Assessing Implementation Strategies for the Uptake of Bundled Interventions to Improve Culturally Relevant Care for Black women with HIV

Andrea Dakin, PhD, MA
AIDS Foundation Chicago

Serena Rajabiun, PhD
University of Massachusetts Lowell

Alicia Downes, LMSW
AIDS United

Corliss Heath, PhD
US Department of Health and Human Services

ABSTRACT:
The Health Resources and Services Administration (HRSA), HIV/AIDS Bureau(HAB), Ryan White HIV/AIDS Program (RWHAP), Part F- Special Projects of National Significance initiative entitled Improving Care and Treatment Coordination for Black women with HIV funded 12 clinical and community-based organizations and one evaluation center to adapt, implement, and assess the uptake of evidence based/informed (EB/EI) bundled interventions to improve health outcomes and well-being for Black women with HIV. This study examines the successes, challenges, and adaptations to implementation strategies to support intervention uptake and cultural responsiveness for Black women with HIV.

Guided by the Expert Recommendations for Implementing Change (ERIC) compilation, the Evaluation and Technical Assistance Center working in partnership with the demonstration sites selected five implementation strategies for intervention uptake: tailoring interventions to local context; train/educate stakeholders; evaluation and iterative strategies; engaging consumers; and changing infrastructure. Tracking implementation strategies and adaptations across sites required multiple approaches to data collection, as each of the twelve sites bundled two-four EB/EIs. Modifications to strategies during the pre-implementation and implementation phases were documented using FRAME-IS core modules gathered through monthly coaching calls with sites and annual site visits with evaluation center coaches and site implementation teams. This presentation will outline the data collection and analysis methods employed by the evaluation center, as well as present a case study from one of the demonstration sites.

Adjunctive Interventions in Implementation Research:​ One “thing”? Two things? Old thing? New thing?

Nanette Benbow, MA
Northwestern University

Dennis Li, MPH, PhD
Northwestern University

James Merle, PhD
University of Utah

ABSTRACT:
Implementation science currently groups change methods into two categories: (1) clinical, behavioral, or biomedical interventions targeting recipients’ health outcomes, and (2) implementation strategies—actions taken to improve system-level delivery of an intervention. Differentiating interventions from strategies based on their intended functions is critical to accurately attributing the effects of each change method on its respective health or implementation outcomes. However, in our work coordinating 200+ HIV implementation research projects and conducting systematic reviews of HIV intervention implementation, we identified change methods that had characteristics of both interventions and strategies and were inconsistently classified. To alleviate confusion and improve change method specification, we propose that implementation science should adopt the term adjunctive interventions to classify change methods that fall into this gray area. Adjunctive interventions are distinguished from other change methods by their intended targets, desired outcomes, and theory of action and causal processes. Whereas health interventions target recipients and have a direct, causal effect on the health outcome, adjunctive interventions enhance recipients’ motivation, self-efficacy, or capacity for initiating, adhering to, or engaging with the health intervention and thus have an indirect causal link to the health outcome via increasing the probability of recipients’ utilization of the health intervention. Adjunctive interventions are incapable of directly producing the health outcome and require additional implementation strategies to deliver alongside the health intervention. We will discuss case examples, logic modeling, and considerations for adjunctive intervention research. Conceptualizing adjunctive interventions as a separate type of change method will advance implementation research by improving tests of effectiveness and the specification of mechanisms and outcomes, which will accelerate research evidence to achieve public health impact.

Developing Metrics to Improve Equitable Implementation of HIV Prevention

Moira McNulty, MD
University of Chicago

Maria Pyra, MEd, MPH, PhD
Northwestern University

ABSTRACT:
A daily pill, PrEP, has changed HIV prevention and could help end the HIV epidemic in the U.S. Thus far, use of PrEP has not been evenly or effectively distributed. Much of the focus to date on PrEP delivery has been on linkage and initiation of PrEP. We know that effectiveness of PrEP depends not only on initiation, but also on adherence, which typically requires retention in care for ongoing monitoring and prescriptions per the CDC guidelines; i.e., persistence on PrEP. While the annual number of PrEP users has been increasing, improvement in retention and adherence has lagged, with many individuals who initiate PrEP no longer adherent or retained at 6 months, despite the likelihood that risk of exposure to HIV continues. Furthermore, some of the most vulnerable populations such as young Black MSM are more likely to fall out of PrEP care than their non-Black peers. Yet, measuring persistence has been challenging, particularly in a way that is standardized and can be used across patient populations and PrEP programs. Dr. Moira McNulty, from the University of Chicago, and Dr. Maria Pyra, from Northwestern University, will present their work on PrEP metrics, particularly around persistence, and how these metrics can improve equitable implementation of PrEP.

