Adapting the self-assessment of contextual fit scale for implementation of evidence-based practices in adolescent HIV settings.

BACKGROUND: Contextual fit is an important variable in the implementation of evidence-based programs (EBPs). The objectives of the current study were to examine the psychometric properties of the adapted Self-Assessment of Contextual Fit (SACF) measure for HIV clinical care settings (calling it SACF-HIV) and explore how perceptions of contextual fit varied across two different interventions (an intervention to scale up tailored motivational interviewing and an individually focused HIV prevention intervention) and 12 clinical sites. METHODS: We collected SACF-HIV data as part of a larger cross-project implementation science study (ATN 153). The study sample includes 128 clinicians, community health workers, interventionists, adherence counselors, and other members of the prevention and care team who engage in the implementation of EBPs at 12 HIV prevention and clinical care sites in the USA. We assessed the internal consistency of the SACF-HIV using Cronbach's alpha and examined the sub-dimensionality of the scale with an exploratory factor analysis. To explore concurrent validity, we examined Pearson's correlation coefficients between the adapted scale and fit-related sub-scale scores from the Evidence-Based Practice Attitudes Scale-50 (EBPAS-50). Variation in perceptions of fit by intervention was examined using descriptive statistics. RESULTS: Internal consistency of the adapted scale was strong (α=0.895). Factor analyses revealed two sub-scales-one capturing general insights regarding contextual fit, such as perceptions of skill, experience, and alignment with client needs (loadings ranging from .5 to .84), and a second centering perceptions regarding implementation support, such as resources and administrative support (loadings ranging from .89 to .97). Concurrent validity was supported by statistically significant correlations in the expected direction with EBPAS-50 fit-related sub-scales (r=.33-.35, p ≤ 0.05). SACF-HIV mean fit scores varied by intervention and the difference was statistically significant (2.78 vs. 2.53, p < 0.05). CONCLUSIONS: There are relatively few tools assessing perceptions of contextual fit in HIV clinical settings. These results suggest the 12-item adapted SACF is a reliable, valid global assessment of perceptions of contextual fit and implementation support. The SACF-HIV can be used by practitioners and researchers interested in understanding an implementation context when planning to prepare and support EBP implementation. TRIAL REGISTRATION: TMI ClinicalTrials.gov NCT03681912; YMPH ClinicalTrials.gov NCT03488914.

Using the Exploration-Preparation-Implementation-Sustainment (EPIS) Framework to prepare for the implementation of evidence-based practices into adolescent HIV settings.

Despite advances in evidence-based practices (EBP) to support HIV prevention and treatment, youth ages 13-24 experience significant disparities in HIV risk and outcomes. An important factor in this disparity is poor EBP implementation, yet implementation research is limited, particularly in youth-serving settings. This study used the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to guide the implementation of four Motivational Interviewing (MI) and MI-framed interventions into youth-serving HIV prevention and treatment settings. Key stakeholders (n = 153) across 13 sites completed pre-implementation interviews. Stakeholders' comments identified two critical factors for effective implementation: fit with the patient population and provider receptivity, including concerns about scope of practice, buy-in, and time. Stakeholders recommended strategies for structuring training, fidelity monitoring, and facilitating implementation including engaging informal leaders, collaboratively developing the implementation strategy, and site-wide implementation. Results highlight the importance of pre-implementation contextual assessment and strategic planning for identifying provider concerns and developing responsive implementation strategies.

RESUMEN: A pesar de los avances en las prácticas basadas en evidencia (EBP, por sus siglas en inglés) para apoyar la prevención y el tratamiento del VIH, los jóvenes de 13 a 24 años atraviesan disparidades significativas en el riesgo y los desenlaces del VIH. Un factor importante en esta disparidad es la implementación deficiente de las EBP, aunque la investigación sobre la implementación es limitada, particularmente en entornos que atienden a jóvenes. Este estudio utilizó el marco de Exploración, Preparación, Implementación, Mantenimiento (EPIS) para guiar la implementación de cuatro entrevistas motivacionales (MI) e intervenciones enmarcadas en MI en entornos de prevención y tratamiento del VIH que atienden a jóvenes. Las partes interesadas clave (n = 153) en 13 sitios completaron las entrevistas previas a la implementación. Los comentarios de las partes interesadas identificaron dos factores críticos para una implementación efectiva: idoneidad para la población de pacientes y receptividad de los proveedores, incluidas las preocupaciones sobre el alcance de la práctica, la aceptación y el tiempo. Las partes interesadas recomendaron estrategias para estructurar la capacitación, monitorear la fidelidad, y facilitar la implementación, incluyendo la participación de líderes informales, el desarrollo colaborativo de la estrategia de implementación y la implementación en todo el sitio. Los resultados destacan la importancia de la evaluación contextual previa a la implementación y la planificación estratégica para identificar las preocupaciones de los proveedores y desarrollar estrategias de implementación que respondan a ellas.

