The HIV/AIDS Epidemic in Miami: Perspectives of Stakeholders and Frontline Providers

Background: Miami, Florida persists as an epicenter of HIV/AIDS nationally and has been more delayed than other areas with high HIV burden in implementing public health measures that mitigate transmission risk. These issues among other social and structural-level determinants have complicated progress in addressing HIV/AIDS in Miami. Purpose: The stagnated progress in improving HIV outcomes in Miami necessitated a more comprehensive understanding of the experiences and insights of stakeholders within the system. We used a stakeholder analysis approach to understand the complexity of driving factors and key challenges facing this HIV epidemic. Methods: A stakeholder analysis was conducted through 11 focus groups (64 participants) with front line workers working in non-profit, community-based agencies in Miami. The interview guide was designed to elicit a broad discussion on the social and intermediary determinants of HIV/AIDS, as well as the context surrounding barriers to treatment. Data were analyzed using qualitative software for thematic analysis. Results: Participants highlighted particular populations vulnerable to HIV/AIDS and insufficiently engaged in treatment, including immigrants and people who use drugs. Stigma surrounding HIV/AIDS as well as sexual orientation, mental health, and drug use was a noted persisting barrier. Participants expressed needs for more targeted outreach and education for both prevention and treatment. Numerous systemic gaps were identified as barriers to treatment engagement and retention. Other comorbidities and socioeconomic challenges, including criminal justice histories, housing instability and low educational attainment, also hamper HIV/AIDS management. Discussion: Through these discussions with stakeholders representing a diversity of voices, findings can inform comprehensive and coordinated strategies for curbing the HIV/AIDS epidemic in Miami. The development of prevention and treatment interventions should consider cultural contexts of health behaviors, multi-level stigma related to HIV/AIDS and other comorbid and socioeconomic challenges, and increased implementation of harm reduction programs such as PrEP delivery and syringe exchange programs

Dentists' Willingness to Provide Expanded HIV Screening in Oral Health Care Settings: Results From a Nationally Representative Survey

Objectives. Using a nationally representative survey, we determined dentists’ willingness to provide oral rapid HIV screening in the oral health care setting. Methods. From November 2010 through November 2011, a nationally representative survey of general dentists (sampling frame obtained from American Dental Association Survey Center) examined barriers and facilitators to offering oral HIV rapid testing (n = 1802; 70.7% response). Multiple logistic regression analysis examined dentists’ willingness to conduct this screening and perceived compatibility with their professional role. Results. Agreement with the importance of annual testing for high-risk persons and familiarity with the Centers for Disease Control and Prevention’s recommendations regarding routine HIV testing were positively associated with willingness to conduct such screening. Respondents’ agreement with patients’ acceptance of HIV testing and colleagues’ improved perception of them were also positively associated with willingness. Conclusions. Oral HIV rapid testing is potentially well suited to the dental setting. Although our analysis identified many predictors of dentists’ willingness to offer screening, there are many barriers, including dentists’ perceptions of patients’ acceptance, that must be addressed before such screening is likely to be widely implemented

HIV medical providers\u27 perceptions of the use of antiretroviral therapy as nonoccupational postexposure prophylaxis in 2 major metropolitan area

INTRO: In 2005, the Centers for Disease Control and Prevention expanded its recommendation of post exposure prophylaxis (PEP) use in the workplace to include non-occupational exposures (nPEP). The availability and extensive use of nPEP has not achieved widespread acceptance among health care providers of high-risk populations, and public health and primary care agencies have been sparse in their implementation of nPEP promotion, protocols, and practices. METHODS: We conducted a survey of HIV providers (n=142, response rate = 61%) in Miami-Dade County (Florida) and the District of Columbia (DC) that focused on their knowledge, attitudes, beliefs and practices related to the delivery of nPEP. We then analyzed differences in survey responses by site and by history of prescribing nPEP using bivariate and multivariate logistic regression. RESULTS: More DC providers (59.7%) reported ever prescribing nPEP than in Miami (39.5%%, p < 0.048). The majority of practices in both cities did not have a written nPEP protocol and rarely or never had patients request nPEP. Multivariable analysis for history of prescribing nPEP was dominated by having patients request nPEP (OR = 21.53) and the belief that nPEP would lead to antiretroviral resistance (OR = 0.14), as well as having an nPEP written protocol (OR = 7.49). DISCUSSION: Our findings are consistent with earlier studies showing the underuse of nPEP as a prevention strategy. The significance of having an nPEP written protocol and of patient requests for nPEP speaks to the importance of using targeted strategies to promote widespread awareness of the use of HIV antiretroviral medications as a prevention intervention