From Rhetoric to Implementation: Stigma Reduction Efforts in New York City Utilizing Implementation Science and Structural Approaches

Cristina Rodriguez-Hart, PhD, MPH
New York City Department of Health and Mental Hygiene

ABSTRACT:
Although widely declared to be a priority for ending the US HIV epidemic, stigma reduction remains siloed, unstructured, and lacking in standard frameworks and methodologies. Much of what has been learned about stigma reduction comes from the global context and focuses on individual and interpersonal-level approaches. What works in high-income, high-burden contexts is still an open question. I will provide an overview of several structural-level stigma reduction efforts in New York City utilizing implementation science, community-planning processes, funding mechanisms, and quality improvement.

Structural Racism, Intersectionality, and Black Men’s Health

Lisa Bowleg, MA, Ph.D.
The George Washington University

Derek Griffith, Ph.D.
Vanderbilt University

ABSTRACT:
As a Black man, I Got 99 Problems and I Sure Ain’t Thinking about HIV at the End of the Day”: Thinking Critically, Structurally and Intersectionally about Black Men’s Health and Health Inequities

Traditional conceptualizations of health typically frame health primarily as a property of individuals (e.g., attitudes, beliefs, perceptions, behaviors), not as a property of systems and structures beyond the individual-level that constrain health, and in turn, shape health inequities and for historically oppressed groups such as Black people in the U.S.  As such, prevention scientists trained in conventional disciplines that have prioritized social-cognitive and biomedical frameworks exclusively, and those that have disdained  “nontraditional” methods (e.g., qualitative) have likely missed key opportunities to reduce racialized health inequities, primarily because of this predominant focus on the individual-level.  Using insights from my 20-year program of HIV prevention mixed methods research with Black men as a foundation, this presentation will:

• provide an overview of the critical theoretical frameworks (i.e., intersectionality, critical race theory, critical psychology) and social-structural perspectives that are fundamental to my research on Black men’s health;

• highlight qualitative narratives from that research to illustrate how Black men talk about the impact of social-structural factors (e.g., structural racism, police brutality, incarceration, unemployment) on their health and wellbeing; and

• advocate for prevention scientists to become more critically, structurally and intersectionally competent.  This competency is essential to prevention, and the ability to help reduce, not just document, health inequities among Black men at diverse intersections such as class, ethnicity, and sexuality.

Black men, mortality, and the COVID-19 pandemic: A syndemics approach.

In this presentation, Dr. Griffith will use a syndemics approach, informed by an intersectional lens, to make a case that Black men should be a larger focus of COVID-19 research, practice, and policy efforts in the United States. Syndemics are two or more epidemics interacting synergistically in ways that exacerbate their health consequences via disease concentration, disease interaction and the structural forces that underlie these factors. He argues that structural racism and the stress of the COVID-19 pandemic create a context for increased mortality from COVID-19, heart disease, and other factors.

To request Dr. Bowleg and Dr. Griffith’s powerpoint slides, please email psmg@northwestern.edu

Bridging the Gap: Implementation Science as an Implementation Strategy for EHE

Sarit Golub, PhD, MPH
Hunter College

ABSTRACT:
This talk will discuss the role of implementation science in Ending the HIV Epidemic (EHE) goals at both the national and local levels. Not only can implementation science inform EHE investments, its tools, models and frameworks are critical to supporting and enhancing successful EHE programs and strategies. Practice-driven, collaborative implementation science research that focuses on mechanisms, intervention specification, and all four levels of strategies and outcomes will have the greatest impact.

