used to identify barriers and select appropriate implementation strategies to increase PrEP care. RESULTS: Twenty Black women and twelve CHC staff were interviewed. PrEP use barriers resulted from low HIV risk awareness, lack of PrEP knowledge, and structural and stigma-related barriers. Methods for PrEP education and motivation included normalizing PrEP in public communications, providing education at places where women congregate, and tailoring PrEP content with Black women as educators. The Expert Recommendations for Implementing Change (ERIC) project provides a way for implementation scientists to select strategies that are consistent within research and practice across studies. Strategies from the ERIC project were selected to address implementation barriers. CONCLUSIONS: Tailoring PrEP implementation protocols to increase Black women's access, engagement, and adherence to PrEP is needed. This is one of the first implementation studies to incorporate these four implementation concepts into a single study: (1) implementation outcomes, (2) i-PARIHS, (3) ERIC's strategy list, and (4) operationalizing the strategies using the Proctor et al., guidelines. Results provide an in-depth comprehensive list of implementation strategies to increase PrEP uptake for Black women in MS.

The Role of Family Factors in the Outcomes of Court-Involved Youth.

Court-involved youth (CIY) comprise a significant portion of the U.S. population and have a high prevalence of psychiatric illness and substance use. Youth delinquency has also been associated with family variables and parenting practices. However, it is not known which family factors are most relevant to behavioral outcomes in CIY mandated to outpatient mental health treatment. Self-report measures from 163 CIY (M = 15.19 years; 58.3% male) starting psychiatric care in two U.S. cities were utilized in a cross-sectional analysis to examine the association of parental monitoring and family functioning with the severity and variety of delinquent acts. Results demonstrate that parental monitoring is significantly associated with the delinquent behavior of CIY in mental health treatment, beyond that of psychiatric symptoms and substance use. Improved understanding of influential family factors can enhance tailoring of existing interventions to ensure that they are relevant to the needs of CIY, especially those in psychiatric treatment.

A Review of Digital Interventions to Decrease Cannabis Use Among Patients With Comorbid Psychiatric Disorders.

OBJECTIVE: Cannabis use disorder (CUD) is associated with an elevated risk for psychiatric disorders and symptoms, contributing to poor health outcomes and increased medical costs. Unfortunately, interventions that simultaneously address cannabis use and co-occurring psychiatric disorders are limited in availability. Targeted digital interventions to reduce cannabis use could be beneficial for patients with psychiatric disorders. Digital interventions could be easily disseminated and used in numerous clinical locations, including outpatient, inpatient, residential, and community psychiatric treatment settings. METHODS: Literature on digital cannabis reduction interventions for persons with psychiatric disorders was examined between April 2021 and June 2021. Articles were obtained from PubMed and PsycINFO databases. English language randomized controlled trials (RCT), feasibility and acceptability studies, pilot studies, and published protocols were included. RESULTS: There is significant evidence that digital interventions can effectively reduce cannabis use in general, non-clinical populations. However, there is less literature examining interventions for persons living with co-occurring psychiatric illness-most of which is tailored to patients living with chronic psychosis. CONCLUSIONS: There is great need for accessible and tailored digital interventions for co-occurring CUD and psychiatric disorders.

Forty-Eight Week Outcomes of a Site-Randomized Trial of Combined Cognitive Behavioral Therapy and Medication Management Algorithm for Treatment of Depression Among Youth With HIV in the United States.

BACKGROUND: Studies suggest that manualized, measurement-guided, depression treatment is more efficacious than usual care but impact can wane. Our study among youth with HIV (YWH), aged 12-24 years at US clinical research sites in the International Maternal Pediatric Adolescent AIDS Clinical Trials Network, found a significant reduction in depressive symptoms among YWH who received a manualized, measurement-guided treatment. This paper reports outcomes up to 24 weeks after the intervention. METHODS: Eligibility included diagnosis of ongoing nonpsychotic depression. Using restricted randomization, sites were assigned to either combination cognitive behavioral therapy and medication management algorithm tailored for YWH or to enhanced standard of care, which provided psychotherapy and medication management. Site-level mean Quick Inventory for Depression Symptomatology Self-Report (QIDS-SR) scores and proportion of youth with treatment response (>50% decrease from baseline) and remission (QIDS-SR ≤ 5) were compared across arms using t tests. RESULTS: Thirteen sites enrolled 156 YWH, with baseline demographic factors, depression severity, and HIV disease status comparable across arms. At week 36, the site-level mean proportions of youth with a treatment response and remission were greater at combination cognitive behavioral therapy and medication management algorithm sites (52.0% vs. 18.8%, P = 0.02; 37.9% vs. 19.4%, P = 0.05), and the mean QIDS-SR was lower (7.45 vs. 9.75, P = 0.05). At week 48, the site-level mean proportion with a treatment response remained significantly greater (58.7% vs. 33.4%, P = 0.047). CONCLUSIONS: The impact of manualized, measurement-guided cognitive behavioral therapy and medication management algorithm tailored for YWH that was efficacious at week 24 continued to be evident at weeks 36 and 48.

A Brief Transdiagnostic Pandemic Mental Health Maintenance Intervention.

