Development of a Human Immunodeficiency Virus Risk Prediction Model Using Electronic Health Record Data From an Academic Health System in the Southern United States.

BACKGROUND: Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) is underutilized in the southern United States. Rapid identification of individuals vulnerable to diagnosis of HIV using electronic health record (EHR)-based tools may augment PrEP uptake in the region. METHODS: Using machine learning, we developed EHR-based models to predict incident HIV diagnosis as a surrogate for PrEP candidacy. We included patients from a southern medical system with encounters between October 2014 and August 2016, training the model to predict incident HIV diagnosis between September 2016 and August 2018. We obtained 74 EHR variables as potential predictors. We compared Extreme Gradient Boosting (XGBoost) versus least absolute shrinkage selection operator (LASSO) logistic regression models, and assessed performance, overall and among women, using area under the receiver operating characteristic curve (AUROC) and area under precision recall curve (AUPRC). RESULTS: Of 998 787 eligible patients, 162 had an incident HIV diagnosis, of whom 49 were women. The XGBoost model outperformed the LASSO model for the total cohort, achieving an AUROC of 0.89 and AUPRC of 0.01. The female-only cohort XGBoost model resulted in an AUROC of 0.78 and AUPRC of 0.00025. The most predictive variables for the overall cohort were race, sex, and male partner. The strongest positive predictors for the female-only cohort were history of pelvic inflammatory disease, drug use, and tobacco use. CONCLUSIONS: Our machine-learning models were able to effectively predict incident HIV diagnoses including among women. This study establishes feasibility of using these models to identify persons most suitable for PrEP in the South.

Durable viral suppression among persons with HIV in the deep south: an observational study.

This study assessed predictors of stable HIV viral suppression in a racially diverse sample of persons living with HIV (PWH) in the southern US. A total of 700 PWH were recruited from one of four HIV clinics in Metro Atlanta, GA. Data were collected from September 2012 to July 2017, and HIV viral loads were retrieved from EMR for 18 months. The baseline visits and EMR data were used for current analyses. Durable viral suppression was categorized as 1. Remain suppressed, 2. Remain unsuppressed, and 3. Unstable suppression. The number of antiretroviral medications and age were significantly associated with durable viral suppression. Older age, fewer ART medications and availability of social support were positively associated with durable viral suppression over the 18-month observation period. Findings suggest that regimen complexity is potentially a better predictor of viral suppression than self-reported medication adherence. The need for consensus on the definition of durable viral suppression is also urged.

Challenges and opportunities for medical referrals at a mobile community health clinic serving sexual and gender minorities in rural South Carolina: a qualitative approach.

BACKGROUND: Sexual and gender minorities (SGM) in the Southern United States face challenges in accessing sexual and gender affirming health care. Alternative care models, like inclusive mobile clinics, help mitigate barriers to care for SGM. There is limited data in the literature on the experience of medical referral processes for SGM individuals accessing services from mobile health clinics. AIMS AND OBJECTIVES: The purpose of this study is to describe the medical referral experiences of SGM clients and their providers at a mobile health clinic in the Southern United States. METHODS: We recruited English-speaking individuals who provided care or received care from the mobile health clinic in South Carolina between June 2019 and August 2020. Participants completed a brief demographic survey and a virtual in-depth, semi-structured individual interview. Data analysis was conducted using an iterative process to generate codes, categories, and themes. Data collection and analysis were terminated once thematic saturation was achieved. RESULTS: The findings from this study indicated that the mobile health clinic had an inconsistent referral process that was largely dependent on providers' knowledge. Furthermore, clients and providers expressed individual barriers to the referral process, such as financial barriers, and opportunities to improve the referral process, such as an opt-in follow-up from the mobile clinic and increased mobile clinic resources. CONCLUSION: The findings in this study underscore the importance of having mobile clinics create a structured referral process that all medical providers are familiar with, and the value of hiring patient navigators that can support and refer clients to care that goes beyond the mobile health clinic setting.

Using Participatory Methods to Assess PrEP Interest and Uptake Among Young People Living in the Southeastern US: A Mixed Methods Assessment.