A tailored clinic-level intervention using a stepped-wedge design to increase PrEP uptake in primary care settings

Parya Saberi, PharmD, MAS, AAHIVP
University of California, San Francisco

Wayne Steward, PhD, MPH
University of California, San Francisco

ABSTRACT:
Lack of healthcare provider knowledge, capacity, and willingness to prescribe PrEP are barriers to PrEP delivery in clinical settings. In this presentation, we will discuss details of the PrEP Optimization Intervention (PrEP-OI) which combines a PrEP Coordinator with an online panel management tool to assist providers with PrEP uptake, persistence, and management in a large safety-net system. The intervention was rolled out at 12 primary care San Francisco Department of Public Health clinics using a stepped-wedge design preceding a follow-up phase. Additionally, we will review the challenges the study overcame with the development of PrEP-OI's technology-based component, onboarding and implementation, and response to the SARS-CoV-2 pandemic.

Advancing implementation of eHealth interventions for HIV prevention through the scale up of Keep It Up!

Brian Mustanski, PhD
Northwestern University

Nanette Benbow, M.A.S.
Northwestern University

Kathryn Macapagal, PhD
Northwestern University

Dennis Li, PhD, MPH
Northwestern University

ABSTRACT:
Despite substantial NIH investment in developing eHealth HIV prevention interventions, little implementation research has examined strategies to effectively scale up these programs. The Keep It Up! 3.0 study advances our knowledge by comparing two approaches for delivering an online CDC-best-evidence HIV intervention in 44 counties. This presentation describes our county-randomized hybrid type III effectiveness–implementation trial, focusing on the pragmatic design of our sampling methodology, outcome measures, the intervention application, and recruitment/retention protocols. By emulating real-world contexts, we can understand how to not only have the greatest public health impact with but also speed up implementation of eHealth HIV interventions.

Ending the HIV epidemic in Chicago: Evidence from high-fidelity local agent-based model

Wouter Vermeer, PhD
Northwestern University

Nanette Benbow, M.A.S.
Northwestern University

ABSTRACT:
Agent-based models have enormous potential for modeling complex social phenomena. The ability to model complex individual-level social dynamics and project system-wide behaviors can help inform decision makers in their effort to curb a phenomenon like the spread of HIV. To produce actionable results, models need to accurately capture the dynamics and behaviors observed by decision makers. As such, models aimed at supporting decision making need to be tailored to the local context by incorporating behaviors based on local data. In this presentation we describe our model for HIV-spread in Chicago and highlight how we used Chicago-level data and input from local public health experts to inform this model. We will illustrate how our model can be used to perform predictive scenario analysis and discuss how these results can be used to inform decision makers as they plan their HIV care and prevention strategies to end the HIV epidemic.

Localized Economic Modeling to Support Implementation of the “Ending the HIV Epidemic in America” Initiative

Bohdan Nosyk, PhD, MA
Simon Fraser University

ABSTRACT:
Rather than a homogeneous national epidemic, the HIV epidemic in the US is a collection of diverse local microepidemics concentrated primarily in the South, hotspot counties, and large urban centers, with fundamental differences in health system infrastructure, funding and HIV-related laws and policies. Recognizing these facts, the US launched the ambitious ‘Ending the HIV Epidemic (EHE) initiative in February 2019. The plan called for an initial focus on 48 of the most-affected counties plus Washington, DC, San Juan, Puerto Rico and seven southern states to reduce new infections by 75% within 5 years and by 90% within 10 years. These goals are now challenged by the onset of the global COVID-19 pandemic, which may have severe consequences for people living with HIV and on HIV microepidemics across the US. A value-based approach, accounting for the pervasive racial/ethnic inequities in healthcare access and explicating key elements of the implementation process are now more critical than ever in reaching the ambitious targets of the EHE initiative.

In 2016 our investigative team began a project aiming to identify optimal combination implementation strategies to reduce the public health burden of HIV/AIDS in six US cities (NIH-DA-041747). These six cities, all subsequently included in the EHE initiative, comprised 12 of 48 EHE-targeted counties and 24.1% of people living with HIV/AIDS in the nation. Considering the impact of 16 evidence-based interventions to Diagnose, Treat and Protect against HIV/AIDS, we found unique combination implementation strategies provided the greatest health benefits in each city; no two cities featured the same mix of interventions in their ‘optimal’ strategy. Moreover, we found the EHE goals were attainable in three of six cities. The biomedical interventions we considered would however have to be delivered at ideal levels of implementation, which would require additional efforts to reduce barriers in access to care and explicitly focus on reducing disparities in healthcare access among Black and Hispanic communities. We argue that promoting health equity is key to bridging this implementation gap and propose an approach to establish an equitable distribution of resources to maximize the impact of the EHE initiative.

