"Nobody wants to have conversation about HIV." A thematic analysis of in-depth interviews with Black adolescent women and providers about strategies for discussing sexual health and HIV prevention.

BACKGROUND: Black adolescent girls and young women (AGYW) in the U.S. Southeast are disproportionately burdened by HIV. Infrequent assessment of sexual health in clinical encounters may contribute to low PrEP uptake for this population. This study explores Black AGYW and providers' perspectives on engaging in discussions about sexual health, including PrEP. METHODS: In-depth interviews (IDIs) were conducted with Black AGYW ages 14-24 and healthcare providers (MD, DO, NP, PA) who self-reported caring for Black AGYWs in Alabama. IDIs were grounded in Andersen's Behavioral Model of Health Service Utilization to explore barriers and facilitators to sexual health discussions. After separate analyses, AGYW and provider IDIs were aggregated and reanalyzed using thematic analysis to identify themes related to their views on ways to improve Black AGYW engagement in sexual health discussions while in clinical settings. RESULTS: Twelve Black AGYW and 11 providers completed IDIs. Client median age was 21, representing nine Alabama counties. Providers were predominately non-Hispanic White (82%), female (73%), and physicians (64%). Themes about ways to improve sexual health discussions included: 1) Improve sexual health education for providers and adolescents; 2) Normalize conversations in clinical settings; 3) Engage communities to continue these conversations outside of clinical settings. CONCLUSIONS: Sexual health and HIV prevention discussions with Black AGYW are not occurring. This study is one of the first to to identify and highlight Black AGYW and provider-identified shared strategies for improving these discussions. Operationalizing these strategies is crucial to facilitating these discussions.

Re-evaluating the relationship between youth with HIV and BMI in an age of increasing rates of overweight and obese youth.

BACKGROUND: Newer antiretrivirals (ART) have shifted the metabolic experiences of people with HIV (PWH) from those of wasting syndrome to increases in body mass index (BMI). This study sought to examine the relationship between BMI and ART use among youth with HIV (YWH). METHODS: Charts from YWH ages 10-24 with at least two documented BMIs at least 6 months apart between 2017 and 2020 were included (N = 44). Statistical analyses were conducted in SAS 9.4. RESULTS: Clients were predominately African American (66%) males (73%) aged 19-24 years (64%), with men having sex with men (48%) being the most common mode of transmission. YWH on non-integrase inhibitor (INSTI) regimens had greater absolute increases in BMI compared to those on INSTI regimens (p = 0.03). Fourteen percent of clients using INSTI experienced an increase in BMI class from normal to overweight or overweight to obese; no non-INSTI users changed BMI class. Time since diagnosis and BMI change due to weight gain were positively associated (p = 0.03) among behaviorally-acquired YWH. CONCLUSIONS: Increasing BMI and changing BMI classes may be more likely among YWH using INSTI. More longitudinal studies inclusive of diet and exercise profiles are needed to understand the relationship between INSTI and YWH BMI.

The Characteristics of Youth With Missed HIV Visits in Alabama.

Gaps in knowledge remain related to understanding missed human immunodeficiency virus (HIV) visits and youth with HIV (YWH). This study examined data from an Alabama academic HIV clinic with clients aged 16 to 24 years old and found that non virally suppressed and older YWH were associated with missed visits among YWH.

Viral load and sexually transmitted infection testing among youth with HIV in a southern United States clinic.

Background: As compared to their older peers, youth with HIV (YWH) are less likely to attain viral suppression and have higher rates of sexually transmitted infections (STI). In this exploratory study, we examine the relationship between HIV viral suppression, STI testing, and STI diagnosis among YWH receiving care at a clinic in the southern United States.Methods: Data from 933 clinical visits (2017-2020) were aggregated into singular patient records for YWH aged 10-24 years in Alabama (N = 139). Analyses included univariate generalized linear mixed models performed with the PROC GLIMMIX procedure approximating the marginal likelihood by using Laplace's method.Results: Sample median age was 22 years at the index visit. Most YWH were 20-24 years old (69.1%), male (67.6%), and identified as Black (77%); 58.3% were virally unsuppressed at index visit. YWH who identified as White or of other races had 4.79 times higher odds of being virally suppressed as compared to Black YWH (p < .01); STI testing behavior and STI positive diagnosis were associated with lower odds of being virally suppression.Conclusions: Findings suggest that among YWH, receiving STI testing and having an STI diagnosis is associated with a lack of viral suppression, suggesting that extra efforts may be necessary to support YWH who have an STI to attain suppression. Research is needed to examine individual behaviors, structural forces, and clinic features that could impact STI care engagement, specifically among unsuppressed YWH.