Adolescents and young adults (AYA; 13-24 years-old) comprise 22% of new HIV infections in the United States (US), most of whom live in the South. We used the situated-Information, Motivation, Behavioral skills (sIMB) model to identify priorities for intervention on multi-level factors that influence HIV preventive care among Black AYA in Durham, North Carolina. We conducted two participatory workshops (ages 13-17, N = 6; ages 18-24, N = 7) to engage youth about how to discuss HIV. We also assessed sIMB constructs from a separate quantitative sample of youth to contextualize the workshop findings (N = 80). HIV knowledge was low overall, but lower among younger Black AYA, suggesting a need for comprehensive sexual education. Trusted adults provided sexual health information, motivation for health maintenance, and behavioral skills support. HIV prevention interventions should provide comprehensive sexual health education to Black AYA, be age-specific, and include social supporters like parents, teachers, and community members.

"No One Does This for the Money or Lifestyle": Abortion Providers' Perspectives on Factors Affecting Workforce Recruitment and Retention in the Southern United States.

OBJECTIVES: Movements to stem abortion accessibility and provision are underway across the southern United States. Preserving access to safe abortion requires a steady maternal health workforce. Targeted laws and limiting environments have contributed to a regional dearth of abortion providers. This study evaluates the consequences of restrictive environments for the abortion workforce to inform strategies to reduce the provider shortage in the South. METHODS: We recruited twelve physicians using purposive sampling and interviewed them on their motivations and experiences practicing in the South. We employed grounded theory analysis to translate their perspectives into recommendations for provider recruitment and retention. RESULTS: Abortion providers identified challenges relating to restrictive legislation, institutional separation of abortion from other medical services, training unavailability, safety concerns, identity struggles, and marginalization within their profession. This contributed to providers widely experiencing stigma and isolation within their work and life environments. Their motivations for practicing in the South despite these challenges included wanting to be impactful in areas of high need, combating health access disparites, and having personal ties to the region. Providers' suggested increasing regional networking and training opportunities, creating an information clearinghouse, and offering additional compensation to better support their work. We conceptualized these findings into a framework detailing the challenges, impacts and opportunities for abortion provision in the southern United States. CONCLUSIONS FOR PRACTICE: Our recommendations for provider recruitment and retention include cooperation between professional organizations, training programs, and healthcare institutions to create opportunities for training and networking and encourage abortion-supportive organizational and policy environments.

Potential Use for Serosurveillance of Feral Swine to Map Risk for Anthrax Exposure, Texas, USA.

Anthrax is a disease of concern in many mammals, including humans. Management primarily consists of prevention through vaccination and tracking clinical-level observations because environmental isolation is laborious and bacterial distribution across large geographic areas difficult to confirm. Feral swine (Sus scrofa) are an invasive species with an extensive range in the southern United States that rarely succumbs to anthrax. We present evidence that feral swine might serve as biosentinels based on comparative seroprevalence in swine from historically defined anthrax-endemic and non-anthrax-endemic regions of Texas. Overall seropositivity was 43.7% (n = 478), and logistic regression revealed county endemicity status, age-class, sex, latitude, and longitude were informative for predicting antibody status. However, of these covariates, only latitude was statistically significant (ß = -0.153, p = 0.047). These results suggests anthrax exposure in swine, when paired with continuous location data, could serve as a proxy for bacterial presence in specific areas.

A Rapid Survey of Avirulence Genes in Field Isolates of Magnaporthe oryzae.