Agent-based models for understanding the impact of transitions between community and criminal justice settings on HIV transmission and opioid mortality: implications for intervention development

Anna Hotton, PhD, MPH
John Schneider, MD, MPH
University of Chicago Medicine

ABSTRACT:
Criminal justice involvement (CJI) has important public health and social consequences, affecting social and sexual network stability, employment and housing opportunities, and access to medical care, all of which can lead to cycles of socioeconomic marginalization and adverse health outcomes. CJI populations are disproportionately impacted by HIV and substance use disorders, which can be exacerbated by frequent cycling between communities and criminal justice settings. However, such settings also offer opportunities for delivery of treatment and prevention interventions, such as PrEP, ART, and medication assisted therapy to populations who may not otherwise access these services. Guidance is needed to determine how interventions for CJI populations can be most effectively deployed, but logistical and ethnical challenges make empirical research difficult in contexts that often include marginalized communities that are highly mobile, have significant loss to follow-up, and cycle frequently between criminal justice and community settings. Agent-based models (ABMs) can generate insights about the processes that drive HIV transmission and opioid related mortality and provide a platform for virtually evaluating potential candidate interventions, thus facilitating more efficient and focused intervention development. By illuminating mechanisms associated with intervention success and providing the ability to parameterize the relevant individual-level heterogeneity via detailed, local data, ABMs allow for exploration of complex interventions, enabling the investigation of specific intervention ingredients and mechanisms likely to have the most impact on the HIV and opioid epidemics in the US. We present early applications of ABMs for evaluating interventions for CJI populations with nascent examples in HIV and opioid mortality, and discuss implications for structural, policy, and network-based interventions.

Title: Cost-Effectiveness of Care Models to Support HCV and HIV Elimination in People Who Inject Drugs

Bruce Schackman, Phd
Weill Cornell Medical College

ABSTRACT:
The United States has set ambitious goals to eliminate Hepatitis C Virus (HCV) and HIV infections nationally, but the current opioid crisis has resulted in increased incidence of HCV as well as outbreaks of HIV among people who inject drugs (PWID). PWID may not access healthcare services because of stigma, abstinence requirements, and lack of available providers. This presentation will describe recent and ongoing work evaluating the effectiveness, cost-effectiveness, and implementation of different healthcare models designed to bring HCV/HIV testing and HCV care to PWID in a variety of settings including methadone maintenance programs, syringe service programs, and clinical settings.

Landscape of Funded Implementation Research in HIV/AIDS: A Scoping Review of
Methodological and Intervention Characteristics

JD Smith, PhD & Nanette Benbow, MAS
Northwestern University

ABSTRACT:
JD and Nanette will present results from a scoping review of NIH-funded grants which will identify the proportion and characteristics of HIV-related implementation research studies funded by NIH, discuss multiple implementation research methods used to study interventions targeting various points in the HIV prevention and care continuums, and present potential opportunities for next steps.

CDC's National HIV Behavioral Surveillance (NHBS) system: Methods and impact on HIV prevention among key populations

Cyprian Wejnert, Ph.D.
Centers for Disease Control and Prevention

ABSTRACT:
The National HIV Behavioral Surveillance (NHBS) system was designed to monitor risk factors for HIV infection and HIV prevalence among individuals at increased risk for HIV infection, that is, sexually active men who have sex with men who attend venues, persons who recently injected drugs, and heterosexuals of low socioeconomic status living in urban areas. These groups were selected as priorities for behavioral surveillance because they represent the major HIV transmission routes and the populations with the highest HIV burden. Accurate data on HIV risk and testing behaviors in these populations are critical for understanding trends in HIV infections and planning and evaluating effective HIV prevention activities. This presentation will provide an overview of NHBS and the methods it employs (respondent-driven sampling and venue-based sampling), and will highlight some of the impact findings from NHBS have had on HIV prevention.

