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Pre-exposure prophylaxis (PrEP) is a lifesaving medical intervention that protects against human immunodeficiency virus (HIV), but to date, PrEP uptake has been limited. PrEP utilization and adherence among youth, including stigmatized and highly vulnerable young sexual and gender minorities, have been exceptionally low across all regions, leading to preventable HIV transmission. Considering the scientific value of measuring and understanding predictors or associations of PrEP adherence, our study team validated two scales: a PrEP Difficulties Scale and a PrEP Confidence Scale tested within the Adolescent Trials Network P3 study (2019-2021). Data from sexual and gender minorities who were prescribed PrEP across nine domestic sites were evaluated (

Background Interventions for increasing the uptake of COVID-19 vaccination among Black young adults are central to ending the pandemic. Black young adults experience harms from structural forces, such as racism and stigma, that reduce receptivity to traditional public health messaging due to skepticism and distrust. As such, Black young adults continue to represent a priority population on which to focus efforts for promoting COVID-19 vaccine uptake. Objective In aims 1 and 2, the Tough Talks digital health intervention for HIV disclosure will be adapted to address COVID-19 vaccine hesitancy and tailored to the experiences of Black young adults in the southern United States (Tough Talks for COVID-19). In aim 3, the newly adapted Tough Talks for COVID-19 digital health intervention will be tested across the following three southern states: Alabama, Georgia, and North Carolina. Methods Our innovative digital health intervention study will include qualitative and quantitative assessments. A unique combination of methodological techniques, including web-based surveys, choose-your-own-adventures, digital storytelling, user acceptability testing, and community-based participatory approaches, will culminate in a 2-arm hybrid type 1 effectiveness implementation randomized controlled trial, wherein participants will be randomized to the Tough Talks for COVID-19 intervention arm or a standard-of-care control condition (N=360). Logistic regression will be used to determine the effect of the treatment arm on the probability of vaccination uptake (primary COVID-19 vaccine series or recommended boosters). Concurrently, the inner and outer contexts of implementation will be ascertained and catalogued to inform future scale-up. Florida State University’s institutional review board approved the study (STUDY00003617). Results Our study was funded at the end of April 2021. Aim 1 data collection concluded in early 2022. The entire study is expected to conclude in January 2025. Conclusions If effective, our digital health intervention will be poised for broad, rapid dissemination to reduce COVID-19 mortality among unvaccinated Black young adults in the southern United States. Our findings will have the potential to inform efforts that seek to address medical mistrust through participatory approaches. The lessons learned from the conduct of our study could be instrumental in improving health care engagement among Black young adults for several critical areas that disproportionately harm this community, such as tobacco control and diabetes prevention. Trial Registration ClinicalTrials.gov NCT05490329; https://clinicaltrials.gov/ct2/show/NCT05490329 International Registered Report Identifier (IRRID) DERR1-10.2196/41240

There remains critical need for community-based approaches to HIV prevention which center youth voices and needs.We established an adolescent health working group (AHWG) to convene youth, parents, providers, and advocates in agenda-setting for interventions to increase pre-exposure prophylaxis uptake in Durham.Our three study phases included six AHWG meetings from 2019 to 2020, youth-only meetings guided by a participatory engagement framework (Youth Generate and Organize), and interviews (n=13) and surveys with youth in the community (N=87). We also developed materials such as an AHWG mission statement, a list of themes and informational needs, and documented strategies about pivoting the project during the onset of the COVID-19 global pandemic.Lessons Learned/Conclusions: Engaging adults in youth-focused HIV prevention differs greatly to engaging youth themselves. Creating spaces to promote adolescent sexual Health requires trust building, breaking down sensitivities and stigma to, and flexibility to navigate both virtual and in-person spaces to do so.

BACKGROUND To understand the types of messages youth believe were motivating and persuasive when asked to text friends to encourage them to seek HIV/STI testing services at a neighborhood clinic. OBJECTIVE To understand the types of messages youth believe are motivating and persuasive when asked to text friends to encourage them to seek HIV/STI testing services at a neighborhood clinic. METHODS We implemented an adolescent peer-based text messaging intervention to encourage clinic attendance and increase STI and HIV testing among youth (n= 100) at an adolescent clinic in San Francisco, California. Participants were asked to send a text message to five friends they believed were sexually active to encourage their friends to visit the clinic and receive STI/HIV screening. Thematic analysis was employed to analyze the content of the text messages sent and received during the clinic visit. Member checking and consensus coding was used to ensure interrater reliability and significance of themes. RESULTS We identified 4 themes in the messages sent by participants: i) calls to action to encourage peers to get tested, ii) personalized messages with sender-specific information, iii) clinic information such as location and hours, and iv) self-disclosure of personal clinic experience. We found that nearly all text messages included some combination of 2 or more of these broad themes. We also found that youth were inclined to send messages they created themselves, as opposed to sending the same message to each peer, which they tailored to each individual to whom they were sent. Many (40%) received an immediate response to their message and most participants reported receiving at least one positive response, while few reported that they had received at least one negative response. There were some differences in responses by the type of message sent. CONCLUSIONS Given the high rates of STI and HIV and low rates of testing among adolescents, peer-driven text messaging interventions to encourage accessing care may be successful at reaching this population. This study suggests that youth are willing to text message their friends and there are clear types of messages they developed and utilized. Future research should employ these methods with a large, more diverse sample of youth and young adults for long-term evaluation of care seeking and care retention outcomes to make progress in reducing HIV/STI among adolescents and young adults.

