Search

Effective antiretroviral therapy (ART) adherence strategies for HIV+ adolescents and young adults (AYA) are needed to prevent HIV-related morbidity, mortality, and onward transmission. In the Adherence Connection for Counseling, Education, and Support (ACCESS) pilot, an exploratory sequential mixed-methods design was used to develop and test a peer-led, mobile health (mHealth) cognitive behavioral ART adherence intervention. HIV+ AYA (ages 16-29 years) with unsuppressed plasma HIV RNA (HIV viral load) were eligible for this five-session intervention directed to improving ART adherence and HIV viral load. A total of 78 peer-led remote videoconferencing sessions (via WebEx) were delivered to 16 participants. High completion rates (97.5%) and client satisfaction scores (mean = 29.13 of 32; SD = 2.45) were observed. Self-reported ART adherence improved (32% increase in doses taken; 95th CI 11.2-53.3) with an annualized average rate of 47.5% (0.28 logSe necesitan estrategias efectivas de adherencia a la terapia antirretroviral (TAR) para adolescentes y adultos jóvenes (AAJ) VIH+ para prevenir la morbilidad, la mortalidad y las transmisiones futuras relacionadas con el VIH. En el proyecto piloto Adherence Connection for Counseling, Education, and Support (ACCESS), se utilizó un diseño exploratorio secuencial de métodos mixtos para desarrollar y testear una intervención de adherencia cognitiva conductual de salud móvil (mHealth) dirigida por pares a la TAR. AAJ VIH+ (de 16 a 29 años de edad) con ARN del VIH (carga viral del VIH) en plasma no suprimido fueron elegibles para esta intervención de cinco sesiones dirigida a mejorar la adherencia a la TAR y la carga viral del VIH. Se dictaron un total de 78 sesiones de videoconferencias remotas dirigidas por pares (a través de WebEx) a 16 participantes. Fueron observadas tasas altas de finalización (97.5%) y puntuaciones de satisfacción del cliente (media=29.13 de 32; SD=2.45). La adherencia autoinformada a la TAR mejoró (aumento del 32% en las dosis tomadas; IC del 95=11.2 a 53.3) con una tasa promedio anualizada de reducción en la carga viral del VIH del 47.5% (0.28 log 10). Establecimos una prueba de concepto para ACCESS, la intervención de adherencia a la TAR cognitivo conductual mHealth dirigida por pares, con datos prometedores sobre la adherencia y los resultados virológicos.

Medical distrust is a potent barrier to participation in HIV care and medication use among African American/Black and Latino (AABL) persons living with HIV (PLWH). However, little is known about sociodemographic and risk factors associated with distrust. We recruited adult AABL PLWH from low socio-economic status backgrounds with insufficient engagement in HIV care ( N = 512). Participants completed structured assessments on three types of distrust (of health care providers, health care systems, and counter-narratives), HIV history, and mental health. We used a type of machine learning called random forest to explore predictors of trust. On average, participants were 47 years old ( SD = 11 years), diagnosed with HIV 18 years prior ( SD = 9 years), and mainly male (64%) and African American/Black (69%). Depression and age were the most important predictors of trust. Among those with elevated depressive symptoms, younger participants had less trust than older, while among those without depression, trust was greater across all ages. The present study adds nuance to the literature on medical distrust among AABL PLWH and identifies junctures where interventions to build trust are needed most.

Innovative methodological frameworks are needed in intervention science to increase efficiency, potency, and community adoption of behavioral health interventions, as it currently takes 17 years and millions of dollars to test and disseminate interventions. The multiphase optimization strategy (MOST) for developing behavioral interventions was designed to optimize efficiency, efficacy, and sustainability, while community-based participatory research (CBPR) engages community members in all research steps. Classical approaches for developing behavioral interventions include testing against control interventions in randomized controlled trials. MOST adds an optimization phase to assess performance of individual intervention components and their interactions on outcomes. This information is used to engineer interventions that meet specific optimization criteria focused on effectiveness, cost, or time. Combining CBPR and MOST facilitates development of behavioral interventions that effectively address complex health challenges, are acceptable to communities, and sustainable by maximizing resources, building community capacity and acceptance. Herein, we present a case study to illustrate the value of combining MOST and CBPR to optimize a multilevel intervention for reducing substance misuse among formerly incarcerated men, for under $250 per person. This integration merged experiential and cutting-edge scientific knowledge and methods, built community capacity, and promoted the development of efficient interventions. Integrating CBPR and MOST principles yielded a framework of intervention development/testing that is more efficient, faster, cheaper, and rigorous than traditional stage models. Combining MOST and CBPR addressed significant intervention science gaps and speeds up testing and implementation of interventions.