A Multicomponent Intervention to Train and Support Family Medicine Providers to Promote Pre-exposure Prophylaxis (PrEP) for Adolescent Girls and Young Women in the Deep South: Protocol for the PrEP-Pro Study.

BACKGROUND: Pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention intervention and a major strategy for reducing the HIV burden in the United States. However, PrEP provision and uptake remain lower than estimated needs, and in ways that may exacerbate HIV disparities among Black adolescent girls and young women in the southern United States. Data suggest that gaps in provider knowledge of HIV epidemiology and PrEP and skills assessing sexual health practices are important barriers to provision and uptake, with limited evidence-based interventions to address these gaps. OBJECTIVE: This paper describes the "PrEP-Pro" intervention, a multicomponent intervention to train and support family medicine (FM) trainees to promote PrEP for adolescent girls and young women in Alabama. METHODS: The PrEP-Pro intervention comprises 3 main components guided by the Capability-Opportunity-Motivation-Behavior (COM-B) model for behavioral change and the Consolidated Framework for Implementation Research (CFIR): (1) provider HIV epidemiology and PrEP education, (2) sexual history taking, and (3) PrEP Champions. In phase 1, we will work with community advisory boards (providers and clients) and then conduct focus groups with FM trainees to adapt content to train FM residents on HIV epidemiology and PrEP and develop implementation strategies, including provider-facing tools and client-facing educational materials. In phase 2, we will pretest and then pilot-test the initially adapted PrEP-Pro intervention with FM trainees. FM trainees will complete baseline, 3-, and 6-month questionnaires post PrEP-Pro intervention. We will also conduct in-depth interviews (IDIs) with FM pilot participants, adolescent girls and young women who accessed care after the PrEP-Pro pilot, and key stakeholders. The primary outcomes are PrEP-Pro acceptability and feasibility, which would be assessed using validated instruments at months 3 (among pretest participants) and 6 (among pilot participants). Secondary outcomes will also be assessed, including PrEP knowledge, sexual history-taking attitudes and practices, PrEP prescriptions among adolescent girls and young women encounters, and sexually transmitted infections (STIs) and HIV testing among adolescent girls and young women encounters in 6 months. RESULTS: Study results will be disseminated to practices, state health officials, and other key stakeholders to solicit feedback on implementation opportunities and challenges to inform a hybrid effectiveness implementation trial. Our results will also be presented at local and national conferences and submitted to peer-reviewed journals. CONCLUSIONS: As PrEP grows, there is a pressing need to train FM providers and develop appropriate, contextually relevant tools to support PrEP implementation. The PrEP-Pro intervention is a multicomponent intervention to train FM residents across Alabama on sexual history-taking, PrEP provision for adolescent girls and young women, and supporting practice-based PrEP Champions. The PrEP-Pro intervention is anticipated to increase PrEP prescriptions for adolescent girls and young women and expand comprehensive sexual and reproductive health care for adolescent girls and young women in rural and urban Alabama. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/44908.

"Sex. Maybe We Should Do Things to be Healthy About It." Adolescent-Caregiver Discussions About Sex.