Through interviews with clinical service providers, we explored stigma's impact on HIV service provision for African Americans during COVID-19.African Americans experience disproportionate rates of HIV and COVID-19. We explored COVID-19's impact on HIV services for African American adults in a Southern city.The study was qualitative and observational.Key informant interviews were conducted (n = 11) across two healthcare centres and two community-based organisations and thematically analysed using phenomenological approaches by two coders. Interviews explored pre- and post-COVID-19 service provision and parallels between COVID-19 and HIV, particularly as related to stigma. The COREQ checklist was utilised to ensure research quality.According to the providers interviewed, all providers offered HIV prevention/treatment, but PrEP and preventive services diminished greatly early in the COVID-19 pandemic. Successful transition to telehealth depended on existing telehealth use. Challenges exacerbated by COVID-19 included food/housing insecurity and physical distancing constraints. Clients' COVID-19 informational needs shifted from concerns to vaccine requests over time. Interviewees stated HIV and COVID-19 both carry 'risk taking'; however, HIV risk was more physically intimate than COVID-19. Notably, some providers used stigmatising language referring to clients with HIV/COVID and omitted person-centred language.Findings suggest need to address challenges in telehealth to improve client experiences now and for future pandemics. More research is needed to examine intersectional stigmatisation of COVID-19 and HIV for African Americans to design person-centred counselling interventions.Results demonstrate need for provider training to reframe stigma discussions using client centeredness, educating African Americans on HIV and COVID-19 prevention, and coordination with local organisations to address multiple care needs.This research highlights needs of clients based on the views of healthcare providers caring for predominantly African American communities in a Southern city. However, no patients, service users, caregivers or members of the public were directly involved in this study.

To date, there are no established scales to assess PrEP stigma among youth. We validated the Youth PrEP Stigma Scale within the Adolescent Trials Network P3 study (2019-2021). Data from sexual and gender minority youth (16-24 years) who were prescribed PrEP across nine domestic sites were evaluated (N = 235). Descriptive statistics, exploratory factor analysis, and correlation coefficients are reported. Results yielded a three-factor solution (PrEP Disapproval by Others, Enacted PrEP Stigma, and PrEP User Stereotypes) with strong factor loadings and Cronbach's alphas ranging from 0.83 to 0.90, suggesting excellent internal consistency. Correlations between this Scale, anticipated HIV stigma, perceived HIV risk, and disclosure of sexual identity were significant, indicating potential for robust application. Given the persistence of HIV infections among youth, stigma as a barrier to prevention, and expansion of PrEP modalities, the Youth PrEP Stigma Scale could enhance intervention and mechanistic research among youth at elevated risk for HIV acquisition.Hasta la fecha, no existen escalas establecidas para evaluar el estigma de la PrEP entre los jóvenes. Validamos la Escala de estigma de la PrEP para jóvenes dentro del estudio P3 de la Red de ensayos para adolescentes (2019–2021). Se evaluaron los datos de jóvenes de minorías sexuales y de género (16–24 años) a quienes se les recetó PrEP en nueve sitios domésticos (N = 235). Se informan estadísticas descriptivas, análisis factorial exploratorio y coeficientes de correlación. Los resultados arrojaron una solución de tres factores (desaprobación de PrEP por parte de otros, estigma de PrEP promulgado y estereotipos de usuarios de PrEP) con fuertes cargas factoriales y alfas de Cronbach que oscilan entre 0.83 y 0.90, lo que sugiere una excelente consistencia interna. Las correlaciones entre esta Escala, el estigma anticipado del VIH, el riesgo percibido del VIH y la divulgación de la identidad sexual fueron significativas, lo que indica un potencial para una aplicación sólida. Dada la persistencia de las infecciones por el VIH entre los jóvenes, el estigma como una barrera para la prevención y la expansión de las modalidades de PrEP, la Escala de estigma de la PrEP para jóvenes podría mejorar la intervención y la investigación mecánica entre los jóvenes con un riesgo elevado de contraer el VIH.

Interactive stories are a relatively newer form of storytelling with great potential to correct misinformation while increasing self-efficacy, which is crucial to vaccine acceptance. To address COVID-19 vaccine hesitancy and medical mistrust in young Black adults (BYA), we sought to adapt a pre-existing application ("app"; Tough Talks) designed to address HIV disclosure decision-making through choose-your-own adventure (CYOA) narratives and other activities. The adapted app (Tough Talks - COVID) uses a similar approach to situate COVID-19 vaccination decision-making within social contexts and to encourage greater deliberation about decisions. To inform content for the CYOA narratives, we conducted an online survey that was used to elicit the behavioral, cognitive, and environmental determinants influencing COVID-19 vaccine hesitancy among 150 BYA (ages 18-29) in Georgia, Alabama, and North Carolina. The survey included scenario questions that were developed with input from a youth advisory board to understand responses to peer and family influences. In two scenarios that involved discussions with family and friends about vaccination status, most respondents chose to be honest about their vaccination status. However, vaccinated individuals perceived more social pressure and stigma about not being vaccinated than unvaccinated respondents who were not as motivated by social pressure. Personal choice/agency in the face of perceived vaccine risks was a more common theme for unvaccinated respondents. Results suggest that relying on changing social norms alone may not impact barriers to vaccination in unvaccinated young adults without also addressing other barriers to vaccination such as concerns about autonomy and vaccine safety. Based on these findings, CYOA narratives in the app were adapted to include discussions with family and friends but also to touch on themes of personal choice as well as other topics that influence behaviors besides norms such as safety, side effects, and risk of COVID-19 in an evolving pandemic.