Getting SMART about adaptive interventions in treatment, prevention and implementation science

Daniel Almirall, Ph.D.
University of Michigan

ABSTRACT:
The effective treatment, prevention or management of a wide variety of health disorders often requires individualized, sequential decision-making. To do this, each individual’s intervention is tailored over time based on the individual’s history, e.g., changing disease or risk status, or adherence. Adaptive interventions (also known as dynamic treatment regimens in the statistical medicine literature) operationalize such individualized decision making using a sequence of decision rules that pre-specify which intervention option to offer, for whom, and when. Intervention options in this case correspond to varying doses, types or delivery modes of pharmacological, behavioral and/or psychosocial interventions. Recently, there has been a surge of interest in developing and evaluating adaptive interventions via randomized trials. Specifically, there is great interest in the use of sequential multiple assignment randomized trials (SMART), a type of multi-stage randomized trial design, to build high-quality adaptive interventions. The primary aim of this talk is to provide a brief, conceptual introduction to adaptive interventions and SMART designs. We will use various examples of adaptive interventions and SMART studies in child and adolescent mental health (e.g., ADHD, autism) to explain and illustrate ideas. If time permits, a secondary aim of this talk is to introduce the idea of adaptive implementation interventions and the use of cluster-randomized SMART designs for their development. In an adaptive implementation intervention, the intervention options—which, typically, are strategies designed to improve the uptake or delivery of evidence-based practices by a provider/site—are tailored over time based on the changing status of the provider/site. As an illustrative example, we will present the design of the AIM-Hi Study, a NIMH-funded cluster-randomized SMART which aims to develop a high-quality adaptive implementation intervention to improve the uptake/adoption of cognitive behavioral treatment in high-schools.

Challenges in the evaluation of interventions to improve engagement along the HIV care continuum in the United States

Kathryn Risher, Ph.D, M.H.S
London School of Hygiene & Tropical Medicine

ABSTRACT:
In the United States (US), a high proportion of individuals living with HIV remain unlinked to care, disengaged from care, or incompletely adherent to antiretroviral therapy (ART). We conducted a systematic review of interventions to improve linkage to care, retention in care, re-engagement among those disengaged from care, and adherence to ART in the US. We find that the bulk of evidence (117/152 included studies) addresses adherence interventions, while a very small minority address linkage or reengagement interventions (7/152 and 4/152, respectively). There was tremendous heterogeneity in measures used to evaluate interventions. We found that most (59%) of studies report significantly improved outcomes, but the effect size was variable across studies and populations. The presentation will additionally include recommendations to address the challenges identified by the systematic review.

Social media for changing and predicting HIV

Sean Young, Ph.D.
University of California Los Angeles

ABSTRACT:
This talk will focus on how social media can be used in HIV prevention research. We'll discuss a social media-based online community for HIV prevention and ways that social media data can be used by HIV researchers.

Resource allocation models for HIV prevention

Emine Yaylali, Ph.D.
Istanbul Technical University

ABSTRACT:
Objective: 
We will briefly explain resource allocation models, how these models could be used in improving HIV prevention and present some examples from literature. Then, we will describe HIV-RAMP, a resource allocation model to optimize health departments’ Centers for Disease Control and Prevention (CDC)–funded HIV prevention budgets to prevent the most new cases of HIV and to evaluate the model’s implementation in four health departments
Design, Settings, and Participants: 
We developed a linear programming model combined with a Bernoulli process model that allocated a fixed budget among HIV prevention interventions and risk subpopulations to maximize the number of new infections prevented. The model, which required epidemiologic, behavioral, budgetary, and programmatic data, was implemented in health departments in Philadelphia, Chicago, Alabama, and Nebraska. 
Main Outcome Measures: 
The optimal allocation of funds, the site-specific cost per case of HIV prevented rankings by intervention, and the expected number of HIV cases prevented.  
Results: 
The model suggested allocating funds to HIV testing and continuum-of-care interventions in all 4 health departments. Behavioral interventions did not receive funding in the optimal allocation for any health department. The most cost-effective intervention for all sites was HIV testing for men who have sex with men (MSM) in non-clinical settings, and the least cost-effective interventions were behavioral interventions for HIV-negative persons. The pilot sites required 3-4 months of technical assistance to develop data inputs and generate and interpret the results. Although the sites found the model easy to use in providing quantitative evidence on allocating HIV prevention resources, they criticized the exclusion of structural interventions and the use of model to allocate only CDC funds.   
Conclusions: 
Resource allocation models have potential to improve the allocation of limited HIV prevention sources and can be used as a decision-making guide for state and local health departments. Using such models may require substantial staff time and technical assistance. Model results suggesting allocating funds towards testing and continuum-of-care interventions and risk populations at highest risk of HIV transmission may lead to better health outcomes. These model results emphasize the allocation of CDC funds toward testing and continuum--of-care interventions and populations at highest risk of HIV transmission. 