Magnaporthe oryzae is the causal agent for the devastating disease rice blast. The avirulence (AVR) genes in M. oryzae are required to initiate robust disease resistance mediated by the corresponding resistance (R) genes in rice. Therefore, monitoring pathogen AVR genes is important to predict the stability of R gene-mediated blast resistance. In the present study, we analyzed the DNA sequence dynamics of five AVR genes, namely, AVR-Pita1, AVR-Pik, AVR-Pizt, AVR-Pia, and AVR-Pii, in field isolates of M. oryzae in order to understand the effectiveness of the R genes, Pi-ta, Pi-k, Pi-zt, Pia, and Pii in the Southern U.S. rice growing region. Genomic DNA of 258 blast isolates collected from commercial fields of the Southern UNITED STATES during 1975-2009 were subjected to PCR amplification with AVR gene-specific PCR markers. PCR products were obtained from 232 isolates. The absence of PCR products in the remaining 26 isolates suggests that these isolates do not contain the tested AVR genes. Amplified PCR products were subsequently gel purified and sequenced. Based on the presence or absence of the five AVR genes, 232 field isolates were classified into 10 haplotype groups. The results revealed that 174 isolates of M. oryzae carried AVR-Pita1, 225 isolates carried AVR-Pizt, 44 isolates carried AVR-Pik, 3 isolates carried AVR-Pia, and one isolate carried AVR-Pii. AVR-Pita1 was highly variable, and 40 AVR-Pita1 haplotypes were identified in avirulent isolates. AVR-Pik had four nucleotide sequence site changes resulting in amino acid substitutions, whereas three other AVR genes, AVR-Pizt, AVR-Pia, and AVR-Pii, were relatively stable. Two AVR genes, AVR-Pik and AVR-Pizt, were found to exist in relatively larger proportions of the tested field isolates, which suggested that their corresponding R genes Pi-k and Pi-zt can be deployed in preventing blast disease in the Southern UNITED STATES in addition to Pi-ta. This study demonstrates that continued AVR gene monitoring in the pathogen population is critical for ensuring the effectiveness of deployed blast R genes in commercial rice fields.

Exploring Family Decisions to Refuse Organ Donation at Imminent Death.

Communication about organ donation at the time of imminent death is a meaningful, yet less understood, area of health communication. We employed a multiple goals framework to explore family normative perceptions of organ donation and the conversational goal tensions experienced during a family member's imminent death. Semi-structured interviews were conducted with 14 family members who refused to donate when approached by an organ procurement coordinator (OPC) upon the imminent death of a family member. Thematic analysis revealed that family members described their decisions to refuse donation as (a) last acts of love, (b) responses to unnecessary requests, and (c) consistent with the known beliefs of the patient. Participants described several goal tensions operating within the organ donation conversation itself, including (a) the management of frequent requests, (b) pressure to donate, and (c) enduring unwanted requests from the OPC. Communication goals frameworks offer practical insights for improving organ-related conversations.

Metabolic Syndrome Among People Living with HIV Receiving Medical Care in Southern United States: Prevalence and Risk Factors.

Using representative data among 1861 in care people living with HIV (PLWH) in four southern states (Texas, Mississippi, Florida, and Georgia) from the 2013-2014 Medical Monitoring Project (MMP) survey, we estimated the prevalence and odds of metabolic syndrome (MetS) among various demographic and HIV related risk factors. Overall MetS prevalence was 34%, with our participants being mostly black (55%), male (72%), ≥ 50 years old (46%), and overweight or obese (60%) with undetectable viral loads (≤ 200 copies/ml, 69%), and were currently taking antiretroviral medication (98%). Compared to those who were ≥ 60 years, 18-39 year olds had a 79% (95% CI 0.13-0.33) lower odds of having MetS. Women were 2.24 times more likely to have MetS than men (95% CI 1.69-2.97). Age and sex were significant predictors of MetS. Since MetS is a combination of chronic disease risk factors, regular screening for MetS risk factors among aging PLWH is crucial.

Reducing the African American HIV Disease Burden in the Deep South: Addressing the Role of Faith and Spirituality.

Nearly half of HIV infections in the United States are concentrated among African Americans, and over half of new HIV infections occur in the South. African Americans have poorer outcomes in the entire continua of HIV and PrEP care. Complex social, structural, and behavioral factors contribute to our nation's alarming racial disparities in HIV infection, particularly in the Deep South. Despite the importance of faith, spirituality and religious practice in the lives of many African Americans, there has been little scientific investment exploring how African Americans' religious participation, faith and spirituality may impact our nation's HIV epidemic. This article summarizes the state of the science on this critical issue. We also identify opportunities for new scholarship on how faith, spirituality and religious participation may impact HIV care continuum outcomes in the South and call for greater federal research investment on these issues.

An educational initiative in response to identified PrEP prescribing needs among PCPs in the Southern U.S.