AIMS AND OBJECTIVE: Advance care planning (ACP) is the communication process of documenting future healthcare preferences in case patients are unable to make healthcare decisions for themselves. Research suggests ACP discussions among persons living with HIV (PLHIV) are infrequent overall and may differ by gender and/or race. BACKGROUND: Previous literature has displayed that African Americans are less likely than other racial groups to use advanced care planning, palliative care or hospice, but does not conclusively account for ACP among PLHIV. African American PLHIV rely on informal care that may be differ by gender and represents an important pathway to increase ACP. DESIGN: The study was mixed methods and observational. METHODS: Participants completed self-report surveys (N = 311) and were interviewed (n = 11). Poisson regression (quantitative) and grounded theory analyses (qualitative) were implemented, using COREQ checklist principles to ensure study rigor. RESULTS: Less than half had discussed ACP (41.2%; N = 267). More ACP knowledge predicted 76% lower likelihood of ACP discussions among women. Men who spent more time caregiving in a given week were nearly 3 times more likely to discuss ACP than men who spent less time caregiving. Women were more likely than men to be caregivers and were also expected to serve in that role more than men, which was qualitatively described as 'being a woman'. CONCLUSIONS: The present study is one of few studies exploring ACP among caregivers in African American populations hardest hit by HIV. Results suggest that ACP skill building and education are critical for African Americans living with HIV to promote ACP discussions with their caregivers. Knowledge about ACP topics was low overall even when healthcare had recently been accessed. Support reciprocity and gender-specific communication skill building may facilitate ACP in African American HIV informal caregiving relationships. RELEVANCE TO CLINICAL PRACTICE: Results underscore the need for ACP education which includes healthcare providers and caregivers, given African Americans' preference for life-sustaining treatments at end-of-life. ACP is crucial now more than ever, as COVID-19 complicates care for older adults with HIV at high risk of complications.

BACKGROUND Few studies have focused on attitudes towards novel coronavirus 2019 (COVID-19) vaccination among Black or African American young adults (BYA) in the Southern United States (US), despite high levels of infection in this population. OBJECTIVE To understand this gap, we conducted an online survey to explore beliefs and experiences related to COVID-19 vaccination among BYA (ages 18-29) in three southern states. METHODS We recruited 150 BYA to participate in an online survey as formative research for an intervention to address vaccine hesitancy/skepticism in Alabama, Georgia, and North Carolina between September 22, 2021, and November 18, 2021. Participants were recruited through social media ads on Facebook, Twitter, Instagram, and YouTube. Additionally, we distributed information about the survey through national organizations working with BYA, our community partners and network collaborations. We used validated measures from prior surveys on COVID-19 vaccination. RESULTS Less than half of vaccinated respondents planned to get a booster shot (47%, n=71) and 14% (n=28) had not received any doses of the COVID-19 vaccine. Half of unvaccinated respondents (50%, n=14) reported they wanted to wait longer before getting vaccinated. Motivators to get vaccinated were similar between unvaccinated and vaccinated respondents (e.g., if required, to protect the health of others); but the main motivator for those vaccinated was to protect one’s own health. Among unvaccinated individuals, reasons for not receiving the COVID-19 vaccine included concern about vaccine side effects (54%) and mistrust of vaccine safety (46%), of effectiveness (43%), and of the government’s involvement with vaccines (43%). Experiences of discrimination (40%) and mistrust of vaccines (36%) were common even among the vaccinated population. Among all respondents, those who said they would be motivated to get vaccinated if it was required for school, work, or travel, were more likely to endorse negative beliefs about vaccines compared to those motivated for other reasons. CONCLUSIONS Mistrust in COVID-19 vaccine safety and efficacy was common among this sample of BYA in the South, irrespective of vaccination status. Other motivators such as safety of family and community and vaccination requirements may be able to tip the scales towards a decision to be vaccinated among those who are initially hesitant. However, it is unclear how vaccine requirements among BYA in the South affect trust in government or healthcare in the long-term. Interventions that include young Black adults in vaccination messaging and programs may consider more proactively addressing trust and countering misinformation.

Successful navigation of the HIV care continuum is necessary to maintain viral suppression. We explored gender-stratified correlates of being virally unsuppressed in the Prevention for Positives (P4P) component of HPTN 065. The outcome of interest was unsuppressed viral load (> 40 copies/mL) among individuals already living with HIV. Correlates included medication adherence factors, social support and stigma. Logistic regression models were stratified by gender (N = 673). Men-specific correlates of being virally unsuppressed included opposite-sex partners, older age and HIV disclosure stigma. Women-specific correlates included time since diagnosis, and personal-level barriers to medication adherence. When more individuals knew about their HIV status, women had over twice the likelihood of being virally unsuppressed; no such association was seen among men. Additionally, higher levels of social support were not associated with viral suppression among women. Interventions should consider gender-specific approaches to engaging social support in de-stigmatization of HIV and promotion of medication adherence and subsequent viral suppression.