Impact of the COVID-19 Pandemic on the Care Continuum of Youth Living with HIV: Qualitative Study of the Scale It Up Program Clinical Sites.

The study objective was to explore the impact of COVID-19 pandemic restrictions on the clinics' ability to provide continuous healthcare services to youth (15-24 years) living with HIV (YLWH). One focused semi-structured interview was conducted with each HIV clinic site-resulting in ten interviews. Data were analyzed using thematic analysis techniques assisted by NVIVO coding software and themes indicating barriers and facilitators to providing uninterrupted healthcare were elicited. Six themes were identified that affected the care continuum of YLWH: Timeframe of clinic preparation to address COVID-19 restrictions; impact on treatment cascade monitoring data; impact on patient care; impact on staff and services offered; software use and virtual visits; community impact. With careful planning and preparation, clinics were able to successfully implement a process of care that adapted to COVID-19 restrictions. Guidance is provided on how healthcare facilities can effectively incorporate strategies to provide continued services during pandemics and natural disasters.

Factors Impacting Video Telehealth Appointment Completion During COVID-19 Pandemic Among People Living with HIV in a Community-Based Health System.

As the threat of COVID-19 on vulnerable populations continues, mitigation protocols have escalated the use of telehealth platforms, secure 2-way video platforms with audio capabilities. The goal of the current study was to examine factors associated with successful completion of video telehealth appointments in HIV care. We utilized a random effects logistic model to assess characteristics of patient encounters that predicted completed telehealth visits. Results show that factors such as identifying as black (AOR = 0.30, 95% CI 0.23-0.40, p < 0.01), identifying as heterosexual (AOR = 0.40, 95% CI, 0.29-0.55, p < 0.01), identifying as Hispanic/Latinx (AOR = 0.67, 95% CI, 0.48-0.95), having public insurance (e.g., Ryan White funding, Medicare/Medicaid) (AOR = .25, 95% CI 0.19-0.33, p < .001), and having detectable viral load (AOR = .049, 95% CI, 0.31-0.76) are negatively associated with completion of telehealth appointments. Results suggest that greater efforts to address the digital divide are needed to increase access to video telehealth.

RESUMEN: A medida que la amenaza de la pandemia de Covid-19 continúa en poblaciones vulnerables, los protocolos para mitigarla han intensificado el uso de plataformas seguras de audio y video bidireccional, conocidas como plataformas de telesalud. El objetivo del estudio actual es el examinar los factores asociados con el logro de completar las consultas por video de telesalud en la atención de personas que viven con VIH. Utilizamos un modelo logístico de efectos aleatorios para evaluar las características de los encuentros con los pacientes, para predecir si una consulta de telesalud se completó. Los resultados muestran que los factores asociados con una consulta de telesalud completa incluyen identificarse de raza negra (RMA = 0.30, 95% IC 0.23­0.40, p < 0.01), etnicidad de hispano/ latinx (RMA = 0.67, 95% IC 0.48­0.95), tener seguro de salud público, por ejemplo fondos de Ryan White, Medicare o Medicaid (RMA = 0.25, 95% IC 0.19­0.33, p < 0.01) y tener una carga viral detectable (RMA = 0.49, 95% IC 0.31­0.76, p < 0.01). Estos resultados sugieren que se necesitan mayores al para abordar el problema de la brecha digital para aumentar el acceso a la plataforma de telesalud.

Barriers and facilitators to implementing a motivational interviewing-based intervention: a multi-site study of organizations caring for youth living with HIV.

Understanding possible barriers and facilitators to effective implementation of evidence-based interventions to help high-risk youth prevent and manage HIV is crucial for their scale-up. This manuscript analyzes qualitative interview data collected during the early phase implementation of a motivational interviewing (MI) based intervention at 10 HIV care clinics in the United States providing services to youth. Using the Exploration-Preparation-Implementation-Sustainment (EPIS) framework to understand the implementation and the dynamic adaptation process (DAP) model to balance notions of intervention fidelity and flexibility, providers and stakeholders at each site (N = 97) were interviewed prior to implementation to gather their perspectives on organizational readiness for the intervention, as well as provider and client characteristics. The interviewers summarized their experience with rapid feedback forms (RFFs). Data extracted from the RFFs highlighted anticipated barriers to and facilitators of the proposed MI-based intervention, with the EPIS framework used to organize these findings. Study findings illustrate the inner and outer contextual factors that affect implementation and denote the points at which the MI-based intervention may be tailored to fit the unique context of a clinic while remaining faithful to the intervention's original design.