PURPOSE: Adolescents are disproportionately burdened with HIV. Numerous barriers limit adolescent pre-exposure prophylaxis (PrEP) use for HIV prevention. We explored adolescent-caregiver perspectives on discussing sexual health and PrEP to inform future caregiver interventions as a possible strategy to promote PrEP use. METHODS: We conducted separate in-depth interviews with adolescents aged 14-18 living in Alabama and their parent/guardian (caregiver). Interviews explored attitudes about sex, knowledge and attitudes about HIV prevention and PrEP, and attitudes about PrEP communication within adolescent-caregiver groups. Thematic analysis of adolescent and caregiver interviews was conducted independently and then triangulated to compare shared themes. RESULTS: Nine adolescents and seven caregivers contributed to five dyads and two triads. Adolescents had a median age of 16 years (range 14-18); five were girls (55%), and five were non-Hispanic Black (55%). Most caregivers were mothers (5, 71%), non-Hispanic Black (5, 71%), with a median age of 41 (36-56) years. All adolescents expressed willingness to involve their caregiver around PrEP use. Major themes included as follows: 1) caregiver efforts to overcome cultural taboos about sex and sexuality foster adolescents' willingness to talk with caregivers about sex; 2) evolving societal norms and reflections on their own upbringings motivate caregivers to discuss and support adolescents with sexual health; and 3) caregivers desire to engage in sexual health discussions with providers and support their teens with PrEP. DISCUSSION: As socio-cultural norms around sex evolve, adolescent-caregiver discussions about sexual health and PrEP may be an opportunity to increase PrEP use and reduce HIV infections among select adolescent sub-populations.

Gaps in sexually transmitted infection screening among youth living with HIV in Alabama.

OBJECTIVE: Gaps in sexually transmitted infection (STI) testing can lead to poor health outcomes due to untreated illness among youth living with HIV (YLHIV). Thus, the objective of this study is to examine STI testing behavior and outcomes among a sample of YLHIV in the southern United States. Clinical records of 139 YLHIV who received HIV care in Alabama (2017-2020) were evaluated for receipt of STI testing (gonorrhea, chlamydia, syphilis), prevalence of positive test results, and factors associated with testing outcomes (933 clinical visits). RESULTS: Nearly 80% of our sample identified as African American, most were 20-24 years, and about 60% reported detectable viral load at first visit during the study period. Just under 60% of cisgender male and transgender female clients reported receipt of at least one STI test, compared to less than 40% of cisgender females. Identifying as a cisgender male and having been diagnosed with HIV related to sex with men were associated with greater likelihood receiving STI testing. Cisgender males reported higher rates of positive syphilis test results than cisgender females; the highest rates of positive STI tests were among transgender females. Results underscore need for providers to promote routine STI testing to YLHIV.

PrEP Prescription for Black Adolescent Girls and Young Women in Alabama: Findings from a Survey of Healthcare Providers.

Black adolescent girls and young women (AGYW) are disproportionately affected by HIV in the United States. HIV pre-exposure prophylaxis (PrEP) is effective for HIV prevention, but prescription rates remain low. We conducted a survey of medical providers caring for Black AGYW in Alabama to explore PrEP prescription practices. While over half of the N = 36 providers reported minimal HIV testing of AGYW in clinic, most (N = 29, 81%) reported feeling confident discussing HIV prevention. Most reported willingness to prescribe PrEP to Black AGYW (58%-72%), but only 11 (31%) had prescribed PrEP to any female client. Low familiarity with CDC guidelines (N = 20, 56%) and PrEP options (N = 19, 53%) were barriers to prescription. Prescribing PrEP to AGYW was associated with provider training, with internal medicine providers being least likely to prescribe. These findings support the need to develop training tools to directly address unique training needs of providers who care for this population.

"We Feel Like Everybody's Going to Judge us": Black Adolescent Girls' and Young Women's Perspectives on Barriers to and Opportunities for Improving Sexual Health Care, Including PrEP, in the Southern U.S.

Black adolescent girls and young women (AGYW) are disproportionately affected by HIV in the southern U.S.; however, PrEP prescriptions to Black AGYW remain scarce. We conducted in-depth interviews (IDIs) with Black AGYW ages 14-24 in Alabama to explore opportunities for and barriers to sexual health care including PrEP prescription. Twelve AGYW participated in IDIs with median age 20 (range 19-24). All reported condomless sex, 1-3 sexual partners in the past 3 months, and 6 reported prior STI. Themes included: 1) Stigma related to sex contributes to inadequate discussions with educators, healthcare providers, and parents about sexual health; 2) Intersecting stigmas around race and gender impact Black women's care-seeking behavior; 3) Many AGYW are aware of PrEP but don't perceive it as an option for them. Multifaceted interventions utilizing the perspectives, voices, and experiences of Black cisgender AGYW are needed to curb the HIV epidemic in Alabama and the U.S. South.

Developing a Clinic-Based, Vaccine-Promoting Intervention for African American Youth in Rural Alabama: Protocol for a Pilot Cluster-Randomized Controlled Implementation Science Trial.