Persons living with HIV (PLWH) are living into old age with more complex care needs that non-PLWH. Promoting quality of life should include advance care planning (ACP) education, particularly among African Americans. We explored faith/spirituality-related correlates of interest in a future quality of life program among African American PLWH. Data were from the AFFIRM study. Participants were recruited from an HIV clinic and completed surveys, interviews, and focus groups. Quantitative analyses included Logistic regression. Qualitative data were coded using grounded theory. Nearly half of participants had less than a high school education (47.9%), and roughly 90% had heard of at least one ACP-related topic (86.6%; N = 315). Qualitative themes related to quality of life and faith/spirituality were: (1) Coping with life challenges; (2) Motivation to improve health for loved ones; and (3) Support programs for people with HIV (N = 39). Satisfaction with religion/spirituality was associated with greater interest in a future program (p

HPTN 065 utilized financial incentives to promote viral suppression among HIV-positive participants. Exit interviews were conducted in a sub-study of participants in Washington, DC and Bronx, NY. The present analyses explored lived experiences of social ties and stigma as individuals navigated the HIV care continuum, including gender differences in lived experiences. Using viral load data and informed by stages-of-change theory, participants were categorized into "Low-Adherers (n = 13)", "Action (n = 29)" and "Maintenance (n = 31)" stages. Secondary analyses of qualitative data were informed by grounded theory, and instances of social ties and stigma discussed by participants were quantified with descriptive statistics. Participants (N = 73) were mostly male (64%), African American (58%), with yearly income under $10,000 (52%). Low-adherers identified fewer, and sometimes more combative social ties than those in other adherence stages. Maintainers identified supportive ties as motivation for medication adherence (68%) but relied less on them for motivation than individuals in other adherence stages. Low-adherers described current experiences of stigma related to being diagnosed with HIV more than other adherence stages (23%). Individuals in Action reported stigma related to disclosing their HIV status to others (52%), while individuals in Maintenance mostly stigmatized others engaging in "risky" behaviors (32%). Findings suggest that women may perceive greater HIV stigma than men, perceive less supportive social ties, and were the majority of Low-adherers. Gender-informed approaches can facilitate community de-stigmatization of HIV, as African American women may be at greater risk of negative HIV health outcomes.

Adherence to care and antiretroviral therapy is challenging, especially for people living with HIV (PLWH) with additional co-occurring risk factors. Case management interventions, including motivational interviewing (MI), show promise to improve HIV treatment adherence, but few studies have examined how such interventions are delivered to or experienced by PLWH who have been reengaged in care. We conducted qualitative interviews with six case managers and 110 PLWH exiting from a randomized study (HPTN 078) who received a MI-based case management intervention in addition to standard patient-navigation services, or standard services only. Our study provided greater insight into the main findings from HPTN 078, including an in-depth description of the multiple barriers to adherence faced by this largely “out-of-care” population, as well as a more nuanced understanding of the benefits and challenges of implementing MI. A blend of MI plus more intensive interventions may be needed for PLWH facing multiple structural barriers.

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.

Objective: To understand the needs of Emergency Medical Service (EMS) providers caring for substance users in an urban setting. Design: Qualitative interviews with EMS providers regarding perceptions of substance users and treatment programs. Setting: Baltimore City. Participants: Twenty-two Baltimore City Fire Department EMS providers. Interventions: Semistructured in-depth interviews were conducted with 22 EMS providers. Topics included experiences caring for substance-using patients and attitudes about local harm reduction approaches. Main outcome measure: Providers were asked their views on receiving training to deliver a brief motivational intervention to encourage patients to enter drug treatment. Interviews were transcribed and analyzed using constant comparison. Results: Participants were mostly Male (68.2 percent), White (66.6 percent), and had Advanced Life Skills training (90.9 percent). Mean experience was 8.7 years. Many providers described EMS misusers as mostly male and middle-aged, although there were variations in substance use patterns among all races and income levels. Most stated that repeated care provision to a small number of substance-users negatively impacted care quality. Provider demands included departmental policies and resource limitations. Many expressed willingness to deliver motivational messages to substance-using patients to consider drug treatment. Other stated that behavioral interventions were beyond their job duties and most reported having little-to-no knowledge of local treatment programs. Conclusions: EMS providers may be uniquely positioned to deliver substance use treatment messages to substance users. This could be a life- and cost-saving improvement to EMS in Baltimore City with incentivized training. More research is needed to inform opioid use preparedness in urban settings, which remain at the center of the opioid epidemic.

African-American men who have sex with men (MSM) with HIV are more likely to have unsuppressed viral load than other racial/ethnic groups. HPTN 065 Study, completed in 2015, consisted of five interconnected study components conducted at clinics in Bronx, New York and Washington, D.C. Participants completed surveys with questions related to socio-demographic factors and individual-level HIV medication adherence barriers, such as forgetting doses or fear of taking medications in front of others. Descriptive analyses and ordinal logistic regression with robust standard errors were conducted. Fifty-seven per cent of participants (N = 359) were African-American (57.1%) and roughly 40% had no more than a high school education. Mean age was 48 years. Overall, MSM with viral load suppression identified fewer individual-level barriers to adherence (p < .01) and individuals with depressive symptoms identified a greater number of barriers to adherence (p < .01). Compared to African-Americans, white MSM had a lower likelihood of identifying barriers to adherence (p < .05). Findings suggest that individual-level barriers to HIV medication adherence are common among MSM, irrespective of time since diagnosis and viral suppression. Race-specific interventions which address intersectional stigma are needed to improve health outcomes among African-American MSM, who bear much of the burden of poor HIV outcomes in the United States.