Transgender Women in Dominican Republic: HIV, Stigma, Substances, and Sex Work.

Exposure to stigma, violence, sex work, and substance use are associated with increased HIV risk, but relationships between these factors have not been fully elucidated among transgender women whose data are often aggregated with men who have sex with men and other sexual and gender minorities. Considering this gap, we aimed to identify a serologically confirmed HIV estimate for transgender women and examine the relationships between stigma, sex work, substance use, and HIV among a national sample of transgender women in Dominican Republic. We analyzed biomarkers and self-report data from the third wave of Dominican Republic's Encuesta de Vigilancia y Comportamiento con Vinculación Serológica, employing logistic and negative binomial regression to estimate models (n = 307). HIV rate was 35.8%. Nearly 75% of respondents engaged in sex work. Over 20% reported experiencing violence; 61.6% reported being stigmatized. Participation in sex work was associated with higher levels of stigma [incidence rate ratio (IRR): 1.70, p < 0.05]. Respondents who experienced violence had over three times higher odds of living with HIV relative to respondents who had not been victimized [odds ratio (OR): 3.15, p < 0.05]. Marijuana users were less likely to experience stigma compared with cocaine users (IRR: 1.72, p < 0.05), and a higher risk of alcohol dependency was associated with higher odds of experiencing violence (OR: 1.17, p < 0.001). Findings illustrate the importance of disaggregating data collected from transgender women compared with other sexual and gender minorities to ascertain subpopulation-specific estimates and indicate an urgent need to implement structural interventions and policies to protect transgender women's health and their human rights.

Implementation of Evidence-Based Practices to Reduce Youth HIV Transmission and Improve Self-Management: A Survey of Key Stakeholder Perspectives.

Understanding the implementation process is critical to disseminating effective interventions that reduce HIV risk and improve self-management in youth populations. As part of a multi-center implementation study, providers (N = 128) from 13 HIV prevention and care sites were surveyed to capture their perspectives on evidence-based practices (EBPs) and their discharge. We employ a descriptive analysis of their perspectives before implementation as defined by the Exploration, Preparation, Implementation, and Sustainment (EPIS) model, with comparisons between organizational role and study site. Factors of interest included the following: attitudes toward EBPs, perceptions of organizational climate, perceptions of leadership behavior, implementation climate, and provider views on organizational support. These factors were assessed using scales with 5-point Likert response options. Attitudinal domains such as Appeal (α = 3.24), Fit (α = 3.31), and Requirements (α = 3.20), were positive. Similarly, providers on average perceived organizational support efforts meant to facilitate EBP implementation (α = 2.74). Our findings point to provider attitudes, perceptions of work climate, general organizational support, and leadership as impacting adoption and sustainment of EBPs. Secondary analysis indicates that some perceptions and attitudes differ by site and by professional role in some assessment domains. Our study highlights factors such as provider attitudes and perspectives on the organizational and implementation climates and on leadership behaviors as impacting EPB implementation.

Barriers and Facilitators to the Collection and Aggregation of Electronic Health Record HIV Data: An Analysis of Study Recruitment Venues Within the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN).

Electronic health record (EHR) data can be leveraged for prospective cohort studies and pragmatic clinical trials, targeting youth living with HIV (YLH). Using EHRs in this manner may minimize the need for costly research infrastructure in service to lowering disease burden. This study characterizes HIV prevention and care continua variables and identifies factors likely to impede or facilitate EHR use for research and interventions. We conducted telephone-based qualitative interviews with National Experts (n = 10) and Key Stakeholders (n = 19) from subject recruitment venues (SRVs), providing care services to YLH and youth at risk for HIV. We found 17 different EHR systems being used for various purposes (e.g., workflow management and billing). Thematic content analysis of interviews highlighted six broad categories of perspectives on barriers to and facilitators of EHR use: specific variable collection, general use barriers, and facilitators, general data collection barriers and facilitators, EHRs for surveillance and research, EHRs for personnel and resource management and capture of HIV specific variables. These findings may inform implementation strategies of future studies, in which we conduct routine monitoring of the youth HIV prevention and care continua using EHRs and test an eHealth intervention.