Economic analysis of AIDS United's access to Care Initiative

Cathy Maulsby, Ph.D. & David Holtgrave, Ph.D.
Johns Hopkins University

ABSTRACT:
Persons diagnosed with HIV but not retained in HIV medical care accounted for the majority of HIV transmissions in 2009 in the United States (U.S.). There is an urgent need to implement and disseminate HIV retention in care programs; however little is known about the costs associated with implementing retention in care programs. We assessed the costs and cost-utility for six Retention in Care (RiC) programs using standard methods recommended by the U.S. Panel on Cost-effectiveness in Health and Medicine.  Program costs from the societal perspective ranged from $47,919 to $423,913 per year or $594 to $2,753 per participant. The programs averted between 0.23-1.65 HIV infections per year.  QALYs gained ranged from 1.51-11.00.  Using a threshold of $163,889 USD, all of the programs were cost-effective and four were cost-saving. Across a range of program models, retention in care interventions were cost effective (and the majority were cost saving), suggesting that retention in care programs are a judicious use of resources.

Sources of racial disparities in HIV prevalence in men who have sex with men in Atlanta: A modeling study

Steven Goodreau, Ph.D.
University of Washington, Seattle

ABSTRACT:

Black men who have sex men (MSM) in the US have a substantially higher prevalence of infection than White MSM, and many proximal and distal explanations have been offered to account for pieces of this disparity.

We created a simulation model to assess the strength of existing hypotheses and data. We built a dynamic, stochastic, agent-based network model of Black and White MSM aged 18–39 years in Atlanta, that incorporated race-specific individual and dyadic-level prevention and risk behaviors, network attributes, and care patterns. We estimated parameters from two Atlanta-based studies in this population (n=1117), supplemented by other published work. We modeled the ability for racial assortativity to generate or sustain disparities in the prevalence of HIV infection, alone or in conjunction with scenarios of observed racial patterns in behavioral, care, and susceptibility parameters. 

Race-assortative mixing alone could not sustain a pre-existing disparity in prevalence of HIV between Black and White MSM. Differences in care cascade, stigma-related behaviors, and CCR5 genotype each contributed substantially to the disparity (explaining 10.0%, 12.7%, and 19.1% of the disparity, respectively), but nearly half (44.5%) could not be explained by the factors investigated. A scenario assessing race-specific reporting differences in risk behavior was the only one to yield a prevalence in black MSM (44.1%) similar to that observed (43.4%). Racial assortativity is an inadequate explanation for observed disparities. Work to close the gap in the care cascade by race is imperative, as are efforts to increase serodiscussion and strengthen relationships among Black MSM particularly. Further work is urgently needed to identify other sources of, and pathways for, this disparity, to integrate concomitant epidemics into models, and to understand reasons for racial differences in behavioral reporting.

Estimating HIV incidence, prevalence, and undiagnosed infection in the United States

Anna Satcher-Johnson, M.P.H. & Rick Song, Ph.D.
Centers for Disease Control and Prevention

ABSTRACT:

The burden of HIV infection and health outcomes for people living with HIV varies across the United States. New methods allow for estimating national and state-level HIV incidence, prevalence, and undiagnosed infections using surveillance data and CD4 values. 

Methods: HIV surveillance data reported to the Centers for Disease Control and Prevention and the first CD4 value after diagnosis were used to estimate the distribution of delay from infection to diagnosis based on a well-characterized CD4 depletion model. This distribution was used to estimate HIV incidence, prevalence, and undiagnosed infections during 2010–2014. Estimated annual percentage changes were calculated to assess trends. 

During 2010–2014, HIV incidence decreased 10.3% (EAPC = -3.1%) and the percentage of undiagnosed infection decreased from 17.1% to 15.0% (EAPC = -3.3%) in the United States; HIV prevalence increased 9.1% (EAPC = 2.2%). In 2014, Southern states accounted for 50% of both new HIV infections and undiagnosed infections. HIV incidence and undiagnosed infection decreased in the United States during 2010–2014; however, outcomes varied by state and region. Progress in national HIV prevention is encouraging but intensified efforts for testing and treatment are needed in the South and states with high percentages of undiagnosed infection.