Persons living with HIV (PLWH) are living into old age with more complex care needs that non-PLWH. Promoting quality of life should include advance care planning (ACP) education, particularly among African Americans. We explored faith/spirituality-related correlates of interest in a future quality of life program among African American PLWH.Data were from the AFFIRM study. Participants were recruited from an HIV clinic and completed surveys, interviews, and focus groups. Quantitative analyses included Logistic regression. Qualitative data were coded using grounded theory.Nearly half of participants had less than a high school education (47.9%), and roughly 90% had heard of at least one ACP-related topic (86.6%; N = 315). Qualitative themes related to quality of life and faith/spirituality were: (1) Coping with life challenges; (2) Motivation to improve health for loved ones; and (3) Support programs for people with HIV (N = 39). Satisfaction with religion/spirituality was associated with greater interest in a future program (p .05); discussing ACP before getting sick was associated with less interest (p .05).Prioritizing skill-building and grounding in spirituality with input from faith leaders can reduce ACP inequities and improve health outcomes among African Americans.

Objective The National Academy of Medicine and Joint Commission recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare to address lesbian, gay, bisexual, or transgender (LGBT) health disparities. We explored transgender patient–reported views on the importance on SO/GI collection, their willingness to disclose, and their perceived facilitators of SO/GI collection in primary care and emergency department (ED) settings. Methods We recruited a national sample of self-identified transgender patients. Participants completed demographic questions, survey questions, and free-response comments regarding their views on SO/GI collection. Data were analyzed using descriptive statistics; inductive content analysis was conducted with open-ended responses. Results Patients mostly self-identified as male gender (54.5%), white (58.4%), and SO other than heterosexual or LGB (33.7%; N = 101). Patients felt that it was more important for primary care providers to know their GI than SO (89.1% vs. 57%; p

OBJECTIVE: Among persons living with HIV/AIDS (PLHIV), approximately two-thirds report moderate to severe pain. Chronic pain can negatively affect PLHIVs’ health behaviors and outcomes by interfering with their reciprocity (mutual exchange) of support in their caregiving relationships, which has been found to be associated with PLHIVs’ antiretroviral (ART) adherence and viral suppression. SUBJECTS: Data were longitudinal (baseline, 6- and 12-month follow-up) from 383 PLHIV who were formerly or currently using drugs. RESULTS: Utilizing a longitudinal lagged fixed effects structural equation model, we found that never having pain in the past 6 months was predictive of increased reciprocity of support. Sub-analyses by care relationship type revealed never having pain was a significant predictor of greater reciprocity for sexual partner caregiving dyads, but not for kin or friend caregiving dyads. CONCLUSIONS: Our study emphasizes the importance of pain management in quality caregiving relationships characterized by reciprocity, which has consistently been found to be associated with stronger, more supportive caregiving relationships and better quality of life. Our findings suggest the importance of pain management intervention for improving reciprocity between vulnerable PLHIVs and their primary caregivers, especially between PLHIVs and caregivers who are current or former sexual partners.

Research suggests that LGBT populations experience barriers to healthcare. Organizations such as the Institute of Medicine recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare, to reduce LGBT disparities. We explore patient views regarding the importance of SO/GI collection, and patient and provider views on risks and benefits of routine SO/GI collection in various settings.We surveyed LGBT/non-LGBT patients and providers on their views on SO/GI collection. Weighted data were analyzed with descriptive statistics; content analysis was conducted with open-ended responses.One-half of the 1516 patients and 60% of 429 providers were female; 64% of patients and 71% of providers were White. Eighty percent of providers felt that collecting SO data would offend patients, whereas only 11% of patients reported that they would be offended. Patients rated it as more important for primary care providers to know the SO of all patients compared with emergency department (ED) providers knowing the SO of all patients (41.3% vs. 31.6%; P 0.001). Patients commonly perceived individualized care as an SO/GI disclosure benefit, whereas providers perceived patient-provider interaction improvement as the main benefit. Patient comments cited bias/discrimination risk most frequently (49.7%; N = 781), whereas provider comments cited patient discomfort/offense most frequently (54.5%; N = 433).Patients see the importance of SO/GI more in primary care than ED settings. However, many LGBT patients seek ED care due to factors including uninsurance; therefore, the ED may represent an initial point of contact for SO/GI collection. Therefore, patient-centered approaches to collecting SO/GI are needed. Patients and providers differed in perceived risks and benefits to routine SO/GI collection. Provider training in LGBT health may address patients' bias/discrimination concerns, and ultimately reduce LGBT health disparities.

Informal care receipt is associated with health outcomes among people living with HIV. Less is known about how caregivers' own social support may affect their care recipient's health. We examined associations between network characteristics of informal caregivers and HIV viral suppression among former or current drug using care recipients. We analyzed data from 258 caregiver-recipient dyads from the Beacon study, of whom 89% of caregivers were African American and 59% were female. In adjusted logistic regression analysis, care recipients had lower odds of being virally suppressed if their caregiver was female, was caring for youth involved in the criminal justice system, and had network members who used illicit drugs. Caregivers' greater numbers of non-kin in their support network was positively associated with viral suppression among care recipients. The findings reveal contextual factors affecting ART outcomes and the need for interventions to support caregivers, especially HIV caregiving women with high-risk youth.