The COVID-19 pandemic has great potential to disrupt the lives of persons living with HIV (PLWH). The present convergent parallel design mixed-methods study explored the early effects of COVID-19 on African American/Black or Latino (AABL) long-term survivors of HIV in a pandemic epicenter, New York City. A total of 96 AABL PLWH were recruited from a larger study of PLWH with non-suppressed HIV viral load. They engaged in structured assessments focused on knowledge, testing, trust in information sources, and potential emotional, social, and behavioral impacts. Twenty-six of these participants were randomly selected for in-depth semi-structured interviews. Participants were mostly men (64%), African American/Black (75%), and had lived with HIV for 17 years, on average (SD=9 years). Quantitative results revealed high levels of concern about and the adoption of recommended COVID-19 prevention recommendations. HIV care visits were commonly canceled but, overall, engagement in HIV care and antiretroviral therapy use were not seriously disrupted. Trust in local sources of information was higher than trust in various federal sources. Qualitative findings complemented and enriched quantitative results and provided a multifaceted description of both risk factors (e.g., phones/internet access were inadequate for some forms of telehealth) and resilience (e.g., "hustling" for food supplies). Participants drew a direct line between structural racism and the disproportional adverse effects of COVID-19 on communities of color, and their knowledge gleaned from the HIV pandemic was applied to COVID-19. Implications for future crisis preparedness are provided, including how the National HIV/AIDS Strategy can serve as a model to prevent COVID-19 from becoming another pandemic of the poor.

Optimal adherence to HIV antiretroviral therapy (ART) is challenging, and racial/ethnic disparities in adherence rates are substantial. The most common reason persons living with HIV (PLWH) give for missed ART doses is forgetting. We took a qualitative exploratory approach to describe, from the perspectives of African American/Black and Hispanic/Latino PLWH, what it means to forget to take ART and factors that influence forgetting. Participants (N = 18) were purposively sampled for maximum variability and engaged in semi-structured/in-depth interviews on HIV/ART management. The analysis took a directed content analysis approach. Participants were mostly male (56%) and African American/Black (79%), between 50 and 69 years old, and had lived with HIV for an average of 21 years. Findings were organised into six inter-related themes: (1) forgetting to take ART was a shorthand description of a complex phenomenon, but rarely a simple lapse of memory; (2) ‘forgetting’ was means of managing negative emotions associated with HIV; (3) life events triggered mental health distress/substance use which disrupted adherence; (4) historical traumatic events (including AZT monotherapy) and recent trauma/loss contributed to forgetting; (5) patient-provider interactions could support or impede adherence; and (6) intrinsic motivation was fundamental. Implications for HIV social service and health care settings are described.

HIV testing among young Black MSM and transwomen (YBMSM/TW) is the gateway to biomedical HIV prevention or treatment. HIV self-testing (HST) is a method that may increase consistent HIV testing. TRUST, a brief, peer-based behavioral intervention, was designed to increase uptake of consistent (every three months) HST among YBMSM/TW in New York City. To test the efficacy of the intervention, we randomized 200 friend pairs into either the intervention condition (TRUST) or a time and attention control condition. A modified intent-to-treat analysis found that self-reported HST at 3-month follow-up was statistically significantly higher (uOR 2.29; 95% CI 1.15, 4.58) and at 6-month follow-up was marginally statistically significantly higher (uOR 1.94; 95% CI 1.00, 3.75) in the intervention arm as compared with the control arm. There were no statistically significant differences by arm at 9- or 12-month follow-up. TRUST, a culturally-congruent intervention to increase HST among YBMSM/TW, had short-term impact on past-three month HST. Clinical Trials Registration ClinicalTrial.gov NCT04210271.

BACKGROUND It is estimated that 70% of all deaths each year in the United States are due to chronic conditions. Cardiovascular disease (CVD), a chronic condition, is the leading cause of death in ethnic and racial minority males. It has been identified as the second most common cause of death in persons with HIV. By the year 2030, it is estimated that 78% of persons with HIV will be diagnosed with CVD. OBJECTIVE We propose the first technology-based virtual environment intervention to address behavioral, modifiable risk factors associated with cardiovascular and metabolic comorbidities in sexual-minority men of color with HIV. METHODS This study will be guided using social cognitive theory and the Technology Acceptance Model. A sequential, mixed method, waitlist controlled randomized control feasibility trial will be conducted. Aim 1 is to qualitatively explore perceptions of cardiovascular risk in 15 participants. Aim 2 is to conduct a waitlist controlled comparison to test if a virtual environment is feasible and acceptable for CVD prevention, based on web-based, self-assessed, behavioral, and psychosocial outcomes in 80 sexual-minority men of color with HIV. RESULTS The study was approved by the New York University Institutional Review Board in 2019, University of Texas Health Science Center at Houston in 2020, and by the Yale University Institutional Review Board in February 2022. As of April 2022, aim 1 data collection is 87% completed. We expect to complete data collection for aim 1 by April 30, 2022. Recruitment for aim 2 will begin mid-May 2022. CONCLUSIONS This study will be the first online virtual environment intervention for CVD prevention in sexual-minority men of color with HIV. We anticipate that the intervention will be beneficial for CVD prevention education and building peer social supports, resulting in change or modification over time in risk behaviors for CVD. CLINICALTRIAL ClinicalTrials.gov NCT05242952; https://clinicaltrials.gov/ct2/show/NCT05242952 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/38348