Ending the HIV Epidemic for Persons Left Behind in the Advances of HIV: Intervention Studies Addressing the HIV Continuum of Care

The advent of antiretroviral therapy and biomedical prevention has transformed HIV from a fatal disease to a chronic condition where people with HIV (PWH) can live long, healthy lives. Yet, there remains a subset of PWH left behind from receiving timely HIV diagnosis and care. Striking inequalities in access to resources, socioeconomic disparities, and social forces have prevented certain PWH from achieving significant health and quality of life (QOL) improvements experienced by those who secure life-saving treatment. For decades, our multidisciplinary team developed a collaborative scientific portfolio focused on helping those left behind advance along the HIV continuum of care. In this manuscript, we highlight some of our U.S.-based social interventions that have addressed the disparities and sub-optimal QOL encountered by overlooked populations with the goal of achieving timely HIV diagnosis, care, and sustained viral suppression. We then outline our many lessons learned and vision for the next crucial steps ahead

Oral health-related quality of life and unmet dental needs among women living with HIV

Oral health-related quality of life (OHRQoL) is a multidimensional, perception-based measure of how oral health affects social and physical functioning and self-image. OHRQoL is important for assessing women living with HIV (WLWH) who may have unmet dental needs and experience disparities that impact dental care accessibility. In 2016, the authors conducted an assessment of OHRQoL among a national sample of 1,526 WLWH in the Women's Interagency HIV Study using the Oral Health Impact Profile instrument, which assesses the frequency of 14 oral health impact items. OHRQoL was measured using multivariable linear regression with a negative binomial distribution to assess the association between report of a recent unmet dental need and OHRQoL. "Fair or poor" oral health condition was reported by 37.8% (n = 576) of WLWH. Multivariable linear regression showed that unmet dental needs had the strongest positive association with poor OHRQoL (difference in Oral Health Impact Profile mean, 2.675; P < .001) compared with not having unmet needs. The frequency of dental care utilization was not associated with higher OHRQoL. Older age, fair or poor dental condition, smoking, symptoms of anxiety and loneliness, and poor OHRQoL were also associated with worse OHRQoL. Self-perceived impact of oral health on social and physical function and self-image, as measured by OHRQoL, may be an easily assessable but underrecognized aspect of OHRQoL, particularly among women aging with HIV. Dentists should implement OHRQoL assessments in their management of the care of patients with HIV to identify those who do have significant oral health impacts

Women's HIV disclosure to the dentist: Does frequent contact matter?

Research has shown inconsistent patterns of patients' HIV serostatus disclosure to their dentists. Common barriers to disclosure have included confidentiality concerns, fear of treatment refusal, and discrimination. This study evaluated the prevalence of HIV serostatus disclosure to the dentist, whether the frequency of dental care utilization is associated with disclosure, and reasons for nondisclosure among women living with HIV. We administered a cross-sectional oral health survey to 1,526 women living with HIV in the Women's Interagency HIV Study including questions regarding HIV serostatus disclosure to dentists. Logistic regression models were used to analyze the association between dental care utilization (at least annually versus less than annually) and HIV serostatus disclosure to dentists. Overall, 83 percent of women reported that they disclosed their HIV serostatus to their dentist. The most common reasons for nondisclosure were: a) the dentist did not ask, b) believing that the dentist did not need to know, and c) not having a consistent dentist. In the multivariable logistic regression model, at least annual dental care utilization, compared to less than annual, led to a 59 percent reduction in the odds of HIV nondisclosure to the dentist. Study findings highlight that dentists who see their patients infrequently should consider methods for overcoming barriers to HIV nondisclosure and the possibility that their patient's HIV serostatus is undisclosed. Educating women living with HIV about how disclosure to dentists is a critical component of their dental assessment and treatment, and how preventive dental treatment can improve overall health outcomes, is important