INTRODUCTION: Research suggests a syndemic of substance use, mental illness, and familial conflict is associated with poor HIV medical outcomes among African American persons living with HIV (PLHIV). Social support, may facilitate positive health outcomes. This study explores these correlates of HIV medical outcomes, defined as undetectable viral load (UVL) and acute care minimization. METHODS: Data were from baseline of the BEACON study (N=351). UVL was ≤40 copies/mL. Acute care minimization was no ER visits and/or hospitalizations in 6 months. Descriptive statistics, and Poisson regression was implemented (N=351). RESULTS: Moderate syndemic burden was associated with viral suppression. Individuals with main partner caregivers had 35% higher likelihood of viral suppression, as individuals whose main supporters was neither kin nor main partners (Adjusted Point-Prevalence Rate Ratio [APR] = 1.35; 95% CI = 1.05, 1.74). Individuals with frequent health-related support had nearly 30 percent lower likelihood of avoiding acute care use, compared to individuals with low health-related support (APR = 0.73; 95% CI = 0.55, 0.97). Finally, interaction tests showed that physical functioning modified the relationship between main supporter type and acute care minimization. DISCUSSION: Results suggest that social support receipt was not consistently associated with HIV medical outcomes. Conversely, higher syndemic burden may have facilitated positive outcomes, through necessitating increased rates of healthcare engagement. Healthcare professionals should elicit discussion of social support to strengthen PLHIVs’ and their supporters’ relationships to improve their health. Results highlight the need for culturally-tailored interventions to improve HIV medical outcomes African American PLHIV substance users.

Background Over the past 2 decades, researchers have recognized the value of qualitative research. Little has been done to characterize its application to surgery. We describe characteristics and overall prevalence of qualitative surgical research. Methods We searched PubMed and CINAHL using “surgery” and 7 qualitative methodology terms. Four researchers extracted information; a fifth researcher reviewed 10% of abstracts for inter-rater reliability. Results A total of 3,112 articles were reviewed. Removing duplicates, 28% were relevant ( N = 878; κ = 0.70). Common qualitative methodologies included phenomenology (34.3%) and grounded theory (30.2%). Interviews were the most common data collection method (81.9%) of patients (64%) within surgical oncology (15.4%). Postdischarge was the most commonly studied topic (30.8%). Overall, 41% of studies were published in nursing journals, while 8% were published in surgical journals. More than half of studies were published since 2011. Conclusion Results suggest qualitative surgical research is gaining popularity. Most is published in nonsurgical journals, however, utilizing only 2 methodologies (phenomenology, grounded theory). The surgical journals that have published qualitative research had study topics restricted to a handful of surgical specialties. Additional surgical qualitative research should take advantage of a greater variety of approaches to provide insight into rare phenomena and social context.

Among disadvantaged persons living with HIV/AIDS (PLHIV), patient-provider engagement, which has been defined as patient-provider relationships that promote the use of health care services and are characterized by active listening and supportive decision making, has been associated with antiretroviral therapy (ART) maintenance and viral suppression. However, chronic pain, depression, and substance use, all of which are prevalent in this population, can reduce the quality of patient-provider engagement. We hypothesized a model in which chronic pain, depression, and substance use would be associated with poorer patient-provider engagement, which would be positively associated with adherence, with the latter associated positively with viral suppression. We analyzed data from the BEACON study, which included surveys from 383 PLHIV who were primarily African American, on ART, and had histories of drug use. Due to six missing cases on the chronic pain variable, we used data from 377 respondents in a structural equation model. Chronic pain and depressive symptoms were significantly associated with poorer patient-provider engagement, while substance use was associated with better engagement. Patient-provider engagement in turn was associated with better ART adherence, which was associated with higher viral suppression. Results suggest the role of chronic pain in poor patient-physician engagement in this population, which has potential implications for quality of HIV patient care and health outcomes. Findings suggest the need for attention to patient-provider engagement in PLHIV.

Among people living with HIV/AIDS (PLHIV), health-related quality of life (HRQOL) is an important clinical metric of perceived well-being. Baseline data from the BEACON study (N = 383) were used to examine relationships between HRQOL and negative social support, HIV-related stigma, viral suppression, and physical and mental health service use among a vulnerable population of low-income, urban PLHIV who currently or formerly used substances, and were primarily African American. Factor analyses and structural equation modeling indicated that increases in negative social support, stigma, mental health care visits and HIV physician visits were associated with lower HRQOL, while viral suppression was associated with greater HRQOL. The association between negative social support and HRQOL suggests the importance of intervening at the dyad or network levels to shape the type of social support being provided to PLHIV. HIV-related stigma is another negative social factor that is prevalent in this sample and could be addressed by intervention. Results indicate that greater mental and physical health service use can be used to identify individuals with lower HRQOL. Therefore, findings increase an understanding of HRQOL in this understudied population and have implications for designing interventions to improve HRQOL among PLHIV.

Persons who inject drugs (PWID) may have less access to, and utilization of, health-care services, and African American PWID may be less likely than other racial groups to utilize health care in the United States. The present study evaluated the prevalence of health-care utilization (HCU) among a cohort of African American PWID in Baltimore. Data were from the 2012 Baltimore National HIV Behavioral Surveillance study. Participants were adult PWID and recruited using respondent-driven sampling (RDS). They completed a comprehensive sociobehavioral survey and voluntary HIV test with trained study interviewers. Analyses included descriptive and bivariate statistics to examine the prevalence of HCU, defined as seeing a health-care provider in the past year. Poisson regression assessed correlates of HCU. Participants were 61% male; 23% self-reported HIV seropositivity. Nearly 90% reported unemployment and/or disability; HCU prevalence was 85%. Significant negative correlates of HCU included age and higher injection frequency; positive correlates included previous incarceration and moderate financial stability. Interaction analyses showed unemployed publicly insured individuals had 30% higher HCU than unemployed and uninsured individuals (χ2 = 2.52; p