Background . The persistence of racial/ethnic disparities in the United States in rates of engagement along the HIV care continuum signals the need for novel approaches. We recently described a new integrated conceptual model (ICM) that combines critical race theory, harm reduction, and self-determination theory. This ICM guided the development of six behavioral intervention components tested in optimization trial (Core component, Component A: motivational interviewing sessions, Component B: pre-adherence skill building, Component C: peer mentorship, Component D: focused support groups, Component E: navigation). The present qualitative exploratory study describes participants’ perspectives on the components’ acceptability, feasibility, and impact. Methods . Participants were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City. From a larger optimization trial (N = 512), we randomly selected 46 participants for in-depth semi-structured interviews. Interviews were audio-recorded and transcribed verbatim, and data were analyzed using directed content analysis. Structured data on components’ acceptability and feasibility were collected. Results . On average, participants were 49 years old (SD = 9) and had lived with HIV for 19 years (SD = 7). Most were male (78%) and African American/Black (76%). Participants reported a constellation of serious mainly social and structural challenges to HIV management including chronic poverty, unstable housing, and stigma. Components were found acceptable (> 70% rated them as quite a bit to very helpful). Feasibility was high: attendance rates for each component was > 80%. For all components, a non-judgmental, pressure-free, and structurally and culturally salient approach was seen as vital and described as lacking in most medical/social service settings. Prominent aspects of components, consistent with the ICM, included establishing trust (core); developing intrinsic motivation and self-reflection (Component A); learning/practicing adherence strategies and habits (Component B); reducing social isolation via peer role models (Component C); reflecting on salient goals and challenges with peers without stigma (Component D); and circumventing structural barriers to HIV management, including related to systemic racism (Component E). Conclusions . The ICM has potential to improve the acceptability and feasibility of interventions and services for AABL-PLWH, key underpinnings of intervention/treatment effectiveness. Future study of the ICM is warranted to address racial/ethnic health disparities.

Marilyn Lewis: How do you think COVID-19 has affected the social work community of educators, researchers, clinicians, and students? Amy Krentzman: The media has reported a significant uptick in al...

Homelessness in the United States has been increasing at an exponential rate over the past three decades, and the US has not experienced the current level of homelessness since the Great Depression of the 1930’s. With this rise in homelessness has come an increase in the number of rules, regulations, and strict and punitive policies within shelters. Given the historic levels of homelessness nationally and increased bureaucracy, this paper aims to expand on the current literature related to governance of homeless shelters to examine: 1) how families residing in the shelters are impacted by policies related to homelessness, and governance within shelters (i.e., shelter rules), and 2) determine potential points of intervention to improve policy and programming and shelter governance that better address the growing needs of homeless families. Using a convergent parallel design, we conducted a mixed methods study with caregiver residents and their children (ages 13 – 17 years), as well as staff, from two family shelters located in a large urban city in the US. Findings from the study revealed that policies and programs aimed at assisting homeless families often did not adequately respond to the needs of families (e.g., finding permanent housing, continuity in education for youth), and residents (both caregivers and youth) found shelter rules to be overly restrictive. Policy and programming recommendations are provided.

Rates of participation in HIV care, medication uptake, and viral suppression are improving among persons living with HIV (PLWH) in the United States. Yet, disparities among African American/Black and Latino PLWH are persistent, signaling the need for new conceptual approaches. To address gaps in services and research (e.g., insufficient attention to structural/systemic factors, inadequate harm reduction services and autonomy support) and improve behavioral interventions, we integrated critical race theory, harm reduction, and self-determination theory into a new conceptual model, then used the model to develop a set of six intervention components which were tested in a larger study. The present qualitative study explores participants' perspectives on the study's acceptability, feasibility, and impact, and the conceptual model's contribution to these experiences.Participants in the larger study were African American/Black and Latino PLWH poorly engaged in HIV care and with non-suppressed HIV viral load in New York City (N = 512). We randomly selected N = 46 for in-depth semi-structured interviews on their experiences with and perspectives on the study. Interviews were audio-recorded and professionally transcribed verbatim, and data were analyzed using directed qualitative content analysis.On average, participants were 49 years old (SD = 9) and had lived with HIV for 19 years (SD = 7). Most were male (78%) and African American/Black (76%). All had taken HIV medication previously. Challenging life contexts were the norm, including poverty, poor quality/unstable housing, trauma histories exacerbated by current trauma, health comorbidities, and substance use. Participants found the study highly acceptable. We organized results into four themes focused on participants' experiences of: 1) being understood as a whole person and in their structural/systemic context; 2) trustworthiness and trust; 3) opportunities for self-reflection; and 4) support of personal autonomy. The salience of nonjudgment was prominent in each theme. Themes reflected grounding in the conceptual model. Participants reported these characteristics were lacking in HIV care settings.The new conceptual model emphasizes the salience of systemic/structural and social factors that drive health behavior and the resultant interventions foster trust, self-reflection, engagement, and behavior change. The model has potential to enhance intervention acceptability, feasibility, and effectiveness with African American/Black and Latino PLWH.

Background Approximately 100 supervised injection facilities (SIFs) operate in 66 cities around the world to reduce overdose deaths, the spread of disease and public disorder, though none legally exist in the United States. Public bathrooms are among the most common public places for injection reported by people who inject drugs in New York City (NYC) and service industry employees (SIEs) inadvertently become first-responders when overdoses occur in business bathrooms. The goal of this study was to assess SIE acceptability of SIFs and the perceived effects that SIFs would have on them, their colleagues, their businesses and communities. Methods Semi-structured qualitative interviews were conducted with 15 SIEs recruited through convenience sampling throughout NYC. Participants were provided with peer-reviewed scientific evidence prior to discussing SIFs. Data were analysed using a hybrid deductive and inductive approach. Results Most SIEs had encountered drug use (93%, n = 14/15) and syringes (73%, n = 11/15) in their business bathrooms and three had encountered unresponsive individuals. Nearly all workers (93%, n = 14/15) were supportive of SIFs and believed SIFs would reduce injection drug use in their business bathrooms. Participants also believed that ‘not in my backyard’ arguments from community boards may impede SIF operation. Conclusions Service industry employees are critical stakeholders due to their exposure to occupational health hazards related to public injection. Those interviewed were amenable to SIF operation as a form of occupational harm reduction and their experiences provide an important dimension to the political debate surrounding SIFs.