Recommendations for the Development of a Mobile HIV Prevention Intervention for Men Who Have Sex With Men and Hijras in Mumbai: Qualitative Study.

BACKGROUND: As Internet and mobile phone use expands in India, there is an opportunity to develop mobile health (mHealth) interventions for marginalized populations, including men who have sex with men (MSM) and hijras (transgender women), hesitant to access traditional health care systems. OBJECTIVE: The purpose of this study was to determine if an mHealth intervention was acceptable to MSM and hijras living in Mumbai, and if so, what features would be useful in targeting the prevention of HIV acquisition and to increase the quality of life among persons living with HIV/AIDS. METHODS: Data from 4 focus groups with MSM and interviews with 4 hijras, 10 health service providers, and 8 mHealth developers were thematically analyzed. RESULTS: Once the need for an mHealth intervention was confirmed, comments about features were organized into 3 themes: content, interface, and retention. Content subthemes included providing sex education for younger community members, providing information about STIs, and providing information and social support for persons living with HIV. Interface subthemes included presenting content using pictures; using videos to present stories of role models; using push notifications for testing, appointment, and medication reminders; using geolocation to link to just-in-time services; and using telemedicine to increase access to health service providers and community services. The 5 retention subthemes included keeping it fun, using gaming mechanics, developing content in regional languages, protecting confidentiality, and linking to social networking apps. CONCLUSIONS: These findings may help inform mHealth development in India.

A qualitative investigation among men who have sex with men on the acceptability of performing a self- or partner anal exam to screen for anal cancer.

PURPOSE: Persistent infection with oncogenic human papillomavirus (HPV) is the primary cause of anal cancer, a disease that disproportionately affects men who have sex with men (MSM); however, there is no uniform screening protocol to detect anal cancer. This qualitative study explores whether a self-anal exam (SAE) or partner anal exam (PAE), that includes self-palpation or palpation of a partner's anal canal, is an acceptable and self-efficacious screening test, which will cue appropriate follow-up care in MSM. METHODS: Twenty-four MSM living in Houston took part in four focus group sessions eliciting their responses to a study teaching them to perform an SAE or PAE (SAE/PAE). Participants were asked about the acceptability and feasibility of executing an SAE/PAE routinely. Thematic analysis of session transcripts was used to identify common patterns in participant responses. RESULTS: Overall, participants expressed self-efficacy for performing an SAE/PAE and voiced a preference for being taught the procedure by a clinician. Participants agreed that they would consult with a clinician if they ever discovered an abnormality while performing an SAE/PAE. A lack of knowledge about anal cancer among MSM may present a barrier to adopting SAE/PAE. In discussing their experience of the exams, some participants suggested that it could become a routine practice for them. CONCLUSIONS: Our findings suggest that SAE and PAE, as a screen for anal cancer, are acceptable and feasible to MSM. Future research should explore attitudes and beliefs of MSM, with the aim of improving anal cancer education and understanding of pathologic findings.

Social Support, Depression, Self-Esteem, and Coping Among LGBTQ Adolescents Participating in Hatch Youth.

Evidence-based interventions that increase social support have the potential to improve the health of lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth. Hatch Youth is a group-level intervention that provides services four nights a week to LGBTQ youth between 13 and 20 years of age. Each Hatch Youth meeting is organized into three 1-hour sections: unstructured social time, consciousness-raising (education), and a youth-led peer support group. Youth attending a Hatch Youth meeting between March and June 2014 (N = 108) completed a cross-sectional survey. Covariate adjusted regression models were used to examine the association between attendance, perceived social support, depressive symptomology, self-esteem, and coping ability. Compared to those who attended Hatch Youth for less than 1 month, participants who attended 1 to 6 months or more than 6 months reported higher social support (ß1-6mo. = 0.57 [0.07, 1.07]; ß6+mo. = 0.44, 95% confidence interval [CI; 0.14, 0.75], respectively). Increased social support was associated with decreased depressive symptomology (ß = -4.84, 95% CI [-6.56, -3.12]), increased self-esteem (ß = 0.72, 95% CI [0.38, 1.06]), and improved coping ability (ß = 1.00, 95% CI [0.66, 1.35]). Hatch Youth is a promising intervention that has the potential to improve the mental health and reduce risk behavior of LGBTQ youth.