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, but many primary care physicians (PCPs) have not incorporated PrEP into practice. While PrEP may be a key strategy to reducing high HIV transmission rates in the southern US, knowledge about PrEP prescribing patterns among PCPs in this region is lacking. An online survey was sent to a large network of PCPs at an academic medical center in North Carolina in October 2015. The survey was repeated in September 2016, after an educational intervention that included on-site trainings at 14 PCP offices. Chi-square tests were used to compare PrEP prescribing patterns among providers. The initial survey was sent to 389 PCPs, with 115 (30%) responding. Of these, 78% reported seeing men who have sex with men (MSM). Only 17% had prescribed PrEP. The most frequently identified barrier was lack of knowledge (60%). When the survey was repeated after the educational initiative, 79 PCPs (20%) responded. Of these, 90% reported seeing MSM, and 35% had prescribed PrEP. PCPs who had attended a training were more likely to have prescribed PrEP (OR 4.84, CI 1.77-13.21). In conclusion, PrEP prescribing among PCPs in the southern US is low. A survey among PCPs identified lack of knowledge as a barrier to prescribing, motivating an institutional-wide educational campaign in response. Further efforts are needed to continue to raise awareness and educate PCPs in the South about PrEP.

Understanding perceptions of stakeholder groups about Forestry Best Management Practices in Georgia.

Forestry Best Management Practices (BMPs) are critical in ensuring sustainable forest management in the United States because of their effectiveness in protecting water quality, reducing soil erosion, maintaining riparian habitat, and sustaining site productivity. The success of forestry BMPs depends heavily on coordination among primary stakeholder groups. It is important to understand perceptions of such groups for a successful forest policy formulation. We used the SWOT-AHP (Strengths, Weaknesses, Opportunities, and Threats analysis with the Analytical Hierarchy Process) framework to assess perceptions of three stakeholder groups (loggers, landowners, agency foresters) about forestry BMPs in Georgia, the largest roundwood producing state in the United States. The agency and logger stakeholder groups gave the highest priority to improved reputation under the strength category, whereas the landowner stakeholder group perceived sustainable forestry as the highest priority under the same category. Lack of landowner education was the highest priority under the weakness category for landowner and agency stakeholder groups, whereas the logger stakeholder group selected lack of trained personnel as the highest priority under the same category. Agency and landowner stakeholder groups gave the highest priority to training and education while loggers indicated maintenance of forest-based environmental benefits as their highest priority under the opportunity category. Finally, landowners and agency stakeholder groups perceived more regulations and restrictions as most significant in the threat category whereas the logger stakeholder group was most concerned about the insufficient accounting of cost sharing under the same category. Overall, selected stakeholder groups recognize the importance of forestry BMPs and had positive perceptions about them. A collaborative approach based on continuous feedback can streamline expectations of stakeholder groups about forestry BMPs in Georgia and several other states that are interested in maintaining high compliance rate of forestry BMPs for ensuring sustainable forest management.

African American Elders' Serious Illness Experiences: Narratives of "God Did," "God Will," and "Life Is Better".

The foundation of culturally sensitive patient-centered palliative care is formed from one's social, spiritual, psychological, and physical experiences of serious illness. The purpose of this study was to describe categories and patterns of psychological, social, and spiritual healing from the perspectives of aging seriously ill African American (AA) elders. Using narrative analysis methodology, 13 open-ended interviews were collected. Three main patterns were "prior experiences," "I changed," and "across past, present experiences and future expectations." Themes were categorized within each pattern: been through it . . . made me strong, I thought about . . . others, went down little hills . . . got me down, I grew stronger, changed priorities, do things I never would have done, quit doing, God did and will take care of me, close-knit relationships, and life is better. "Faith" in God helped the aging seriously ill AA elders "overcome things," whether their current illness or other life difficulties.

Obstacles to Shared Expectations in a Burn Intensive Care Unit.