Substance use problems are highly prevalent among persons living with (PLWH) in the United States and serve as serious barriers to engagement in HIV care. Yet, in contrast to studies of single substances, little is known about patterns of polysubstance use in this population. Moreover, other risk factors (e.g., financial hardship, incarceration, homelessness, and mental health distress) are also prevalent and complicate HIV management. The present study drew on a cross-sectional survey with African American/Black and Latino (AABL) adult PLWH from low socioeconomic status backgrounds in New York City who were insufficiently engaged in HIV care and evidenced detectable HIV viral load (N = 512). We used latent class analysis (LCA) to explore patterns of polysubstance use and their relationships to financial hardship, incarceration, homelessness, and mental health. LCA yielded three substance use classes: Class 1, a high polysubstance use/high-risk substance use class (9%); Class 2, a polysubstance use/moderate substance use risk class (18%); and Class 3, a moderate polysubstance use/moderate-to-low-risk substance use class (74%). Mental health symptoms were prevalent in all classes, but Class 1 had greater mental health distress than the other two classes. Current homelessness was more prevalent in Classes 1 and 2. We cannot end the HIV epidemic without engaging and treating AABL PLWH who have serious barriers to engagement along the HIV care continuum, and who evidence polysubstance use along with co-occurring risk factors. Clinical settings can develop outreach and engagement approaches to bring this subpopulation of PLWH into care settings, and further, specialized services are needed to successfully screen, treat, and retain them.

We conducted a novel pilot randomized controlled trial of the Treatment Ambassador Program (TAP), an 8-session, peer-based, behavioral intervention for people with HIV (PWH) in South Africa not on antiretroviral therapy (ART). PWH (43 intervention, 41 controls) completed baseline, three- and six-month assessments. TAP was highly feasible (90% completion), with peer counselors demonstrating good intervention fidelity. Post-intervention interviews showed high acceptability of TAP and counselors, who supported autonomy, assisted with clinical navigation, and provided psychosocial support. Intention-to-treat analyses indicated increased ART initiation by three months in the intervention vs. control arm (12.2% [5/41] vs. 2.3% [1/43], Fisher exact p-value = 0.105; Cohen’s h = 0.41). Among those previously on ART (off for >6 months), 33.3% initiated ART by three months in the intervention vs. 14.3% in the control arm (Cohen’s h = 0.45). Results suggest that TAP was highly acceptable and feasible among PWH not on ART.

Background Persons living with HIV (PLWH) are living longer, although racial/ethnic and socioeconomic status (SES) disparities persist. Yet, little is known about the experience of living with and managing HIV over decades. The present study took a qualitative approach and used the lens of symbolic violence, a type of internalized, non-physical violence manifested in the power differential between social groups. We focused on adult African American/Black and Latinx (AABL) PLWH from low-SES backgrounds. Methods Data were drawn from two studies with AABL PLWH in New York City (N = 59). After providing signed informed consent, participants engaged in in-depth semi-structured interviews on aspects of HIV management. Interviews were audio-recorded and professionally transcribed verbatim, and data were analyzed using directed qualitative content analysis. Results Participants in the two studies were comparable on sociodemographic and background characteristics. They had lived with HIV for 20 years, on average (range 3–33 years). All were from low-SES backgrounds and most were African American/Black and men. Participants experienced a convergence of multiple social exclusions, harms, and stigmas, consistent with symbolic violence, which contributed to disengagement from HIV care and discontinuation of HIV medications. We organized results into five sub-themes: (1) participants were “ground down” over time by material, social, and emotional challenges and this diminished self-worth and, at times, the will to live; (2) social isolation and self-isolation, based in part on feeling devalued and dehumanized, served as stigma-avoidance strategies and mechanisms of social exclusion; (3) stigmatizing aspects of patient-provider interactions, both experienced and anticipated, along with (4) restricted autonomy in HIV care and other settings (e.g., parole) reduced engagement; and (5) poor HIV management was internalized as a personal failure. Importantly, resilience was evident throughout the five sub-themes. Conclusions Symbolic violence is a useful framework for understanding long-term HIV management and survivorship among AABL PLWH from low-SES backgrounds. Indeed, forms of symbolic violence are internalized over time (e.g., experiencing devaluation, dehumanization, loss of self-worth, and anticipated stigma), thereby impeding successful HIV management, in part because avoiding HIV care and discontinuing HIV medications are primary coping strategies. Results have implications for interventions in community and health care settings.

