Assessing readiness to implement long-acting injectable HIV antiretroviral therapy: Provider and staff perspectives

Background: Long-acting injectable antiretroviral therapy (LAI-ART) represents the next innovation in HIV therapy. Pre-implementation research is needed to develop effective strategies to ensure equitable access to LAI-ART to individuals living with HIV. Methods: We conducted focus group discussions (FGDs) with providers and staff affiliated with HIV clinics in San Francisco, Chicago, and Atlanta to understand barriers to and facilitators of LAI-ART implementation. Participants also completed a short survey about implementation intentions. FGDs were held via video conference, recorded, transcribed, and thematically analyzed using domains associated with the Consolidated Framework for Implementation Research (CFIR). Results: Between September 2020 and April 2021, we led 10 FDGs with 49 participants, of whom ~60% were prescribing providers. Organizational readiness for implementing change was high, with 85% agreeing to being committed to figuring out how to implement LAI-ART. While responses were influenced by the unique inner and outer resources available in each setting, several common themes, including implementation mechanisms, dominated: (1) optimism and enthusiasm about LAI-ART was contingent on ensuring equitable access to LAI-ART; (2) LAI-ART shifts the primary responsibility of ART adherence from the patient to the clinic; and (3) existing clinic systems require strengthening to meet the needs of patients with adherence challenges. Current systems in all sites could support the use of LAI-ART in a limited number of stable patients. Scale-up and equitable use would be challenging or impossible without additional personnel. Participants outlined programmatic elements necessary to realize equitable access including centralized tracking of patients, capacity for in-depth, hands-on outreach, and mobile delivery of LAI-ART. Sites further specified unknown logistical impacts on implementation related to billing/payer source as well as shipping and drug storage. Conclusions: Among these HIV care sites, clinic readiness to offer LAI-ART to a subset of patients is high. The main challenges to implementation include concerns about unequal access and a recognition that strengthening the clinic system is critical.</p

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

A Qualitative Study Exploring Factors Associated with Retention in HIV Care among Women with HIV in a Large HIV Clinic in Lagos, Nigeria, after Implementing the Test and Treat Policy

Background. In Nigeria, various sociocultural and economic factors may prevent women from being retained in HIV care. This study explores the factors associated with retention in care among women with HIV in a large HIV clinic in Lagos, Nigeria, under the Test and Treat policy. Methods. Women living with HIV/AIDS (n = 24) enrolled in an HIV study at the AIDS Prevention Initiative in Nigeria (APIN) clinic in Lagos, Nigeria, were interviewed from April 1 to October 31, 2021, using a semistructured interview guide. Interviews were audio-taped, transcribed verbatim, and the themes were analyzed using the framework of Andersen and Newman’s Behavioural Model for Healthcare Utilization. Results. The mean age of the respondents was 37.4 ± 9.27 years. The identified themes were as follows: being aware of the antiretroviral medications and their benefits, the household’s awareness of the respondents’ HIV status, and the presence of social support. Other themes were the presence of a dependable source of income and the ability to overcome the challenges encountered in obtaining income, ease of travel to and from the clinic (length of travel time and transportation costs), securing support from the clinic, challenges encountered in the process of accessing care at the clinic, and the ability to overcome these challenges. Also mentioned were self-perception of being HIV positive, motivation to remain in care, linkage to care, and intention to stay in care. Conclusion. Several deterring factors to retention in HIV care, such as nondisclosure of status, absence of social support, and clinic barriers, persist under the Test and Treat policy. Therefore, to achieve the “treatment as prevention” for HIV/AIDS, especially in sub-Saharan Africa, it is essential to employ strategies that address these barriers and leverage the facilitators for better health outcomes among women with HIV/AIDS

Clinic-level complexities prevent effective engagement of people living with HIV who are out-of-care.

Approximately half of people living with HIV (PLWH) in the United States are not retained in HIV care. Although numerous studies have identified individual-level barriers to care (i.e., substance abuse, mental health, housing, transportation challenges), less is known about institutional-level barriers. We aimed to identify clinic-level barriers to HIV care and strategies to address them to better engage PLWH who have been out of care (PLWH-OOC). As part of a larger qualitative study in a Ryan White-funded HIV Clinic in Atlanta, which aimed to understand the acceptance and feasibility of community-based HIV care models to better reach PLWH-OOC, we explored barriers and facilitators of HIV care engagement. From October 2022-March 2023, 18 in-depth-interviews were conducted with HIV-care providers, administrators, social workers, and members of a Community Advisory Board (CAB) comprised of PLWH-OOC. Transcripts were coded by trained team members using a consensus approach. Several clinic-level barriers emerged: 1) the large burden placed on patients to provide proof of eligibility to receive Ryan White Program services, 2) inflexibility of provider clinic schedules, 3) inadequate processes to identify patients at risk of disengaging from care, 4) poorly-resourced hospital-to-clinic transitions, 5) inadequate systems to address primary care needs outside of HIV care, and 6) HIV stigma among medical professionals. Strategies to address these barriers included: 1) colocation of HIV and non-HIV services, 2) community-based care options that do not require patients to navigate complex transportation systems, 3) hospital and community-based peer navigation services, 4) dedicated staffing to identify and support PLWH-OOC, and 5) enhanced systems support to help patients collect the high burden of documentation required to receive subsidized HIV care. Several systems-level HIV care barriers exist and intersect with individual and community-level barriers to disproportionately affect HIV care engagement among PLWH-OOC. Findings suggest several strategies that should be considered to reach the remaining 50% of PLWH who remain out-of-care

Predictors of pain-related functional impairment among people living with HIV on long-term opioid therapy

