Community-Identified Implementation Strategies for Promoting the Adoption of HIV Self-Testing in a Southern California American Indian community: A Rapid Qualitative Analysis.

HIV incidence increased by 18% between 2015 and 2019 among American Indians (AIs) despite declining rates in other racial/ethnic groups. Culturally-appropriate implementation of prevention programs is needed to address the intersectional conditions contributing to HIV vulnerabilities experienced by AIs. The objectives of this study were to understand factors influencing HIV testing decisions and identify implementation strategies to promote the acceptability of HIV self-testing (HIVST) in a southern California AI community. A total of 15 semi-structured interviews were completed with adult community members of a southern California AI reservation. Analysis used a rapid analytic approach that was guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework and expert recommendations for implementing change (ERIC) compilation. Two team members applied a standardized summary template to elucidate implementation determinants and implementation strategies for adopting HIVST. Barriers to HIV testing identified by community members included HIV-related stigma and privacy concerns within their community. Community members expressed positive perceptions of the acceptability of HIVST, with many identifying ease of use and privacy as appealing attributes. Several implementation strategies were suggested for facilitating the adoption of HIVST, including increasing access to tests by mailing kits to community members and increasing demand for kits through media campaigns (e.g., local flyers, social media posts, and booths at tribal events). Community members also recommended discreet packaging of kits and cultural adaptation of accompanying materials (e.g., educational videos featuring community members). The qualitative input from AI community members facilitated identification of implementation strategies that may promote the acceptability and culturally-appropriateness of HIVST.

RESUMEN: Entre 2015 y 2019, la incidencia del VIH entre los indígenas norteamericanos (INs) aumentó un 18%, a pesar de que en otros grupos étnicos y raciales se observaron reducciones. La implementación culturalmente apropiada de programas preventivos es fundamental para abordar las circunstancias interseccionales que contribuyen a la vulnerabilidad al VIH entre INs. Los objetivos de este estudio fueron comprender los factores que influyen en la decisión de hacerse la prueba del VIH e identificar estrategias para fomentar la aceptabilidad de las auto pruebas, en una comunidad de INs en el Sur de California. Se realizaron 15 entrevistas semiestructuradas con los miembros adultos de una reserva situada en el Sur de California. El análisis se realizó utilizando un método cualitativo rápido, basado en el marco Exploration, Preparation, Implementation and Sustainment (EPIS) (español: Exploración, Preparación, Implementación y Sostenimiento) así como una recopilación de sugerencias de expertas en implementación de intervenciones, conocida como ERIC. Dos miembros del equipo de investigación utilizaron una plantilla estandarizada resumida para investigar factores determinantes y estrategias para la adopción de las auto pruebas del VIH. Los miembros de la reserva de INs identificaron el estigma asociado al VIH, así como preocupación por la privacidad entre la comunidad, como barreras para realizarse las pruebas del VIH. Los miembros reaccionaron positivamente a la aceptabilidad de las auto pruebas del VIH, destacándola facilidad del uso y la privacidad asociadas con estas pruebas. También, se sugirieron varias estrategias para facilitar la adopción de las auto pruebas, incluyendo el envío de pruebas a miembros de la comunidad y el aumento de la demanda de pruebas a través de difusión (e.g., folletos, publicaciones en las redes sociales, y puestos en eventos tribales). Los miembros también recomendaron que los empaques de las auto pruebas sean discretos, y que contengan materiales educativos culturalmente apropiados. Las contribuciones cualitativas de la comunidad INs ayudaron identificar estrategias de implementación que pueden fomentar la aceptabilidad de las auto pruebas del VIH en una manera culturalmente apropiada.

Real world effectiveness of digital mental health services during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic created an unprecedented need for mental health services that can be remotely delivered. Digital mental health services that offer personalized care recommendations hold promise to efficiently expand service, but evidence of the effectiveness of digitally delivered mental health care in real-world settings remains limited. METHODS: A retrospective cohort of adults (N = 1,852) receiving care through a digital mental health platform with elevated depressive symptoms during the COVID-19 pandemic was analyzed to estimate changes in subjective well-being and clinical improvement in depressive symptoms (using the World Health Organization-Five [WHO-5] Well-Being Index), as well as compare the relative effectiveness and cost of different care utilization patterns. RESULTS: The average improvement in WHO-5 score was 10.1 points (CI: 9.3-10.9, p<0.001) at follow-up, which constituted a medium effect size (d = 0.73). The odds of clinical improvement in depressive symptoms were significantly greater among those who utilized telecoaching (aOR = 2.45, 95%CI: 1.91-3.15, p < .001), teletherapy (aOR = 2.01, 95%CI: 1.57-2.57, p < .001), and both services (aOR = 2.28, 95%CI: 1.67-3.11, p < .001) compared to those who only utilized assessments, adjusting for baseline WHO-5 score, age, sex, and number of days between baseline and follow-up assessments. The average estimated cost of care for telecoaching was $124 per individual, which was significantly less than teletherapy ($413) or both services ($559). CONCLUSION: Digitally delivered care with a therapist and/or coach was effective in improving subjective well-being and clinical improvement in depressive symptoms. Although clinical outcomes were similar across utilization patterns, the cost of care was lowest among those utilizing telecoaching.

