Examining the Intersection of Ethnoracial Disparities and HIV Status in Substance Use Risks among U.S. Adults.

Black/African American and Hispanic Americans experience significant HIV-related disparities. Substance use might be a contributing factor to these disparities, but there is limited research on this topic. This study investigated various substance use risks by HIV status and race/ethnicity (Black, Hispanic, White) among U.S. adults. We used data from the 2005-2019 National Survey on Drug Use and Health (N = 541,921). In each racial/ethnic group, the prevalence rates of past-year and past-month tobacco, alcohol, cannabis, and cocaine use, and past-year alcohol and illicit drug use disorders were estimated by HIV status. A series of logistic regressions with the interaction term of HIV x race/ethnicity were performed to examine race/ethnicity's moderating effect on the HIV-substance use associations, while controlling for sociodemographic factors and survey year. Moderation analysis showed that HIV status's association with the risks of past-year tobacco use (AOR = 1.67, 95% CI = 1.01-2.75), past-year cocaine use (AOR = 3.80, 95% CI = 1.91-7.57), past-month cocaine use (AOR = 5.34, 95% CI = 2.10-13.60), and past-year alcohol use disorder (AOR = 2.52, 95% CI = 1.29-4.92) differed significantly between Black and White adults. Between the Hispanic and White groups, HIV status's association with the risks of past-year alcohol use (AOR = 2.00, 95% CI = 1.09-3.69), past-year cocaine use (AOR = 2.40, 95% CI = 1.06-5.39), and past-month cocaine use (AOR = 3.69, 95% CI = 1.36-10.02) also differed significantly. It is well-established that individuals with HIV face an elevated risk of substance use. Our study added valuable insights by highlighting that this phenomenon is particularly more significant among Black and Hispanic adults for several substances when compared to White adults. Implications for practice are discussed.

Emerging directions of cognitive aging with HIV: practice and policy implications for social work.

Cognitive impairments have been endemic to the HIV epidemic since its beginning and persist to this day. These impairments are attributed to HIV-induced neuroinflammation, the long-term effects of combination antiretroviral therapy, lifestyle factors (e.g., sedentary behavior, substance use), neuro-comorbidities (e.g., depression), age-associated comorbidities (e.g., heart disease, hypertension), and others causes. Normal aging and lifestyle also contribute to the development of cognitive impairment. Regardless of the etiology, such cognitive impairments interfere with HIV care (e.g., medication adherence) and everyday functioning (e.g., driving safely, financial management). With more than half of people with HIV (PWH) 50 years and older, and ~45% of all PWH meeting the criteria for HIV-Associated Neurocognitive Disorder (HAND), those aging PWH are more vulnerable for developing cognitive impairment. This article provides an update to a social work model to identify and monitor PWH for cognitive impairment. Within this update, the state of the science on protecting brain health and cognitive reserve within the context of neuroHIV is also presented. From this, implications for practice and policy to promote successful cognitive functioning in older PWH are provided.

Practice Transformation in HIV Primary Care: Perspectives of Coaches and Champions in the Southeast United States.

INTRODUCTION/OBJECTIVES: Across the United States, and particularly in the South, there is an urgent need to improve health outcomes for people with HIV. In response, the Southeast AIDS Education & Training Center (AETC) conducted a 4-year Practice Transformation (PT) initiative (2015-2018) in 12 mostly primary care clinics across 4 states in the region. Drawing on the leadership of PT facilitators ("coaches") from AETC partner sites throughout the region and specific clinic staff members ("champions"), clinics worked toward self-selected organizational goals to increase their HIV care capacity and improve HIV health outcomes. METHODS: To explore coaches' and champions' experiences and perspectives of PT, we conducted 2 focus group sessions, 1 tailored for coaches (n = 5) and another for champions (n = 9). RESULTS: Content analysis of qualitative data revealed 4 major themes around coaches' and champions' experiences and perspectives of PT. These themes include Challenges, Facilitators, Successes, and Suggestions for PT Improvement. CONCLUSION: Primary care and infectious diseases/HIV clinics can help improve HIV Care Continuum outcomes through increasing their capacity to serve the needs of their clients, as facilitated through coaches and clinic champions. Since no single clinic or clinic patient population is alike, it is important work within organizations to address specific needs and leverage unique skillsets. Future PT initiatives can learn from experiences of this PT program to optimize the effectiveness of their programs.

Data for Care (D4C) Alabama: Clinic-Wide Risk Stratification With Enhanced Personal Contacts for Retention in HIV Care via the Alabama Quality Management Group.