Background Approaches that move beyond individuals and target couples may be an effective strategy for reducing sexual and reproductive health (SRH) disparities among adolescents and young adults (AYA). However, few researchers have attempted to recruit couples due to feasibility and methodological issues. This study aims to enhance implementation and methodological approaches to successfully engage heterosexual Black and Latino adolescent and young adult (AYA) couples in sexual reproductive health (SRH) research. Methods We developed a four-step approach to systematically engage AYA couples in a qualitative study examining factors that influence uptake of combination HIV prevention methods: 1) understanding barriers and facilitators to engaging AYA couples, (2) identifying AYAs living in geographic areas of HIV vulnerability, (3) recruiting and screening AYA couples, and (4) scheduling and completion of the interview session. Results Black and Latino youth aged 16 to 24 and their opposite sex romantic were recruited in the South Bronx, New York from September 2017–May 2018. Three hundred and seventy-two men and women completed screening procedures to determine eligibility for the index participant; 125 were eligible and enrolled into the study. Forty-nine nominated partners (NPs) participated in screening procedures and enrolled into the study. A total of 49 couples enrolled into the study; 23 couples completed study activities. Conclusions Developing a systematic recruitment plan aided in successfully engaging Black and Latino heterosexual youth. Nevertheless, barriers to study enrollment remained including locating eligible IPs and screening of the NP. Targeting both young men and women was an effective recruitment strategy. Moreover, dyadic strategies that allow for simultaneous interaction with both couple members may be a beneficial strategy to couples’ study enrollment and completion of study activities.

Background Persons living with HIV (PLWH) are living longer, although racial/ethnic and socioeconomic status (SES) disparities persist. Yet, little is known about successful HIV management over decades. To address this gap, the present study took a qualitative approach and used the lens of symbolic violence, a type of internalized, non-physical violence manifested in the power differential between social groups. We focused on adult African American/Black and Hispanic/Latinx (AABHL) PLWH from low SES-backgrounds. Methods Data were drawn from two studies with AABHL PLWH in New York City ( N =59). After providing signed informed consent, participants engaged in in-depth semi-structured interviews on aspects of HIV management. Interviews were audio-recorded and professionally transcribed verbatim, and data were analyzed using a systematic content analysis approach. Results Participants in the two studies were comparable on sociodemographic and HIV history characteristics. They had lived with HIV for 20 years, on average (range 3-33 years). All were from low-SES backgrounds and most were African American/Black and men. Participants experienced a convergence of multiple intersecting social exclusions, harms, and stigmas, consistent with symbolic violence, which contributed to disengagement from HIV care and medications. We found five specific sub-themes: (1) material, social, and emotional challenges combined to “grind down” participants over time and diminish self-worth and even, at times, the will to live, (2) social isolation and self-isolation, based in part on feeling devalued and dehumanized, served as both a stigma-avoidance strategy and a mechanism of social exclusion, (3) stigmatizing aspects of patient-provider interactions, both experienced and anticipated, and (4) perceived restricted autonomy in HIV care reduced engagement, and (5) poor HIV management was internalized as a personal failure. Importantly, resilience was also evident throughout the five sub-themes. Conclusions Symbolic violence is a useful framework for understanding the experiences of long-term HIV management/survivorship among AABHL PLWH from low-SES backgrounds. Aspects of symbolic violence are internalized over time (e.g., experiencing devaluation, dehumanization, loss of self-worth, and anticipated stigma), thereby impeding successful HIV management, including because avoiding HIV care and stopping HIV medications are primary coping strategies. Study findings have implications for interventions in community and health care settings.

Background Maintaining adherence to antiretroviral therapy (ART) is a significant challenge for human immunodeficiency virus (HIV)-infected racial and ethnic minority adolescents and young adults (youth). Given the consequences of suboptimal ART adherence, there is a pressing need for an expanded understanding of adherence behavior in this cohort. Objectives As part of an exploratory sequential, mixed-methods study, we used qualitative inquiry to explore adherence information, motivation, and behavioral skills among HIV-infected racial and ethnic minority youth. Our secondary aim was to gain an understanding of the contextual factors surrounding adherence behavior. Methods The information-motivation-behavioral skills model (IMB model) was applied to identify the conceptual determinants of adherence behavior in our target population, along with attention to emergent themes. In-depth, individual, semistructured interviews, including open-ended questions with probes, were conducted with a convenience sample of HIV-infected racial and ethnic minority youth (ages 16-29 years), receiving ART and with evidence of virologic failure (i.e., detectable HIV viral load). New participants were interviewed until information redundancy was reached. Qualitative interviews were digitally recorded, transcribed verbatim, and analyzed using Atlas.ti (v8). Directed content analysis was performed to generate categories and broad themes. Coding was initially conceptually driven (IMB model) and shifted to a data-driven approach, allowing for the discovery of key contextual factors that influence adherence behavior in this population. Methodological rigor was ensured by member checks, an audit trail, thick descriptive data, and triangulation of data sources. Results Twenty racial and ethnic minority participants (mean age = 24.3 years, 55.0% male) completed interviews. We found adherence information was understood in relation to HIV biomarkers; adherence motivation and behavioral skills were influenced by stigma and social context. We identified five primary themes regarding ART self-management: (a) emerging adulthood with a chronic illness, (b) stigma and disclosure concerns, (c) support systems and support deficits, (d) mental and behavioral health risks and challenges, and (e) mode of HIV transmission and perceptions of power and control. Discussion Key constructs of the IMB model were applicable to participating HIV-infected youth yet did not fully explain the essence of adherence behavior. As such, we recommend expansion of current adherence models and frameworks to include known contextual factors associated with ART self-management among HIV-infected racial and ethnic minority youth.