Social network approaches to HIV prevention and care

Carl Latkin, Ph.D.
Johns Hopkins Bloomberg School of Public Health

ABSTRACT:
The presentation will outline how social network approach can be utilized to reach hidden populations. Embedded in social network dynamics are social influence process that can be capitalized on to promote and sustain behavior change. The presentation will briefly provide guidance on tailoring social network inventories and then focus on developing and implementing RCT of network interventions and  measuring outcomes and controlling for contamination.

Alcohol and HIV medication adherence: Taking an intervention from efficacy to effectiveness

Jeffrey Parsons, Ph.D.
Hunter College

ABSTRACT:
Dr. Parsons will present on his series of research projects focused on the relationship between alcohol and other drug use and HIV medication adherence. Data from an efficacy trial of an 8 session behavioral intervention utilizing motivational interviewing and cognitive behavioral skills-building will be presented, followed by how this project led to a second RCT, and a current effectiveness trial focused on implementation issues. Throughout his presentation, Dr. Parsons will highlight the mistakes he and his team made throughout the process, and how they have learned from these.

Addressing the HIV epidemic among YMSM: The Care Continuum 2.0

Lisa Hightow-Weidman, M.D
University of North Carolina-Chapel Hill

ABSTRACT:
While the epidemic of HIV in the US has leveled off for many age groups, from 2000-2010, the annual number of new HIV diagnoses among young men who have sex with men (YMSM) more than doubled. The success of treatment as prevention in reducing the number of new HIV infections among youth, and particularly YMSM, relies on HIV testing, antiretroviral treatment (both for treatment and prevention), adherence and viral suppression among those with HIV. Technology-delivered interventions are well suited for youth given its modality, its suitability to deliver tailored content specific to each user’s HIV/AIDS risk behaviors and context, and its unique capability to diffuse HIV/AIDS prevention programs to large numbers of youth residing in numerous geographic locations. Dr. Hightow-Weidman will describe her work addressing gaps in the continuum of care for youth through novel technology-based interventions including those delivered using smartphones, applications “apps” and incorporating virtual reality avatars and game-based elements.

Trends in racial and ethnic disparities in antiretroviral therapy prescription and viral suppression in the United States, 2009-2013

Linda Beer, Ph.D
Centers for Disease Control and Prevention

ABSTRACT:
Objectives: To examine trends in racial/ethnic disparities in antiretroviral therapy (ART) prescription and viral suppression among HIV-infected persons in care, overall and among men who have sex with men (MSM), from 2009 to 2013.
Design: The Medical Monitoring Project (MMP) is a complex sample survey of HIV-infected adults receiving medical care in the United States.
Methods: We used weighted interview and medical record data collected 06/2009-05/2014 to estimate the prevalence of ART prescription and viral suppression among racial/ethnic groups overall and among MSM. 
Results: We found significant increases in ART prescription and viral suppression among all racial/ethnic groups from 2009 to 2013, both overall and among MSM. By 2013, overall and among MSM, the Hispanic-white disparity in ART prescription was non-existent, and the black-white disparity was not significant after accounting for differences between blacks and whites in age and length of HIV diagnosis. Despite reductions in racial/ethnic disparities in viral suppression over the time period, significant disparities remained among the total population, even after adjusting for differences in racial/ethnic group characteristics. Encouragingly, however, there was no significant Hispanic-white disparity in viral suppression among MSM by 2013.
Conclusions: Despite significant improvements in ART prescription and viral suppression in recent years, racial and ethnic disparities persist, particularly for black persons. If the United States is to achieve the National HIV/AIDS Strategy goal of reducing HIV-related health disparities, continued efforts to accelerate the rate of improvement in ART prescription and viral suppression among Hispanic and black persons may need to be prioritized.

Mathematical models for infectious disease transmission dynamics over networks: statistical methods, software tools, and applications for HIV/STI prevention science

Samuel Jenness, Ph.D.
Emory University

ABSTRACT:
HIV and STIs are transmitted over highly structured sexual partnership networks that evolve over time. Investigating network-based drivers of epidemics and opportunities for disease prevention has required the development of statistical approaches to modeling dynamic network structures embedded within broader mathematical models of intra- and inter-host epidemiology, demography, and bio-behavioral disease risk. In this talk, I present on temporal exponential random graph models (ERGMs) to model dynamic networks using easily collected egocentric network data, the integration of these methods within our epidemic modeling software, EpiModel (www.epimodel.org), and our recent applications of these tools to investigate empirical and intervention questions for HIV/STI prevention among men who have sex with men in the United States.