Critical care patients are dependent on the health care team and their family members to effect care goals that are consistent with their core values and wishes. This study aimed to identify and understand how obstacles to communication affect these two disparate groups. Ten burn intensive care unit (BICU) care team and 20 family members participated in in-depth semistructured interviews. A two-cycle coding, inductive analytical approach was used to derive three obstacle metathemes: family engagement, information exchange, and process transparency and standardization. However, care team and family members' themes within each metatheme were different. Although the thematic structure was derived inductively, our findings in retrospect appeared to be consistent with Law's four resistances associated with actor-networks. From this perspective, actor-network theory provides a plausible explanation for perceived obstacles and may, in the future, guide the development of interventions to improve shared agency across networks.

The Role of Social Capital in African Americans' Attempts to Reduce and Quit Cocaine Use.

BACKGROUND: Research examining substance users' recovery has focused on individual-level outcomes while paying limited attention to the contexts within which individuals are embedded, and the social processes involved in recovery. OBJECTIVES: This paper examines factors underlying African American cocaine users' decisions to reduce or quit cocaine use and uses practice theory to understand how lifestyle changes and shifts in social networks facilitate access to the capital needed to change cocaine use patterns. METHODS: The study, an in-depth analysis of substance-use life history interviews carried out from 2010 to 2012, included 51 currently not-in-treatment African American cocaine users in the Arkansas Mississippi Delta region. A blended inductive and deductive approach to data analysis was used to examine the socio-cultural and economic processes shaping cocaine use and recovery. RESULTS: The majority of participants reported at least one lifetime attempt to reduce or quit cocaine use; motivations to reduce use or quit included desires to meet social role expectations, being tired of using, and incarceration. Abstinence-supporting networks, participation in conventional activities, and religious and spiritual practices afforded access to capital, facilitating cocaine use reduction and sobriety. CONCLUSIONS: Interventions designed to increase connection to and support from nondrug using family and friends with access to recovery capital (e.g., employment, faith community, and education) might be ideal methods to reduce substance use among minorities in low-income, resource-poor communities.

Landowner response to wildfire risk: Adaptation, mitigation or doing nothing.

Wildfire has brought about ecological, economic, and social consequences that engender human responses in many parts of the world. How to respond to wildfire risk is a common challenge across the globe particularly in areas where lands are controlled by many small private owners because effective wildfire prevention and protection require coordinated efforts of neighboring stakeholders. We explore (i) wildfire response strategies adopted by family forestland owners in the southern United States, one of the most important and productive forest regions in the world, through a landowner survey; and (ii) linkages between the responses of these landowners and their characteristics via multinomial logistic regression. We find that landowners used diverse strategies to respond to wildfire risk, with the most popular responses being "doing nothing" and combined adaptation and mitigation, followed by adaptation or mitigation alone. Landowners who had lost properties to wildfire, lived on their forestlands, had a forest management plan, and were better educated were more likely to proactively respond to wildfire risk. Our results indicate the possibility to enhance the effectiveness of collective action of wildfire risk response by private forestland owners and to coordinate wildfire response with forest conservation and certification efforts. These findings shed new light on engaging private landowners in wildfire management in the study region and beyond.

Human Immunodeficiency Virus in the South: An Epidemic Within an Epidemic.

The authors examine the HIV epidemic in the Southern United States, emphasizing its severe impact on minority and young populations. The authors highlight challenges including limited health care access, systemic racism influencing social determinants of health, and lesbian, gay, bisexual, transgender, and queer+ stigma. The South faces a critical human immunodeficiency virus (HIV) workforce shortage, especially in rural areas, and struggles with coexisting syndemics like other sexually transmitted infections and substance-use disorders. The authors describe comprehensive strategies such as Medicaid expansion, workforce enhancement, stigma reduction, and policy reforms to improve HIV prevention and treatment, emphasizing the need for a multifaceted approach to improve health outcomes for those living with HIV in the South.

Sleep Quality and Disability for Custodial Grandparents Caregivers in the Southern United States.