Runaway and homeless youth (RHY) are dependent on the specialized settings that locate, engage, and serve them. Yet, little research has focused on the features of effective settings for RHY. The present qualitative study, grounded in the Youth Program Quality Assessment model, explored characteristics of higher quality organizations for RHY and gaps that remain from staff and RHY perspectives. A total of 29 diverse settings serving RHY in New York State were randomly selected for participation, and ranked on a quantitative program quality index. Within settings, we conducted in-depth semi-structured interviews with program administrators (N = 30) and other staff (N = 24). Focus group interviews were conducted with RHY (N = 13 focus groups; N = 84 RHY). Data were analyzed using a systematic content analysis approach that was both theory-driven and inductive, comparing higher to lower quality settings. We found all settings provided vital services and experienced challenges, but higher quality settings ameliorated challenges through (1) a youth-centered program philosophy equally understood by staff and RHY; (2) developmentally appropriate relationships between staff and RHY that promoted autonomy; (3) a focus on short- and long-term goals within anticipated crises; and (4) ongoing internal quality assessment procedures. Within lower quality settings we found (1) difficulties retaining effective staff and (2) a primary focus on basic services and managing crises, but less attention to emotional support, exacerbated by (3) funding and other challenges emerging from the larger environment. The present study extends the literature on organizations for RHY by identifying characteristics of higher quality settings, and challenges that remain.

Background Illicit drug use (DU) and hazardous drinking (HD) among marginalized populations may be associated with greater barriers to care. Methods We used baseline data on the participants of the Seek, Test, Treat, and Retain data harmonization initiative. DU includes use of any illicit drugs within the past 6 months. HD was defined as scores ≥8 for men and ≥ 7 for women on Alcohol Use Disorders Identification Test within the past 12 months. Social support scores were assigned by summing scores from individual questions related to social support. Two outcomes for multivariable regression models and mediation analysis were perceived access to care and perceived barriers to care scores, calculated from summated points from individual questions within each domain. All models were adjusted for age, gender, race/ethnicity, and social support and stratified by HIV status. Results Among 1403 illicit drug users and 4984 non-drug users, the mean age was 39.6 ± 12.2 years old, 71% were male, 57% African Americans, and 39% Hispanic/Latinos. Over 25% reported difficulties in covering medical costs and finding transportation to health care facilities and greater proportions of drug users and hazardous drinkers reported these issues than non-DU/non-HD. In multivariable models, DU and HD were both independently associated with having greater barriers to care (β: 0.49 (95% confidence interval: 0.19 to 0.79) p

Identifying undiagnosed HIV infection is necessary for the elimination of HIV transmission in the United States. The present study evaluated the efficacy of 3 community-based approaches for uncovering undiagnosed HIV among heterosexuals at high-risk (HHR), who are mainly African American/Black and Hispanic. Heterosexuals comprise 24% of newly reported HIV infections in the United States, but experience complex multilevel barriers to HIV testing. We recruited African American/Black and Hispanic HHR in a discrete urban area with both elevated HIV prevalence and poverty rates. Approaches tested were (1) respondent-driven sampling (RDS) and confidential HIV testing in 2 sessions (n = 3116); (2) RDS and anonymous HIV testing in one session (n = 498); and (3) venue-based sampling (VBS) and HIV testing in a single session (n = 403). The main outcome was newly diagnosed HIV infection. RDS with anonymous testing and one session reached HHR with less HIV testing experience and more risk factors than the other approaches. Furthermore, RDS with anonymous (4.0%) and confidential (1.0%) testing yielded significantly higher rates of newly diagnosed HIV than VBS (0.3%). Thus peer-referral approaches were more efficacious than VBS for uncovering HHR with undiagnosed HIV, particularly a single-session/anonymous strategy, and have a vital role to play in efforts to eliminate HIV transmission.

Runaway and homeless youth (RHY) are served by specialized settings (e.g., Drop-In Centers, Transitional Living Programs, and multi-program settings), but little is known about the characteristics of these organizations or their effects on RHY’s behavioral and psychosocial outcomes. To address this gap we studied 29 randomly selected diverse settings across New York State, including those in rural, suburban, and urban areas. Within settings, we used the Youth Program Quality Assessment model to observe and rate programs for RHY (N = 53), assess program administrators (N = 30), and conduct anonymous structured assessment batteries with RHY aged 16-21 years (N = 463). We found settings overall evidenced satisfactory-to-high quality on a multi-perspective setting quality score. With respect to RHY’s behavioral outcomes, engagement in school/job training/work was high (81 %), substance use was moderate (mean use: 17 of the past 90 days), and 37 % evidenced involvement in the street economy (e.g., drug dealing, burglary). RHY in Transitional Living Programs and multi-program settings had more engagement in school/job training/work and less involvement in the street economy than their peers in Drop-In Centers. The quality of settings was not associated with these three behavioral outcomes (school/training/work, substance use, street economy), likely due to issues of restricted range. However, higher setting quality was associated with four constructive psychosocial outcomes; namely, RHY’s perceptions that settings foster positive outcomes in these three domains, and perceived resilience. Thus the present study highlights settings’ overall good quality, with some variability, and provides guidance on strategies to assess setting quality. Consistent with the existing literature, RHY in Drop-In Centers are highly vulnerable and may require additional types of services/programs to achieve their potential. Further, while the present study suggests all settings benefit RHY, better quality settings may be able to move beyond meeting RHY’s basic requirements and address higher order relational, psychosocial, and motivational needs. Importantly, fostering a sense of resilience among RHY, as well as young people’s experiences of settings as helpful to them in achieving good behavioral outcomes, may have long-term beneficial effects on RHY’s engagement in other settings, relationships, adaptation, and functioning.