Advance care planning (ACP) is the process of planning for when individuals are unable to make their own healthcare decisions. Research suggests ACP is understudied among HIV-positive African Americans. We explored ACP knowledge, preferences, and practices with HIV-positive African Americans from an urban HIV-specialty clinic (AFFIRM study). Participants completed surveys and interviews. Descriptive analyses and Poisson regression were conducted on survey data. Qualitative interviews were coded using grounded theory/constant comparative method. Participants were mostly male (55.1%). Half rated their current pain as at least six out of ten (50.8%). Two-thirds had discussed ACP with providers or supporters (66.2%). Qualitative themes were: (1) impact of managing pain on quality of life and healthcare, (2) knowledge/preferences for ACP, and (3) sources of HIV supportive care and coping (N = 39). Correlates of having discussed ACP included: moderate pain intensity (p

Background Patients with disabilities experience disparities in accessing and receiving high-quality health care services as compared to patients without disabilities. To address the disparities, health care organizations need to identify which of their patients have disabilities to track quality of care and provide appropriate health care accommodations. To date, no evidence-based sets of disability questions exist that serve these purposes. A study was conducted to identify patient-centered disability questions for health care organizations to determine which patients require health care accommodations and to track the quality of care experienced by patients with disabilities. Methods In the first of three phases, a focus group with patients and caregivers ( N = 54) and interviews with providers ( N = 15) were conducted to explore the disability questions that they believed were important. In the second phase, nationally recognized experts ( N = 17) participated in a modified Delphi panel to develop a set of disability questions. The third phase entailed cognitive interviews ( N = 46) with patients with and without disabilities to refine the wording of the disability questions identified through the previous rounds. Results Through the three phases, six essential questions and three additional recommended questions were identified. Questions addressed hearing, visual, motor, cognitive, communication, and learning disabilities, and the ability to conduct activities of daily living. An overall question for disabilities not included in the previous questions was also identified. Conclusion Through a rigorous, three-stage process that engaged multiple stakeholders, patient-centered disability questions were identified for health care organizations to use to identify disparities within their organizations and accommodations that address these disparities.

IntroductionResearch suggests Emergency Medical Services (EMS) over-use in urban cities is partly due to substance users with limited access to medical/social services. Recent efforts to deliver brief, motivational messages to encourage these individuals to enter treatment have not considered EMS providers.ProblemLittle research has been done with EMS providers who serve substance-using patients. The EMS providers were interviewed about participating in a pilot program where they would be trained to screen their patients for substance abuse and encourage them to enter drug treatment.MethodsQualitative interviews were conducted with Baltimore City Fire Department (BCFD; Baltimore, Maryland USA) EMS providers (N=22). Topics included EMS misuse, work demands, and views on participating in the pilot program. Interviews were transcribed and analyzed using grounded theory and constant-comparison.ResultsParticipants were mostly white (68.1%); male (68.2%); with Advanced Life Skills training (90.9%). Mean age was 37.5 years. Providers described the “frequent flyer problem” (eg, EMS over-use by a few repeat non-emergent cases). Providers expressed disappointment with local health delivery due to resource limitations and being excluded from decision making within their administration, leading to reduced team morale and burnout. Nonetheless, providers acknowledged they are well-positioned to intervene with substance-using patients because they are in direct contact and have built rapport with them. They noted patients might be most receptive to motivational messages immediately after overdose revival, which several called “hitting their bottom.” Several stated that involvement with the proposed study would be facilitated by direct incorporation into EMS providers’ current workflow. Many recommended that research team members accompany EMS providers while on-call to observe their day-to-day work. Barriers identified by the providers included time constraints to intervene, limited knowledge of substance abuse treatment modalities, and fearing negative repercussions from supervisors and/or patients. Despite reservations, several EMS providers expressed inclination to deliver brief motivational messages to encourage substance-using patients to consider treatment, given adequate training and skill-building.ConclusionsEmergency Medical Service providers may have many demands, including difficult case time/resource limitations. Even so, participants recognized their unique position as first responders to deliver motivational, harm-reduction messages to substance-using patients during transport. With incentivized training, implementing this program could be life- and cost-saving, improving emergency and behavioral health services. Findings will inform future efforts to connect substance users with drug treatment, potentially reducing EMS over-use in Baltimore.Maragh-BassAC, FieldsJC, McWilliamsJ, KnowltonAR. Challenges and opportunities to engaging Emergency Medical Service providers in substance use research: a qualitative study. Prehosp Disaster Med. 2017;32(2):148–155.

Objective: The study explored high-risk participants' experiences with pain management regarding clinical access to and use of prescription opioids. Design: Qualitative semistructured interviews and focus groups. Setting: Data were collected August 2014 to May 2015 at an urban community-based research facility in Baltimore City, MD. Participants: HIV participants with chronic pain and a history of illicit drug use. Methods: Qualitative coding and analysis used an iterative, inductive, and thematic approach and coders achieved inter-coder consistency. Results: The authors identified two major themes. First, participants had positive and negative interactions with healthcare providers regarding chronic pain treatment. Participants perceived that providers lacked empathy for their pain and/or were not adequately managing their pain. These interactions resulted in participants seeking new providers or mistrusting the medical system. Further, providers’ surveillance of participants’ pain treatment regimen contributed to distress surrounding pain management. The second theme centered on participants’ pain management experiences with prescribed opioid analgesics. Participants felt they were receiving dosages and classes of analgesics that did not sufficiently address their pain, and consequently modified their dosages or rationed prescription opioids. Other participants were reluctant to take analgesics due to their history of illicit drug use. Some participants relapsed to illicit drug use when they felt their prescription opioids did not adequately address their pain needs. Conclusions: Participant struggles with receiving and managing prescribed opioid analgesics suggest a need for: therapies beyond these medications; guidelines for providers specific to this population; and harm reduction trainings for providers.