BACKGROUND: The Alabama Quality Management Group (AQMG), a consortium of 9 Ryan White-funded part C and D clinics, distributed statewide was established in 2006 under the guidance from the Health and Resources Services Administration with a clinical quality improvement (CQI) focus. METHODS: We describe the origins and evolution of the AQMG, including requisite shifts from aggregate clinic-wide to de-identified individual-level data reporting for implementation of the Data for Care (D4C-AL) Alabama program. The D4C-AL strategy uses a clinic-wide risk stratification of all patients based on missed clinic visits in the previous 12 months. Intermediate (1-2 missed visits) and high-risk patients (>3 missed visits) receive the evidence-informed Retention through Enhanced Personal Contact intervention. We report on a pilot of the D4CAL program in 4 of 33 primary HIV care clinics at the UAB 1917 Clinic. RESULTS: Among 3859 patients seen between April 2018 and February 2019, the missed visit rate was not significantly different between the D4C-1917 (19.2%) and non-D4C clinics (20.5%) in a preintervention period (May 2017-April 2018). However, a significantly lower missed visit rate was observed in the D4C-1917 vs. non-D4C-1917 clinics during the intervention period (April 2018-February 2019, P = 0.049). CONCLUSIONS: The AQMG has been transformed into a health service research and implementation science platform, building on a shared vision, mission, data reporting, and quality improvement focus. Moreover, CQI may be viewed as an implementation strategy that seeks to enhance uptake and sustained use of effective interventions with D4C-AL representing a prototype for future initiatives embedded within extant quality improvement consortia.

Experienced HIV-Related Stigma in Health Care and Community Settings: Mediated Associations With Psychosocial and Health Outcomes.

INTRODUCTION: There are multiple dimensions of HIV-related stigma that can compromise the mental and physical health of people living with HIV. We focused on the dimension of experienced stigma, defined as exposure to acts of discrimination, devaluation, and prejudice, and investigated its relationship with HIV health and psychosocial outcomes. METHODS: We examined associations between experienced stigma in the community and health care settings and psychosocial and health outcomes for people living with HIV (N = 203) receiving care at an urban HIV clinic in the Southeastern United States. We also investigated whether those effects are unique to experienced stigma or are mediated by other dimensions of HIV-related stigma. RESULTS: Experienced stigma was associated with suboptimal clinical outcomes such as viral nonsuppression, as well as poor affective, cognitive, and mental health outcomes (self-esteem, depressive symptoms, avoidance coping, and blame coping) and interpersonal outcomes such as social support and physician trust. Furthermore, serial mediation models suggested significant indirect effects of experienced stigma through internalized stigma and anticipated stigma from various theoretically expected sources of stigma (eg, community members, friends and family, and health care workers), with varying effects depending on the source. CONCLUSIONS: These findings suggest nuanced mechanisms for the effects of experienced HIV-related stigma, especially in health care settings, and may be used to inform stigma-reduction interventions. Interventions designed to address experienced stigma in health care settings might be more tailored to specific outcomes, such as depression and physician trust, than interventions designed to address experienced stigma in the community.

Assessing efficacy of a retention-in-care intervention among HIV patients with depression, anxiety, heavy alcohol consumption and illicit drug use.

OBJECTIVE: We evaluated whether heavy alcohol use, illicit drug use or high levels of anxiety, and depression symptoms were modifiers of the retention through enhanced personal contact intervention. The intervention had previously demonstrated overall efficacy in the parent study. DESIGN: Randomized trial. METHODS: A total of 1838 patients from six US HIV clinics were enrolled into a randomized trial in which intervention patients received an 'enhanced contact' protocol for 12 months. All participants completed an audio computer-assisted self-interview that measured depression and anxiety symptoms from the Brief Symptom Inventory, alcohol use from the Alcohol Use Disorders Identification Test-Consumption instrument, and drug use from the WHO (Alcohol, Smoking and Substance Involvement Screening Test) questions. The 12-month binary outcome was completing an HIV primary care visit in three consecutive 4-month intervals. The outcome was compared between intervention and standard of care patients within subgroups on the effect modifier variables using log-binomial regression models. RESULTS: Persons with high levels of anxiety or depression symptoms and those reporting illicit drug use, or heavy alcohol consumption had no response to the intervention. Patients without these 'higher risk' characteristics responded significantly to the intervention. Further analysis revealed higher risk patients were less likely to have successfully received the telephone contact component of the intervention. Among higher risk patients who did successfully receive this component, the intervention effect was significant. CONCLUSION: Our findings suggest that clinic-based retention-in-care interventions are able to have significant effects on HIV patients with common behavioral health issues, but the design of those interventions should assure successful delivery of intervention components to increase effectiveness.