Background: Many adolescent mothers are parenting young children under highly stressful conditions as they are managing first-time parenthood, poverty, lack of housing, school and work, and challenging peer and familial relationships. Mobile health (mHealth) technology has the potential to intervene at various points in the emotion regulation process of adolescent mothers to provide them support for more adaptive emotional and behavioral regulation in the course of their daily life. Objective: The goal of this study was to examine the acceptability, feasibility, use patterns, and mechanisms by which a mobile technology used as an adjunct to in-person, provider-delivered sessions fostered adolescent mothers’ adaptive emotion regulation strategies under real-life conditions. Methods: Participants (N=49) were enrolled in the intervention condition of a larger pilot study of homeless adolescent mothers living in group-based shelters. The mHealth technology. Calm Mom, consisted of a mobile app and a wrist-worn sensorband for the ambulatory measurement and alerting of increased electrodermal activity (EDA), a physiological measurement of stress. We examined logs of mobile app activity and conducted semistructured qualitative interviews with a subsample (N=10) of participants. Qualitative data analysis was guided by the theoretical frames of the intervention and a technology acceptance model and included an analysis of emerging themes and concepts. Results: Overall, participants indicated that one or more of the elements of Calm Mom supported their ability to effectively regulate their emotions in the course of their daily life in ways that were consonant with the intervention’s theoretical model. For many adolescent mothers, the app became an integral tool for managing stress. Due to technical challenges, fewer participants received sensorband alerts; however, those who received alerts reported high levels of acceptability as the technology helped them to identify their emotions and supported them in engaging in more adaptive behaviors during real-life stressful situations with their children, peers, and family members. Conclusions: Calm Mom is a promising technology for providing theoretically driven behavioral intervention strategies during real-life stressful moments among a highly vulnerable population. Future research efforts will involve addressing technology challenges and refining tailoring algorithms for implementation in larger-scale studies.

It is estimated that one in six Black and Latino adult persons living with HIV (PLWH) spend time in correctional institutions each year. Yet after release, PLWH of color evidence poor HIV health outcomes across the HIV care continuum. This study, guided by an ecological approach and Critical Race Theory, sought to understand the lived experiences of socioeconomically disadvantaged PLWH of color who received an HIV diagnosis and/or medical care while incarcerated, and the ways in which those experiences influenced engagement in medical care after release. Drawn from a larger study in Brooklyn, NY, in 2013-2016, a subset of 28 participants who received in-depth qualitative interviews were purposively sampled for a secondary analysis of participants who received an HIV diagnosis and/or medical care while incarcerated. Using an Interpretive Phenomenological Analysis, we found participant's experiences were shaped by longstanding mistrust of the medical establishment. While incarcerated, lack of autonomy, substandard medical care, and poor social support exacerbated medical mistrust and avoidance of HIV medical care long after release. Engagement in HIV medical care and treatment were also impacted by a dynamic interplay of factors including substance use, prolonged periods of denial, poverty, and repeated bouts of incarceration. Given that experiences of HIV diagnosis and medical care while incarcerated have long-ranging, adverse effects, we argue that a better understanding of the ways in which PLWH of color experience HIV diagnosis and medical care while incarcerated may serve to inform intervention efforts within correctional institutions to improve HIV health outcomes.

Background Annual HIV testing is recommended for populations at-risk for HIV in the United States, including heterosexuals geographically connected to urban high-risk areas (HRA) with elevated rates of HIV prevalence and poverty, who are primarily African American/Black or Hispanic. Yet this subpopulation of “individuals residing in HRA” (IR-HRA) evidence low rates of regular HIV testing. HIV stigma is a recognized primary barrier to testing, in part due to its interaction with other stigmatized social identities. Guided by social-cognitive and intersectionality theories, this qualitative descriptive study explored stigma as a barrier to HIV testing and identified ways IR-HRA manage stigma. Methods In 2012-2014, we conducted in-depth qualitative interviews with 31 adult IR-HRA (74% male, 84% African American/Black) with unknown or negative HIV status, purposively sampled from a larger study for maximum variation on HIV testing experiences. Interviews were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach that was both theory-driven and inductive. Results Stigma was a primary barrier to HIV testing among IR-HRA. In the context of an under-resourced community, HIV stigma was experienced as emerging from, and being perpetuated by, health care organizations and educational institutions, as well as community members. Participants noted it was “better not to know” one’s HIV status, to avoid experiencing HIV-related stigma, which could interact with other stigmatized social identities and threaten vital social relationships, life chances, and resources. Yet most had tested for HIV previously. Factors facilitating testing included health education to boost knowledge of effective treatments for HIV; understanding HIV does not necessitate ending social relationships; and tapping into altruism. Conclusions In the context of economic and social inequality, HIV stigma operates on multiple, intersecting layers. IR-HRA struggle with an aversion to HIV testing, because adopting another stigmatized status is dangerous. They also find ways to manage stigma to engage in testing, even if not at recommended levels. Findings highlight strategies to reduce HIV stigma at the levels of communities, institutions, and individuals to improve rates of annual HIV testing necessary to eliminate HIV transmission and reduce HIV-related racial and ethnic health disparities among IR-HRA.