The COVID-19 pandemic qualifies as a major national and global disaster. Behavioral health providers are poised to provide psychological crisis interventions to reduce the psychosocial effects. This paper presents a brief transdiagnostic mental health maintenance intervention tailored to treat adults and families with distress symptoms as a consequence of the ongoing COVID-19 pandemic. The intervention components include evidence-based techniques which have been strategically selected to address mental health distress related to the pandemic and to prevent the escalation of distress as the pandemic continues. The intervention aims to be flexibly incorporated into care based on the provider and needs of the presenting individuals. The intervention incorporates components of evidence-based treatments such as Cognitive Behavioral Therapy and associated "third wave" therapies (e.g. Dialectical Behavioral Therapy and Acceptance and Commitment Therapy). The intervention can be delivered via telehealth and includes the following modules: 1) Agenda Setting & Avoidance Identification; 2) Responding to Difficult News/Normalizing Reactions; 3) Perspective Taking; 4) Situational Control/Acceptance; 5) Maintaining a Healthy Routine; 6) Coping with Stress; 7) Insomnia Preventions; and 8) Building Resiliency & Hope. A list of pleasurable activities that can be completed at home and technology modalities to maintain social interactions is included. The intervention also includes the Pandemic Mental Health Maintenance Intervention handout to provide to patients. Research is needed to test this intervention in a randomized controlled trial and assess efficacious intervention implementation strategies.

Site-Randomized Controlled Trial of a Combined Cognitive Behavioral Therapy and a Medication Management Algorithm for Treatment of Depression Among Youth Living With HIV in the United States.

BACKGROUND: Depression is frequent among youth living with HIV (YLWH). Studies suggest that manualized treatment guided by symptom measurement is more efficacious than usual care. SETTING: This study evaluated manualized, measurement-guided depression treatment among YLWH, aged 12-24 years at 13 US sites of the International Maternal Pediatric Adolescent AIDS Clinical Trials Network. METHODS: Using restricted randomization, sites were assigned to either a 24-week, combination cognitive behavioral therapy and medication management algorithm (COMB-R) tailored for YLWH or to enhanced standard of care, which provided standard psychotherapy and medication management. Eligibility included diagnosis of nonpsychotic depression and current depressive symptoms. Arm comparisons used t tests on site-level means. RESULTS: Thirteen sites enrolled 156 YLWH, with a median of 13 participants per site (range 2-16). At baseline, there were no significant differences between arms on demographic factors, severity of depression, or HIV status. The average site-level participant characteristics were as follows: mean age of 21 years, 45% male, 61% Black, and 53% acquired HIV through perinatal transmission. At week 24, youth at COMB-R sites, compared with enhanced standard of care sites, reported significantly fewer depressive symptoms on the Quick Inventory for Depression Symptomatology Self-Report (QIDS-SR score 6.7 vs. 10.6, P = 0.01) and a greater proportion in remission (QIDS-SR score ≤ 5; 47.9% vs. 17.0%, P = 0.01). The site mean HIV viral load and CD4 T-cell level were not significantly different between arms at week 24. CONCLUSIONS: A manualized, measurement-guided psychotherapy and medication management algorithm tailored for YLWH significantly reduced depressive symptoms compared with standard care at HIV clinics.

A Review of Interventions to Enhance HIV Medication Adherence.

PURPOSE OF REVIEW: Adherence to antiretroviral treatment (ART) is crucial for the successful treatment of HIV. Unfortunately, it is estimated that 45% of persons living with HIV (PLWH) have poor adherence to ART. To provide health care professionals and PLWH with effective tools for supporting adherence, researchers have investigated the effectiveness of psychosocial interventions to enhance adherence to ART. In this paper, interventional studies, systematic reviews, and meta-analyses that examine ART adherence interventions for PLWH are reviewed. RECENT FINDINGS: There is great variability among interventions in terms of quality, sample, measures, and outcome characteristics. Despite a diverse and wide-ranging assortment of ART adherence interventions, consistent lessons have been learned. Interventions that focus on individual and interpersonal factors have been effective for improving ART adherence; however, the improvement in adherence tends to be short-lived. Additionally, interventions are most successful when tailored to those at risk for poor adherence. Finally, theory-based interventions are more likely to be effective than non-theory-based interventions. A variety of individual-level psychological interventions have been shown to be effective in improving ART adherence in the short term. Digital and mobile interventions have the potential to improve dissemination and implementation of these evidence-based interventions and could be used to extend intervention effects. Future interventions that address issues of accessibility, inequality, structural and institutional barriers to ART adherence should also be tested and prioritized. Implementation science frameworks can be used to assess and address issues of accessibility and systematic barriers to care.

The Impact of a Mobile Gaming Intervention to Increase Adherence to Pre-exposure Prophylaxis.

Pre-exposure prophylaxis is effective in preventing HIV, but data show that its effectiveness is compromised by suboptimal adherence. This randomized controlled trial (n = 69) tested the impact of an iPhone game, Viral Combat, on PrEP adherence over 24 weeks. Tenofovir-diphosphate in red blood cells was collected as a biological outcome of adherence. At 24-weeks, intervention participants were 3.75 (95% CI: 1.20-11.77; p = 0.02) times as likely to engage in optimal PrEP dosing compared to controls. Viral Combat showed preliminary efficacy in improving PrEP adherence for diverse young men who have sex with men.

Factors associated with PrEP adherence among MSM living in Jackson, Mississippi.

Understanding the determinants of pre-exposure prophylaxis (PrEP) adherence is integral to reducing HIV incidence in the United States, especially for those at highest risk. To this end, the present study explored demographic, psychosocial, and behavioral factors related to adherence among 43 Southern, predominately Black, men who have sex with men (MSM). During the study months, 46% of the sample reported being nonadherent to PrEP. Those with more sexual partners (p = .05), greater self-efficacy for taking PrEP (p = .03), and those who felt condoms were less important (p = .02), were more likely to be adherent to PrEP at six-month follow-up. Further interventions that consider perceived sexual risk, condom use, and adherence self-efficacy are needed to improve PrEP adherence among Southern MSM.