A patient navigation/contingency management
RCT for hospitalized HIV-positive substance users (CTN 0049)

Lisa Metsch, Ph.D.
Columbia University

Dan Feaster, Ph.D.
University of Miami

ABSTRACT:
Importance:  Substance use is a major driver of the HIV epidemic and is 7 associated with poor HIV care outcomes. Patient navigation (care 8 coordination with case management) and the use of financial incentives for 9 achieving pre-determined outcomes are interventions increasingly promoted 10 to engage patients in substance use disorders treatment and HIV care, but 11 there is little evidence for their efficacy in improving HIV-1 viral 12 suppression rates.

Objective:  To assess the effect of a structured patient navigation 14 intervention with or without financial incentives to improve HIV-1 viral 15 suppression rates among patients with elevated HIV-1 viral loads and 16 substance use recruited as hospital inpatients.

Design, Setting, and Participants:  From July 2012 through January 2014, 18 801 patients with HIV infection and substance use from 11 hospitals across the United States were randomly assigned to receive either patient 1 navigation alone (n = 266), patient navigation plus financial incentives (n = 2 271), or treatment as usual (n = 264). The HIV-1 plasma viral load was 3 measured at baseline and at, 6 and 12 months.

Interventions:  Patient navigation included up to 11 sessions of care 5 coordination with case management and motivational interviewing over 6 6 months. Financial incentives (up to $1160) were provided for achieving 7 targeted behaviors aimed at reducing substance use, increasing engagement 8 in HIV care, and improving HIV outcomes. Treatment as usual was the 9 standard practice at each hospital for linking hospitalized patients to 10 outpatient HIV care and substance use disorders treatment.

Main Outcome and Measures:  The pre-specified primary outcome was HIV viral suppression (≤200 copies/mL) relative to viral non-suppression/all-cause mortality at 12-month follow-up.

Results:  There were no differences in rates of HIV viral suppression among the three groups at 12-months (PN=89/249, 35.7%, PN+FI=98/254, 38.6%, TAU=85/249, 34.1%, χ2(2) = 0.78, p < .68).  At 6-months 120/236 (46.2%) more participants in the PN+CM group were virally suppressed compared to 89/253 (35.2%) in the TAU group (p<.04).

Conclusion and Relevance:  Time-limited patient navigation and contingency management had short-term effects but were not sufficient to achieve sustained post-intervention viral suppression among substance users with advanced HIV disease.  More sustained individual-level interventions and broader-reaching approaches that address the social determinants of health may be needed for this population.

HIV transmission networks and their potential public health applications

Joel Wertheim, Ph.D.
University of California-San Diego

ABSTRACT:
Understanding the path over which viruses such as HIV have been transmitted may be crucial for directing public health resources. Contact tracing of named sexual and injection drug-use partners of people recently diagnosed with HIV is an indispensable tool for reconstructing this transmission network. In addition, viral genetic sequence data—routinely collected by public health agencies—can also be used to infer the dynamics of HIV transmission. We explore the ways in which HIV sequence data has been used to better understand both global and local HIV transmission dynamics. Further, we validate the use viral genetic sequences in reconstructing these viral transmission networks in a public health surveillance setting and demonstrate how genetic sequence data are better than partner naming data for reconstructing the viral transmission network.

Use of agent-based models to inform HIV prevention for men who have sex with men

Patrick Sullivan, Ph.D.
Emory University

ABSTRACT: 
Agent-based models allow a virtual “laboratory” to evaluate counterfactual scenarios, evaluate the potential impact of combinations of HIV prevention, and benchmark levels of prevention services required to achieve population-level impacts of programs. We will review agent-based models of HIV prevention approaches for MSM in 5 countries, and describe how the findings of these models have been used to design combination prevention programs and guide programmatic goal setting. The results of agent-based models in different countries support the role of smart combinations of prevention interventions (e.g., PrEP, testing, treatment) and of ancillary services to increase the impact of specific modalities (e.g., adherence promotion for PrEP).

Examining HIV, substance use, and implementation factors within a RCT of TF-CBT for risky sexual behaviors in adolescents in Zambia

Laura Murray, Ph.D.
Johns Hopkins University