Sleep quality amongst caregivers with disability may have been compounded by the COVID-19 pandemic. We evaluated differences in sleep quality amongst custodial grandparents from a southern state that were identified through state-based Kinship Care support groups coordinators and online. Participants (N = 102) completed the Pittsburgh Sleep Quality Index and self-reported disability statuses. Gamma tests showed a strong negative relationship between disability and sleep duration indicating fewer hours of sleep, higher use of sleep medication and greater sleep disturbances. Disability is not significantly related to sleep latency, sleep efficiency, and daytime dysfunction. T-tests showed no strength of relationship between disability and overall sleep quality. During the first year of the COVID-19 pandemic, custodial grandparents with disability had greater issues with their sleep quality than those without disability. Sleep, as it pertains to its overall preponderant role in maintaining good health, should be examined amongst custodial grandparent caregivers and those with disability.

A survey of South Carolina pharmacists' readiness to prescribe human immunodeficiency virus pre-exposure prophylaxis.

Introduction: HIV pre-exposure prophylaxis (PrEP) is largely underutilized in the Southern United States. Given their community presence, pharmacists are well positioned to provide PrEP within rural, Southern regions. However, pharmacists' readiness to prescribe PrEP in these communities remains unknown. Objective: To determine the perceived feasibility and acceptability of prescribing PrEP by pharmacists in South Carolina (SC). Methods: We distributed a 43-question online descriptive survey through the University of SC Kennedy Pharmacy Innovation Center's listerv of licensed SC pharmacists. We assessed pharmacists' comfort, knowledge, and readiness to provide PrEP. Results: A total of 150 pharmacists responded to the survey. The majority were White (73%, n=110), female (62%, n=93), and non-Hispanic (83%, n=125). Pharmacists practiced in retail (25%, n=37), hospital (22%, n=33), independent (17%, n=25), community (13%, n=19), specialty (6%, n=9), and academic settings (3%, n=4); 11% (n=17) practiced in rural locales. Pharmacists viewed PrEP as both effective (97%, n=122/125) and beneficial (74% n=97/131) for their clients. Many pharmacists reported being ready (60% n=79/130) and willing (86% n=111/129) to prescribe PrEP, although over half (62% n=73/118) cited lack of PrEP knowledge as a barrier. Pharmacists described pharmacies as an appropriate location to prescribe PrEP (72% n=97/134). Conclusions: Most SC pharmacists surveyed considered PrEP to be effective and beneficial for individuals who frequent their pharmacy and are willing to prescribe this therapy if statewide statutes allow. Many felt that pharmacies are an appropriate location to prescribe PrEP but lack a complete understanding of required protocols to manage these patients. Further investigation into facilitators and barriers of pharmacy-driven PrEP are needed to enhance utilization within communities.

Outness, Discrimination, and Psychological Distress Among LGBTQ+ People Living in the Southern United States.

Purpose: Lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) people face mental health disparities. These disparities are amplified in the Southern regions of the United States. This study assessed the role of outness, discrimination, and other demographic variables on possible serious mental illness (SMI) among LGBTQ+ Southerners. Methods: This study used data from the 2017 LGBT Institute Southern Survey, a cross-sectional convenience sample of 6502 LGBTQ+ adults living in 14 Southern states. Multivariable logistic regression was performed to examine differences between those with and without possible SMI. Results: Outness was associated with a lower likelihood of possible SMI (odds ratio [OR]: 0.696, 95% confidence interval [CI]: 0.574-0.844, p = 0.001), especially when controlling for discrimination in the past 12 months (OR: 0.693, 95% CI: 0.576-0.834, p ≤ 0.001) and lifetime discrimination (OR: 0.678, 95% CI: 0.554-0.829, p = 0.001). Lifetime discrimination was associated with a higher likelihood of possible SMI (OR: 1.413, 95% CI: 1.034-1.932, p = 0.033), as was discrimination experienced in the past 12 months (OR: 1.626, 95% CI: 1.408-1.877, p ≤ 0.001). Black/African American respondents had the lowest percentage of possible SMI (21.0%) compared with other races, despite having lower or comparable rates of outness. Conclusion: These results indicate a possible promotive effect of outness against possible SMI among LGBTQ+ Southerners, as well as possible promotive group-level factors among Black/African American LGBTQ+ Southerners. Policies and interventions that address discrimination against LGBTQ+ Southerners should be expanded, and future research should address how the relationships between outness, discrimination, and mental health outcomes may vary by subgroup.