BACKGROUND: African American youth in rural Alabama are clinically underserved and have limited knowledge about the human papillomavirus and the novel coronavirus 2019 (COVID-19) vaccines, including knowledge about the risk for developing cervical or oropharyngeal cancers or COVID-19. OBJECTIVE: In this 30-month study, we propose to develop an in-clinic, youth-tailored, vaccine-promoting intervention for vaccine hesitancy reduction that can be seamlessly integrated into the existing environments of pediatric and family practice settings in rural Alabama. METHODS: This exploratory, sequential mixed methods study will be conducted in 3 phases. In the first phase, we will assess stakeholders' knowledge, sentiments, and beliefs related to vaccination in general, COVID-19 vaccination, and human papillomavirus vaccination. We will also assess stakeholders' perceptions of barriers to vaccination that exist in rural Alabama. This will be followed by a second phase wherein we will use the data collected in the first phase to inform the development and finalization of a noninvasive, modular, synchronous counseling intervention that targets the behaviors of 15- to 26-year-old adolescents. In the third phase, we will conduct a pilot hybrid type 1 effectiveness-implementation cluster-randomized controlled trial to assess intervention acceptability and feasibility (clinics: N=4; African American youth: N=120) while assessing a "clinical signal" of effectiveness. We will document implementation contexts to provide real-world insight and support dissemination and scale-up. RESULTS: The study was funded at the end of December 2020. Approval from the University of Alabama at Birmingham Institutional Review Board was obtained in May 2021, and the qualitative data collection process outlined in the first phase of this project concluded in November 2021. The entire study is expected to be complete at the end of December 2023. CONCLUSIONS: The results of the trial will provide much needed information on vaccine hesitancy in rural Alabama, and if found efficacious, the intervention could notably increase rates of vaccinations in one of the most underserved parts of the United States. The results from the trial will provide information that is valuable to public health practitioners and providers in rural settings to inform their efforts in increasing vaccination rates among 15- to 26-year-old African American youth in rural southern United States. TRIAL REGISTRATION: ClinicalTrials.gov NCT04604743; https://clinicaltrials.gov/ct2/show/NCT04604743. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33982.

Implementing a graduate medical education anti-racism workshop at an academic university in the Southern USA.

Coronavirus Disease 2019 (COVID-19) and the social justice movement in early 2020 awakened many Americans to the health disparities and health care inequities affecting Black communities. This heightened awareness has strengthened the call to address social determinants of health, like racism. Physicians can play an important role in dismantling racism through knowledge of implicit biases and understanding of historical trauma resulting in medical distrust as a crucial step to help advance the health of minority communities. The purpose of this project was to develop an anti-racism workshop for Graduate Medical Education. Two discussants led 1.5-hour interactive workshops. Content covered microagressions, colorblindness, tokenism, stereotypes, levels of racism, the impact of racism on health, and anti-racism concepts. Facilitated breakout sessions allowed participants to provide examples of witnessed racism and discuss application of anti-racism tools in those settings. Following the workshops, participants were asked to complete a 16-item survey to evaluate workshop effectiveness. Between July and August 2020, four workshops were delivered to 131 attendees. Fifty-nine completed post workshop surveys. Most respondents were White (75%), female (63%), and aged 31-40 (29%). Over half were faculty; 24% were residents, 8% fellows. The majority agreed they could apply knowledge to their work (95%) and found the workshop useful (95%). Over two-thirds reported being able to better identify disparities and better identify and communicate about racism. In open-ended questions, many participants requested an interactive longitudinal curriculum. Developing an antiracism workshop for an academic medical center located in the Deep South provided more insight into tangible next steps to foster an institutional culture centered on antiracism.

COVID-19 Vaccine Sentiments Among African American or Black Adolescents in Rural Alabama.

Considering the urgent need to increase vaccine uptake in Alabama, a rural state with the lowest rates of COVID-19 vaccination in the country, we conducted an exploratory study to elucidate sentiments toward vaccination among African American or black adolescents. We conducted in-depth interviews with 15-17 year olds in rural Alabama (N = 28). About 54% of our sample were female. Nearly a third lived with an older family member; 18% knew someone who contracted COVID-19. Using Rapid Qualitative Analysis, 3 COVID-19 vaccine-related themes emerged: influence of community leaders and older family members, fear of side effects and misinformation, and institutional distrust. To address COVID-19 vaccine hesitancy among rural African American or black adolescents, we suggest adopting a socioecological approach to public health messaging that addresses misinformation and government distrust and is delivered by local influencers with the social capital necessary to promote behavior change, namely older family members and Church officials.