People living with HIV (PLWH) have high levels of functional impairment due to pain, also called pain interference. Long-term opioid therapy (LTOT) is commonly prescribed for chronic pain among PLWH. We sought to better understand the predictors of pain interference, measured with the Brief Pain Inventory Interference subscale (BPI-I), among PLWH with chronic pain on LTOT. Using a prospective cohort of PLWH on LTOT we developed a model to identify predictors of increased pain interference over 1 year of follow up. Participants (n = 166) were 34% female, 72% African American with a median age of 55 years, and 40% had severe pain interference (BPI-I ≥ 7). In multivariable models, substance use disorder, depressive symptoms, PTSD symptoms, financial instability, and higher opioid doses were associated with increased pain interference. Measures of behavioral health and socioeconomic status had the most consistent association with pain interference. In contrast, the biomedical aspects of chronic pain and LTOT - comorbidities, duration of pain - were not predictive of pain interference. PLWH with chronic pain on LTOT with lower socioeconomic status and behavioral health symptoms have higher risk of pain interference. Addressing the social determinants of health and providing access to behavioral health services could improve patients' pain-related functional status

Are Patients and Their Providers Talking About Long-Acting Injectable Antiretroviral Therapy? Penetration into Clinical Encounters at Three U.S. Care Sites.

Use of long-acting injectable antiretroviral therapy depends on patient awareness, provider discussion, and patient willingness to use. We conducted a postvisit survey with patients at 3 HIV clinics in San Francisco, Chicago, and Atlanta in May 2021 to assess for inequities in these early implementation phases

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

Substance Use Treatment Utilization Among Women With and Without Human Immunodeficiency Virus

Among a cohort of older women with and without HIV, substance use treatment utilization was high, especially with methadone; however, findings suggest opportunities to increase access to substance use treatment in the context of HIV care for women

Substance Use Treatment Utilization Among Women With and Without Human Immunodeficiency Virus

BackgroundSubstance use (SU) contributes to poor health outcomes, yet limited data exist to inform strategies to optimize SU treatment among persons with human immunodeficiency virus (HIV). We describe SU and SU treatment utilization among women with and without HIV in the Women's Interagency HIV Study (WIHS).MethodsWe included data from women enrolled in WIHS from 2013 to 2020. Current SU was self-reported, nonmedical use of drugs in the past year, excluding use of only marijuana. SU treatment utilization was self-reported use of a drug treatment program in the past year. Multivariable regression models were used to investigate associations between participant characteristics and SU treatment.ResultsAmong 2559 women (1802 women living with HIV [WWH], 757 women without HIV), 14% reported current SU. Among those with current SU (n = 367), 71% reported crack/cocaine followed by 40% reporting opioids, and 42% reported any treatment in the past year. The most common treatments were methadone (64%), Narcotics Anonymous (29%), inpatient programs (28%), and outpatient programs (16%). Among women using opioids (n = 147), 67% reported methadone use in the past year compared to 5% using buprenorphine/naloxone. Multivariable analysis showed lower odds of treatment utilization among WWH with concurrent alcohol or marijuana use. Visiting a psychiatrist/counselor was associated with higher odds of treatment. Among WWH, SU treatment was not associated with HIV-related clinical outcomes.ConclusionsTreatment utilization was high, especially for methadone use. Our results highlight opportunities for accessing SU treatment for WWH, such as the need to prioritize buprenorphine and comprehensive, wraparound services in HIV care settings

1574. Co-Utilization of HIV, Substance Use, and Mental Health Services Among Women with Current Substance Use

Abstract Background Integrated HIV, mental health, and substance use (SU) treatment strategies to improve health outcomes among women living with HIV (WWH) are limited. We described co-utilization of HIV, SU, and mental health treatment services among women enrolled in the Women’s Interagency HIV Study (WIHS) who report current SU. Methods We included data from participants enrolled in 10 WIHS sites during their last study visit from 2013-2020. Current SU was defined as self-reported, non-medical use of drugs in the past year, excluding use of only marijuana. We described utilization of each treatment service (SU treatment, HIV care, mental health care, alcohol use treatment, tobacco cessation treatment) by subgroups of participants with current SU and either HIV, depressive symptoms (Center for Epidemiologic Studies–Depression score ≥ 16), heavy alcohol use ( > 7 drinks/week), or current tobacco use. We then compared utilization of services by those who did or did not utilize SU treatment using Chi-square/Fisher exact tests. Results Among women with current SU (n=377), 41.9% reported utilizing SU treatment (Table) and 82.7% receiving any health care. Among women with current SU+HIV (n=233), 86.3% had an HIV healthcare provider visit since last study visit; among current SU+depressive symptoms (n=204), 39.2% had a mental health provider visit since last visit; among current SU+heavy alcohol use (n=87), 23.0% utilized alcohol treatment in the past year; and among current SU+current tobacco use (n=296), 10.1% utilized tobacco cessation treatment in the past year. Among subgroups of women with current SU who were eligible for another service, utilization of other services was significantly higher among those who utilized SU treatment for alcohol and tobacco cessation treatment, but not for any healthcare provider, HIV care, or mental health care provider (Figure). Conclusion Among this sample of WWH with current SU, we found 1) high engagement in SU treatment, and high engagement in health care and HIV care regardless of SU treatment, but 2) low engagement in alcohol and tobacco cessation treatments. Integrated drug, alcohol, and tobacco treatment programs should not be missed opportunities for WWH with concurrent SU, alcohol or tobacco use. Disclosures Cyra Christina Mehta, PhD, MSPH, Merck: Grant/Research Support Ellen Eaton, MD, MPH, Gilead: Grant/Research Support|Gilead: Honorari