Runaway and homeless youth (RHY) comprise a large population of young people who reside outside the control and protection of parents and guardians and who experience numerous traumas and risk factors, but few buffering resources. Specialized settings have developed to serve RHY, but little is known about their effects. The present cross-sectional qualitative descriptive study, grounded in the positive youth development approach and the Youth Program Quality Assessment model, addressed this gap in the literature. From a larger sample of 29 RHY-specific settings across New York State, RHY ages 16–21 from 11 settings were purposively sampled for semi-structured in-depth interviews on their transitions into homelessness, experiences with settings, and unmet needs (N = 37 RHY). Data were analyzed with a theory-driven and inductive systematic content analysis approach. Half of participants (54%) were female; almost half (49%) identified as non-heterosexual; and 42% were African American/Black, 31% were Latino/Hispanic, and 28% were White/other. Results indicated that because RHY are a uniquely challenged population, distrustful of service settings and professional adults and skilled at surviving independently, the population-tailored approaches found in RHY-specific settings are vital to settings’ abilities to effectively engage and serve RHY. We found the following four major themes regarding the positive effects of settings: (1) engaging with an RHY setting was emotionally challenging and frightening, and thus the experiences of safety and services tailored to RHY needs were critical; (2) instrumental support from staff was vital and most effective when received in a context of emotional support; (3) RHY were skilled at survival on the streets, but benefited from socialization into more traditional systems to foster future independent living; and (4) follow-through and aftercare were needed as RHY transitioned out of services. With respect to gaps in settings, RHY highlighted the following: (1) a desire for better management of tension between youths’ needs for structure and wishes for autonomy and (2) lack of RHY input into program governance. This study advances our understanding of RHY, their service needs, and the ways settings meet these needs, as well as remaining gaps. It underscores the vital, life-changing, and even life-saving role these settings play for RHY.

INTRODUCTION We used a computer simulation of HIV progression and transmission to evaluate the cost-effectiveness of a scale-up of 3 strategies to seek out and test individuals with undiagnosed HIV in New York City (NYC). SETTING Hypothetical NYC population. METHODS We incorporated the observed effects and costs of the 3 "seek and test" strategies in a computer simulation of HIV in NYC, comparing a scenario in which the strategies were scaled up with a 1-year implementation or a long-term implementation with a counterfactual scenario with no scale-up. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression, calibrated to NYC epidemiological data from 2003 to 2015. The 3 approaches were respondent-driven sampling (RDS) with anonymous HIV testing ("RDS-A"), RDS with a 2-session confidential HIV testing approach ("RDS-C"), and venue-based sampling ("VBS"). RESULTS RDS-A was the most cost-effective strategy tested. When implemented for only 1 year and then stopped thereafter, using a societal perspective, the cost per quality-adjusted life-year (QALY) gained versus no intervention was $812/QALY, $18,110/QALY, and $20,362/QALY for RDS-A, RDS-C, and VBS, respectively. When interventions were implemented long term, the cost per QALY gained versus no intervention was cost-saving, $31,773/QALY, and $35,148/QALY for RDS-A, RDS-C, and VBS, respectively. When compared with RDS-A, the incremental cost-effectiveness ratios for both VBS and RDS-C were dominated. CONCLUSIONS The expansion of the RDS-A strategy would substantially reduce HIV-related deaths and new HIV infections in NYC, and would be either cost-saving or have favorable cost-effectiveness.

Purpose Assertive communication has been associated with higher levels of condom use among youth using self-report survey methodology. The purpose of this study was to examine the subjective ratings of assertiveness among young, romantically involved couples in the context of a condom negotiation task. Methods Using an innovative video-recall procedure, 32 couples (64 youth) engaged in a videotaped condom negotiation task and then rated self and partners' level of assertiveness. Both individual ratings of assertiveness and couple-level assertiveness were assessed using dyadic hierarchical linear modeling. Results Individuals' assertiveness was positively associated with condom use. Unexpectedly, the overall level of assertiveness in couples showed a curvilinear association with condom use. Very high and very low assertiveness was associated with lower condom use, whereas moderate levels of assertiveness were associated with higher condom use. Conclusions Moderate levels of assertiveness during condom negotiation may facilitate condom use in young couples. Increasing condom use among romantic partners may require developing interventions that strengthen youths' ability to engage in assertive communication strategies that balance emotional intimacy with self-advocacy.

The objective of this integrative review was to describe current US trends for health technology-enabled adherence interventions among behaviorally HIV-infected youth (ages 13–29 years), and present the feasibility and efficacy of identified interventions. A comprehensive search was executed across five electronic databases (January 2005–March 2016). Of the 1911 identified studies, nine met the inclusion criteria of quantitative or mixed methods design, technology-enabled adherence and or retention intervention for US HIV-infected youth. The majority were small pilots. Intervention dose varied between studies applying similar technology platforms with more than half not informed by a theoretical framework. Retention in care was not a reported outcome, and operationalization of adherence was heterogeneous across studies. Despite these limitations, synthesized findings from this review demonstrate feasibility of computer-based interventions, and initial efficacy of SMS texting for adherence support among HIV-infected youth. Moving forward, there is a pressing need for the expansion of this evidence base.