Effectiveness of Evidence-Based Telecoaching Delivered Through an Employer-Sponsored Mental Health Benefits Platform.

Introduction: Coaches delivering telemental health services as part of an employer-sponsored benefit may increase access to affordable and effective care. We examined the effectiveness of evidence-based telecoaching delivered via videoconferencing to people requesting mental health services during the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: We analyzed data from 1,228 employees (mean age = 35 ± 8 years; 67.2% female) who utilized telecoaching through the Modern Health benefits platform between March 11, 2020 and March 11, 2021. We used paired samples t tests to examine changes in well-being, burnout, absenteeism, and presenteeism before and after telecoaching and moderated regressions to test whether these changes depended on visit utilization. We analyzed rates of clinical improvement for well-being and reduction from entry in symptoms for burnout. We conducted analyses in the full sample and participants presenting with elevated symptoms at baseline. Results: Participants utilized an average of 2.6 visits. Well-being (p = 0.02) significantly increased, while both presenteeism (p < 0.001) and absenteeism (p < 0.001) significantly decreased at follow-up in our full sample, but represented negligible effect sizes. Burnout was not found to have significantly changed at follow-up in our full sample (p = 0.69). In participants beginning care with elevated depressive-related symptoms, well-being significantly increased (p < 0.001) and 46.3% experienced a clinically relevant improvement. In participants beginning care with elevated levels of burnout, burnout significantly decreased (p < 0.001) and 20.9% experienced a reduction in symptoms from entry. Conclusions: Leveraging videoconferencing, telecoaching had positive effects on mental health and workplace outcomes, even during the COVID-19 pandemic. Evidence-based telecoaching represents a promising option for achieving optimal outcomes in people who need mental health services.

Assessing the Care Modality Preferences and Predictors for Digital Mental Health Treatment Seekers in a Technology-Enabled Stepped Care Delivery System: Cross-sectional Study.

BACKGROUND: Access to mental health services continues to be a systemic problem in the United States and around the world owing to a variety of barriers including the limited availability of skilled providers and lack of mental health literacy among patients. Individuals seeking mental health treatment may not be aware of the multiple modalities of digital mental health care available to address their problems (eg, self-guided and group modalities, or one-to-one care with a provider). In fact, one-to-one, in-person treatment is the dominant care model with a masters- or doctoral-level trained mental health provider, and it may or may not be the appropriate or preferred level of care for an individual. Technology-enabled mental health platforms may be one way to improve access to mental health care by offering stepped care, but more research is needed to understand the care modality preferences of digital mental health care seekers because additional modalities become increasingly validated as effective treatment options. OBJECTIVE: The purpose of this study was to describe and evaluate the predictors of care modality preferences among individuals enrolled in a technology-enabled stepped mental health care platform. METHODS: This exploratory, cross-sectional study used employee data from the 2021 Modern Health database, an employer-sponsored mental health benefit that uses a technology-enabled platform to optimize digital mental health care delivery. Chi-square tests and one-way analysis of variance (ANOVA) were conducted to evaluate associations among the categorical and continuous factors of interest and the preferred care modality. Bivariate logistic regression models were constructed to estimate the odds ratios (ORs) of preferring a one-on-one versus self-guided group, or no preference for digital mental health care modalities. RESULTS: Data were analyzed for 3661 employees. The most common modality preference was one-on-one care (1613/3661, 44.06%). Approximately one-fourth of the digital mental health care seekers (881/3661, 24.06%) expressed a preference for pursuing self-guided care, and others (294/3661, 8.03%) expressed a preference for group care. The ORs indicated that individuals aged 45 years and above were significantly more likely to express a preference for self-guided care compared to individuals aged between 18 and 24 years (OR 2.47, 95% CI 1.70-3.59; P<.001). Individuals screening positive for anxiety (OR 0.73, 95% CI 0.62-0.86; P<.001) or depression (OR 0.79, 95% CI 0.66-0.95; P=.02) were more likely to prefer one-on-one care. CONCLUSIONS: Our findings elucidated that care modality preferences vary and are related to clinical severity factors and demographic variables among individuals seeking digital mental health care.

Bridging the Digital Divide Among Racial and Ethnic Minority Men Who Have Sex With Men to Reduce Substance Use and HIV Risk: Mixed Methods Feasibility Study.