Multisite Study of Women Living With HIV's Perceived Barriers to, and Interest in, Long-Acting Injectable Antiretroviral Therapy

Adherence to antiretroviral therapy (ART) is imperative for viral suppression and reducing HIV transmission, but many people living with HIV report difficultly sustaining long-term adherence. Long-acting injectable (LAI) ART has the potential to transform HIV treatment and prevention. However, little LAI ART-related behavioral research has occurred among women, particularly outside of clinical trials. Six Women's Interagency HIV Study sites: New York, Chicago, Washington DC, Atlanta, Chapel Hill, and San Francisco. We conducted 59 in-depth interviews with women living with HIV across 6 Women's Interagency HIV Study sites (10 per site; 9 at Washington DC). We interviewed women who were not included in LAI ART clinical trials but who receive care at university settings that will administer LAI ART once it is approved. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Most women enthusiastically endorsed monthly LAI ART and would prefer it over pills. The following 3 reasons emerged for this preference: (1) convenience and confidentiality, (2) avoiding daily reminders about living with HIV, and (3) believing that shots are more effective than pills. Challenges remain, however, specifically around (1) medical mistrust, (2) concerns about safety and effectiveness, (3) pill burden for HIV and other conditions, and (4) barriers to additional medical visits. Most women preferred LAI ART over daily pills given its benefits, including convenience, privacy, and perceived effectiveness. Future research should incorporate more women into LAI ART trials to better understand and align development with user concerns and preferences to enhance uptake

Interest in Long-Acting Injectable Pre-exposure Prophylaxis (LAI PrEP) Among Women in the Women’s Interagency HIV Study (WIHS): A Qualitative Study Across Six Cities in the United States

Long-acting injectable (LAI) pre-exposure prophylaxis (PrEP) has the potential to facilitate adherence and transform HIV prevention. However, little LAI PrEP research has occurred among women, who face unique barriers. We conducted 30 in-depth interviews with HIV-negative women from 2017–2018 across six sites (New York; Chicago; San Francisco; Atlanta; Washington, DC; Chapel Hill) of the Women’s Interagency HIV Study. Interviews were recorded, transcribed, and analyzed using thematic content analysis. Few women expressed interest in PrEP and when prompted to choose a regimen, 55% would prefer LAI, 10% daily pills, and 33% said they would not take PrEP regardless of formulation. Perceived barriers included: (1) the fear of new—and perceived untested—injectable products and (2) potential side effects (e.g., injection-site pain, nausea). Facilitators included: (1) believing shots were more effective than pills; (2) ease and convenience; and (3) confidentiality. Future studies should incorporate women’s LAI PrEP-related experiences to facilitate uptake

Insurer Views on Reimbursement of Preventive Services in the Dental Setting: Results From a Qualitative Study

Objectives. We explored insurers’ perceptions regarding barriers to reimbursement for oral rapid HIV testing and other preventive screenings during dental care. Methods. We conducted semistructured interviews between April and October 2010 with a targeted sample of 13 dental insurance company executives and consultants, whose firms’ cumulative market share exceeded 50% of US employer-based dental insurance markets. Participants represented viewpoints from a significant share of the dental insurance industry. Results. Some preventive screenings, such as for oral cancer, received widespread insurer support and reimbursement. Others, such as population-based HIV screening, appeared to face many barriers to insurance reimbursement. The principal barriers were minimal employer demand, limited evidence of effectiveness and return on investment specific to dental settings, implementation and organizational constraints, lack of provider training, and perceived lack of patient acceptance. Conclusions. The dental setting is a promising venue for preventive screenings, and addressing barriers to insurance reimbursement for such services is a key challenge for public health policy