Prevalence of Chlamydia trachomatis Infection in Young Women and Associated Predictors.

BACKGROUND: Chlamydia trachomatis (CT) infection remains highly prevalent, and young women are disproportionately affected. Most CT-infected women are asymptomatic, and their infection often goes unrecognized and untreated. We hypothesized that testing for active CT infection with molecular diagnostics and obtaining a reported history of CT infection underestimate the prevalence of current and past CT infection, and incorporating serum CT antibody testing in addition to these other prevalence measures would generate more accurate estimates of the prevalence of CT infection in asymptomatic young women. METHODS: We enrolled 362 asymptomatic women aged 16 to 29 years at 4 different clinical settings in Birmingham, AL, between August 2016 and January 2020 and determined the prevalence of CT infection based on having 1 or more of the following prevalence measures: an active urogenital CT infection based on molecular testing, reported prior CT infection, and/or being CT seropositive. Multivariable regression analysis was used to determine predictors of the prevalence of CT infection after adjustment for participant characteristics. RESULTS: The prevalence of CT infection was 67.7% (95% confidence interval, 62.6%-72.5%). Addition of CT antibody testing to the other individual prevalence measures more than doubled the CT infection prevalence. Non-Hispanic Black race, reported prior gonorrhea, and reported prior trichomoniasis predicted a higher prevalence of CT infection. CONCLUSIONS: More than half of women were unaware of ever having CT infection, suggesting many were at risk for CT-associated reproductive complications. These data reinforce the need to adhere to chlamydia screening guidelines and to increase screening coverage in those at risk.

Exploring adults as support persons for improved pre-exposure prophylaxis for HIV use among select adolescents and young adults in the Deep South.

PURPOSE: Pre-exposure prophylaxis for HIV (PrEP) is an effective yet underutilized biomedical tool for adolescents and young adults' (AYA) HIV prevention due to barriers such as PrEP adherence. We assessed HIV prevention knowledge, attitudes and beliefs from adults who self-identified as a primary support person to an AYA. METHODS: We surveyed AYA primary support persons at an academic hospital. Univariate and multivariate regression analyses were completed to identify factors associated with the belief AYAs engaging in HIV-associated behaviors should use PrEP and willingness to support AYAs on PrEP. RESULTS: 200 primary support persons completed the survey. Participants were predominately female (77%) and black (56%). Nearly all primary support persons believed AYAs engaging in HIV-associated behaviors should take PrEP (94%) and 98% would support an AYA taking PrEP via transportation to appointments, assistance with refilling prescriptions, medication reminders, or encouragement. CONCLUSIONS: Primary support persons are willing to support AYAs using PrEP.

Preliminary study on HIV status disclosure to perinatal infected children: retrospective analysis of administrative records from a pediatric HIV clinic in the southern United States.

OBJECTIVE: The World Health Organization recommends disclosing HIV-status between 6 and 12 years; American Academy of Pediatrics recommends that children are informed at "school age." Neither suggests an optimal age when children should learn of their status to improve viral load suppression. Considering that virally suppressed people do not transmit HIV and that interrupting the transmission cycle is critical to ending the HIV epidemic, our objective is to examine the relationship between age of disclosure and viral load suppression by evaluating data from a pediatric HIV clinic in the southern United States. Records from perinatal infected patients seen between 2008 and 2018 were analyzed (N = 61). RESULTS: Longitudinal suppression was low across all groups when benchmarked against the UNAIDS 90% global target; black patients were less likely to achieve suppression compared to white patients (41% vs. 75%, p = 0.04). Adopted children were more likely to achieve suppression than children living with biological family (71% vs. 44%, p < 0.05). Children who learned of their status between 10 and 12 had the highest rate of suppression (65%) compared to peers who learned of their status younger (56%) or older (38%). Our preliminary study is designed to spark research on refining the current recommendations on HIV-status disclosure to perinatal infected children.