BACKGROUND: Ecological momentary assessment (EMA) is a promising data collection tool for mobile health interventions targeting episodic health behaviors. For substance-using men who have sex with men (SUMSM), EMA is becoming more widely utilized in efforts to characterize substance use and sexual risk factors for HIV transmission. However, recent literature demonstrates emerging concerns over compliance and lower EMA engagement and data concordance among racial and ethnic minority SUMSM. OBJECTIVE: This study aimed to provide a qualitative evaluation of the barriers and facilitators of EMA as a data collection tool among racial and ethnic minority SUMSM. METHODS: Between October and November 2017, 45 racial and ethnic minority SUMSM were recruited from a list of prior research participants at the San Francisco Department of Public Health to participate in daily EMA surveys on their substance use and sexual health behaviors for 1 week, followed by in-person focus groups (FGs). A total of 4 FGs explored the participants' experiences with the surveys, issues regarding privacy and confidentiality, and suggestions for improvement. Qualitative analysis was performed using content analysis. Descriptive statistics and Fisher exact tests were used to assess the associations between demographics or substance use behaviors and EMA completion. RESULTS: Overall, 93.9% (295/314) of all delivered surveys were initiated, and of those, 98.0% (289/295) were completed. Neither participant demographics, including race (P=.65) or age (P=.43), nor substance use behaviors, including the frequency of alcohol (P=.40) or methamphetamine (P=.91) use or any cocaine (P=.28), crack (P=.99), or polysubstance use (P=.24), were found to be associated with survey completion. Overall, participants were receptive to the text message-based EMA surveys. Facilitators included survey timing, user-friendly survey design, survey-stimulated self-reflection, coding of sensitive phrases, and other privacy benefits of a mobile survey. Barriers included an inability to correct texting errors and participants' perception of judgment or stigmatization related to questions about condomless sex. To improve EMA compliance and uptake, participants suggested adding response confirmations, clarifying survey language, and continuing to diversify the study audience. CONCLUSIONS: EMA appears to be feasible and acceptable among this sample of racial and ethnic minority SUMSM. Close attention to EMA study design and the development of nonjudgmental, contextualized questions regarding stigmatized health behaviors may be critical to further improve EMA compliance.

Partnership-level correlates of sexual risk taking within the sexual partnerships of young transwomen in San Francisco, California.

OBJECTIVES: Little is known about the sexual networks of young transwomen, leaving a major gap in what we know about transmission dynamics and the elevated rates of HIV in this population. The objective of this study was to understand partnership-level factors associated with condomless anal sex among young transwomen. METHODS: A secondary data analysis of the sexual partnerships of young transwomen was conducted using baseline data from the SHINE study. Generalised estimating equation logistic regressions were used to assess for partnership-level associations between partnership type, age, injection drug use and racial concordance, HIV seroconcordance, sexual role and condomless receptive (CRAI) and insertive anal intercourse (CIAI). RESULTS: Our analysis included 187 young transwomen that reported a total of 464 sexual partnerships where they had at least one episode of anal sex in the past 6 months. We found casual (n=232 or 50%) and commercial partnerships (n=106 or 22.8%) to be significantly associated with a lower odds of CIAI (OR=0.53, 95% CI 0.32 to 0.86 and OR=0.39, 95% CI 0.18 to 0.82) and CRAI (OR=0.30, 95% CI 0.19 to 0.47 and OR=0.35, 95% CI 0.2 to 0.62) compared with main partnerships (n=126 or 27.2%). Additionally, HIV-positive seroconcordant (n=25 or 5.4%, OR=4.05, 95% CI 1.44 to 11.40) and injection-drug using partnerships (n=25 or 5.4%, OR=3.66, 95% CI 1.34 to 9.95) were found to be significantly associated with an increased odds of CIAI among participants compared with HIV-negative seroconcordant (n=330 or 71.1%) and non-using partnerships (n=338 or 72.8%), respectively. CONCLUSION: Young transwomen, like other populations, engage in condomless sex more often with main than casual and commercial partners, suggesting a need for interventions that address sexual practices with steady main partners.

Does HIV Pre-Exposure Prophylaxis Modify the Effect of Partnership Characteristics on Condom Use? A Cross-Sectional Study of Sexual Partnerships Among Men Who Have Sex with Men in San Francisco, California.