Accessible diagnostic equipment, including height-adjustable examination tables, is necessary to accommodate patients with disabilities. Studies demonstrate that only a minority of clinics provide accessible equipment. For clinics with this equipment, no studies have examined the use of such equipment in routine clinical care. In primary care clinics with and without height-adjustable examination tables, we compared the frequency and variation in physical evaluations on examination tables and patients’ perceptions of quality care. Survey administered to patients at two primary care clinics in Rochester, MN, in 2015. One clinic had height-adjustable examination tables in every exam room; the other clinic had none. A total of 399 English-speaking adult primary care patients (61% participation). Participants were asked whether they were physically evaluated on a table during their clinical encounter. In addition, they completed two subscales of the Patient Perception of Quality of Care survey: Perceptions of Provider’s Bedside Manner and Perceptions of Provider’s Work. Overall, there were no differences between clinics in the likelihood of patients being examined on an exam table or in their perceptions of quality of care. Across both clinics, patients who reported a disability were 27% less likely to be examined on a table, were less likely to rate their provider’s bedside manner favorably (74% vs. 59%) and to have positive perceptions of their provider’s work (46% vs. 32%) than patients without disabilities. The presence of accessible medical equipment was not associated with care delivered to patients. While this might not be meaningful for most patients, it could be problematic for patients with disabilities, who are less likely to be examined. Therefore, accessible equipment alone may not be sufficient to reduce disparities in the care experience. Provider- and organization-level factors must thus be considered in efforts to provide equitable care to patients with disabilities.

Background Recent healthcare mandates require availability of accessible medical exam equipment, which may reduce barriers to care for patients with disabilities (PWD). However, more research is needed to explore healthcare provider views on implementation and routine use of accessible equipment. Objective This study qualitatively explored healthcare provider perceptions of: (1) daily use of accessible medical examination tables with PWD; and (2) recommendations for addressing challenges to using this equipment. Methods Qualitative interviews and focus groups were conducted with physicians, nurse practitioners and registered nurses at a clinic where accessible examination tables were recently implemented in all clinic rooms. Data were coded and thematically analyzed by two researchers trained in qualitative methods. Results A total of 17 providers participated in focus groups or interviews. Participants were mostly female (82%; N = 14), and registered nurses (47%; N = 8), but also included nurse practitioners (29.4%; N = 5), and physicians (23%; N = 4). Common themes were: (1) Ease of use and functionality of tables; and (2) Challenges with use and available training. Overall, providers reported satisfaction with the tables' ability to accommodate patients who are PWD, although they expressed challenges with functionally using the tables with specific populations, such as pediatric patients. Conclusions Healthcare organizations seeking to implement height-adjustable tables should account for structural requirements of the height-adjustable tables (e.g. accommodating clearance needed when planning room sizes). Practical recommendations and policies for integrating height-adjustable tables into routine clinical care are needed to ensure equitable care for PWD.

Chronic pain and substance use can strain the supportive relationships of persons with serious chronic illness, which may increase the likelihood of receiving negative, rather than positive, social support from informal caregivers and social network members. To our knowledge, this is the first study to longitudinally examine the effects of chronic pain and substance use on negative social support. The sample (N=383) comprised disadvantaged, primarily African-American, persons living with HIV/AIDS (PLHIV) with a history of injection drug use, 32.4% of whom reported frequent or constant pain in the prior 6 months. Using factor analysis and structural equation modeling, current substance use and greater levels of chronic pain positively predicted negative social support 12 months later, after controlling for baseline negative support, viral load, age and sex. We also found a significant interaction effect such that among those not using substances, there was a significant positive association between pain and negative support, but no such association among those currently using substances. The findings emphasize the importance of treatment of chronic pain and substance use in the supportive functioning of social networks of a disadvantaged population with serious chronic conditions and persistent health disparities.

Health care disparities (differential access, care, and outcomes owing to factors such as race/ethnicity) are widely established. Compared with other groups, African American individuals have an increased mortality risk across multiple surgical procedures. Gender, sexual orientation, age, and geographic disparities are also well documented. Further research is needed to mitigate these inequities. To do so, the American College of Surgeons and the National Institutes of Health–National Institute of Minority Health and Disparities convened a research summit to develop a national surgical disparities research agenda and funding priorities. Sixty leading researchers and clinicians gathered in May 2015 for a 2-day summit. First, literature on surgical disparities was presented within 5 themes: (1) clinician, (2) patient, (3) systemic/access, (4) clinical quality, and (5) postoperative care and rehabilitation-related factors. These themes were identified via an exhaustive preconference literature review and guided the summit and its interactive consensus-building exercises. After individual thematic presentations, attendees contributed research priorities for each theme. Suggestions were collated, refined, and prioritized during the latter half of the summit. Breakout sessions yielded 3 to 5 top research priorities by theme. Overall priorities, regardless of theme, included improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery. The National Institutes of Health and American College of Surgeons Summit on Surgical Disparities Research succeeded in identifying a comprehensive research agenda. Future research and funding priorities should prioritize patients’ care perspectives, workforce diversification and training, and systematic evaluation of health technologies to reduce surgical disparities.