Increasing rates of sexually transmitted infections (STIs) in the United States among men who have sex with men (MSM) have raised concerns that pre-exposure prophylaxis (PrEP) has been associated with higher engagement in condomless anal intercourse (CAI). While partnership characteristics have previously been found to influence condom use, the extent to which PrEP use may modify their effect on CAI remains unknown. A secondary analysis of 535 sexual partnerships from a cross-sectional study in San Francisco was conducted to evaluate interactions between PrEP use and partnership characteristics on CAI. Bivariate and multivariate generalized estimating equation (GEE) logistic regression models were used to estimate relative measures of association, adjusted for confounding by seroconcordance and partnership type, as well as account for repeated partnerships per respondent. Partnerships where both partners used biomedical prevention had significantly greater odds of CAI [odds ratio (OR) = 5.19, 95% confidence interval (CI): 2.27-11.9] compared to those where only one partner used biomedical prevention, while those where neither partner used biomedical prevention had significantly lower odds of CAI (OR = 0.61, 95% CI: 0.40-0.93). There was no significant association between meeting place (online vs. offline) and sexual risk taking (OR = 1.03, p = 0.894). Having one partner disclose their HIV status (compared to neither partner having disclosed) was associated with significantly higher odds of CAI among partnerships of PrEP-using MSM [adjusted OR (aOR) = 5.28, 95% CI: 1.91-14.61], while the association was not significant among the partnerships of non-PrEP-using MSM (aOR = 1.29, 95% CI: 0.75-2.21). Differences in condom use among MSM using PrEP may not be well explained by differences in the effect of partnership characteristics. MSM using PrEP appear to commonly practice biomedical matching and high engagement in CAI with other biomedical prevention users, which could indicate relatively concentrated sexual networks and partly explain their disproportionate risk for STIs. Future studies should further investigate biomedical matching to develop interventions that further promote the sexual health of those using PrEP.

Prevalence and correlates of hazardous alcohol consumption and binge drinking among men who have sex with men (MSM) in San Francisco.

OBJECTIVES: To describe heavy alcohol use patterns and correlates in a diverse sample of MSM. METHODS: We used respondent-driven sampling (RDS) to enroll 252 alcohol-using MSM in San Francisco from March 2015-July 2017. We examined heavy alcohol use patterns and conducted RDS-adjusted multivariable analyses to characterize correlates of hazardous alcohol consumption and binge drinking. RESULTS: RDS-adjusted prevalence of weekly and at least weekly binge drinking was 24.9% and 19.3%, respectively. Hazardous consumption was common; prevalence of mid- and high-levels of hazardous drinking was 11.4% and 29.9%, respectively. In multivariable analyses, identifying as Hispanic/Latino or mixed/other race; being moderately or extremely interested in reducing alcohol use; ever receiving alcohol treatment; using ecstasy; reporting syphilis diagnosis; and having more than 5 male partners were independently associated with hazardous alcohol consumption. Less hazardous consumption was associated with having a bachelor's degree or completing post-graduate studies; and not being in a relationship. Reporting chlamydia infection; being somewhat, moderately or extremely interested in reducing alcohol use; and having multiple male sex partners were associated with higher odds of at least weekly binge drinking. Lower odds of binge drinking were associated with completing post-graduate studies. Moreover, for the outcomes of hazardous alcohol consumption and binge-drinking, we observed significant interaction effects between race/ethnicity and interest in reducing alcohol, past receipt of alcohol treatment, use of ecstasy, syphilis diagnosis, and number of male partners. CONCLUSION: Among alcohol-using MSM in San Francisco, heavy drinking patterns were common and independently associated with greater number of male sexual partners and sexually transmitted infections (STI). Moreover, significant racial/ethnic and socioeconomic disparities related to heavy alcohol use were observed and race/ethnicity modified the effect of the risk factors associated with these outcomes. These findings underscore the need to develop more MSM-specific interventions that jointly address heavy alcohol use and HIV/STI risk, as well as culturally-tailored and targeted strategies to alleviate health disparities.

Comparative chemical genomics reveal that the spiroindolone antimalarial KAE609 (Cipargamin) is a P-type ATPase inhibitor.

The spiroindolones, a new class of antimalarial medicines discovered in a cellular screen, are rendered less active by mutations in a parasite P-type ATPase, PfATP4. We show here that S. cerevisiae also acquires mutations in a gene encoding a P-type ATPase (ScPMA1) after exposure to spiroindolones and that these mutations are sufficient for resistance. KAE609 resistance mutations in ScPMA1 do not confer resistance to unrelated antimicrobials, but do confer cross sensitivity to the alkyl-lysophospholipid edelfosine, which is known to displace ScPma1p from the plasma membrane. Using an in vitro cell-free assay, we demonstrate that KAE609 directly inhibits ScPma1p ATPase activity. KAE609 also increases cytoplasmic hydrogen ion concentrations in yeast cells. Computer docking into a ScPma1p homology model identifies a binding mode that supports genetic resistance determinants and in vitro experimental structure-activity relationships in both P. falciparum and S. cerevisiae. This model also suggests a shared binding site with the dihydroisoquinolones antimalarials. Our data support a model in which KAE609 exerts its antimalarial activity by directly interfering with P-type ATPase activity.