Reaching Populations at Risk for HIV Through Targeted Facebook Advertisements: Cost-Consequence Analysis

BackgroundAn undiagnosed HIV infection remains a public health challenge. In the digital era, social media and digital health communication have been widely used to accelerate research, improve consumer health, and facilitate public health interventions including HIV prevention. ObjectiveWe aimed to evaluate and compare the projected cost and efficacy of different simulated Facebook (FB) advertisement (ad) approaches targeting at-risk populations for HIV based on new HIV diagnosis rates by age group and geographic region in the United States. MethodsWe used the FB ad platform to simulate (without actually launching) an automatically placed video ad for a 10-day duration targeting at-risk populations for HIV. We compared the estimated total ad audience, daily reach, daily clicks, and cost. We tested ads for the age group of 13 to 24 years (in which undiagnosed HIV is most prevalent), other age groups, US geographic regions and states, and different campaign budgets. We then estimated the ad cost per new HIV diagnosis based on HIV positivity rates and the average health care industry conversion rate. ResultsOn April 20, 2021, the potential reach of targeted ads to at-risk populations for HIV in the United States was approximately 16 million for all age groups and 3.3 million for age group 13 to 24 years, with the highest potential reach in California, Texas, Florida, and New York. When using different FB ad budgets, the daily reach and daily clicks per US dollar followed a cumulative distribution curve of an exponential function. Using multiple US $10 ten-day ads, the cost per every new HIV diagnosis ranged from US$13.09 to US $37.82, with an average cost of US$19.45. In contrast, a 1-time national ad had a cost of US $72.76 to US$452.25 per new HIV diagnosis (mean US $166.79). The estimated cost per new HIV diagnosis ranged from US$13.96 to US $55.10 for all age groups (highest potential reach and lowest cost in the age groups 20-29 and 30-39 years) and from US$12.55 to US $24.67 for all US regions (with the highest potential reach of 6.2 million and the lowest cost per new HIV diagnosis at US$12.55 in the US South). ConclusionsTargeted personalized FB ads are a potential means to encourage at-risk populations for HIV to be tested, especially those aged 20 to 39 years in the US South, where the disease burden and potential reach on FB are high and the ad cost per new HIV diagnosis is low. Considering the cost efficiency of ads, the combined cost of multiple low-cost ads may be more economical than a single high-cost ad, suggesting that local FB ads could be more cost-effective than a single large-budget national FB ad

Rapid Start of Antiretroviral Therapy in a Large Urban Clinic in the US South: Impact on HIV Care Continuum Outcomes and Medication Adherence

Rapid start of antiretroviral therapy (ART) has been associated with improvement in several HIV-related outcomes in clinical trials as well as demonstration projects, but how regional and contextual differences may affect the effectiveness of this intervention necessitates further study. In this study of a large, urban, Southern US clinic-based retrospective cohort, we identified 544 patients with a new diagnosis of HIV during 2016 to 2019 and compared HIV care continuum outcomes for the first 12 months of care before and after rapid start implementation. Kaplan-Meier time-to-event curves were used to summarize time to virologic suppression, and stepwise Cox, linear, and logistic regression models were used to create multivariate models to evaluate the association between rapid start and time to virologic suppression, medication adherence, and retention in care and sustained virologic suppression, respectively. We found that rapid start was significantly associated with improved medication adherence scores (+15.37 points, 95% confidence interval [CI] 9.36-21.39, P  < .01) and retention in care (adjusted odds ratio = 1.51, 95% CI 1.05-2.19, P  = .03). Time to virologic suppression (median 2.46 months before, 2.56 months after rapid start) and sustained virologic suppression were not associated with rapid start in our setting. Though rapid start was associated with improved medication adherence and retention in care, more support may be needed to achieve the same outcomes seen in other studies and sustained over the entire HIV care continuum, especially in settings with significant patient and systemic barriers to care such as unstable housing, lack of Medicaid expansion, and frequent coverage interruptions

Psychosocial Factors Associated with Problem Drinking Among Substance Users with Poorly Controlled HIV Infection

We aimed to identify psychosocial factors related to problem drinking among patients with poorly controlled human immunodeficiency virus (HIV) infection. We aimed to identify psychosocial factors related to problem drinking among those with poorly controlled HIV infection. Increased levels of interpersonal conflict were associated with greater severity of alcohol problems. Poorer mental health, medical mistrust and less satisfaction with one's physician related to excessive drinking. This secondary analysis used baseline data from a large multisite randomized controlled trial of substance users whose HIV infection was currently poorly controlled, from 11 urban hospitals across the USA. Participants were HIV-infected adult inpatients (n = 801; 67% male, 75% African American) with substance use histories. Participants self-reported on their drinking, perceived health, mental health, social relationships and patient-provider relationship. Structural equation models examined psychosocial factors associated with problem drinking, controlling for demographic covariates. Increased levels of interpersonal conflict were associated with greater severity of alcohol problems. Poorer mental health, medical mistrust and less satisfaction with one's physician were associated with excessive drinking. Several psychosocial factors, including interpersonal conflict, poor mental health (i.e. anxiety, depression and somatization), medical mistrust and less satisfaction with one's provider, were associated with problem drinking among HIV-infected substance users with poorly controlled HIV infection. The co-occurrence of these concerns highlights the need for comprehensive services (including attention to problem drinking, social services, mental health and quality medical care) in this at-risk group

Gonorrhea and Chlamydia Case Detection Increased When Testing Increased in a Multisite US HIV Cohort, 2004–2014

ObjectivesAnnual screening for gonorrhea [Neisseria gonorrhoeae (NG)] and chlamydia [Chlamydia trachomatis (CT)] is recommended for all sexually active persons living with HIV but is poorly implemented. Studies demonstrating no increases in NG and/or CT (NG/CT) case detection in clinics that successfully expanded NG/CT screening raise questions about this broad screening approach. We evaluated NG/CT case detection in the HIV Research Network during 2004-2014, a period of expanding testing.MethodsWe analyzed linear time trends in annual testing (patients tested divided by all patients in care), test positivity (patients positive divided by all tested), and case detection (the number of patients with a positive result divided by all patients in care) using multivariate repeated measures logistic regression. We determined trends overall and stratified by men who have sex with men (MSM), men who have sex exclusively with women, and women.ResultsAmong 15,614 patients (50% MSM, 26% men who have sex exclusively with women, and 24% women), annual NG/CT testing increased from 22% in 2004 to 60% in 2014 [adjusted odds ratio (AOR) per year 1.22 (1.21-1.22)]. Despite the increase in testing, test positivity also increased [AOR per year 1.10 (1.07-1.12)], and overall case detection increased from 0.8% in 2004 to 3.9% in 2014 [AOR per year 1.20 (1.17-1.22)]. Case detection was highest among MSM but increased over time among all 3 groups.ConclusionsNG/CT case detection increased as testing expanded in the population. This supports a broad approach to NG/CT screening among persons living with HIV to decrease transmission and complications of NG/CT and of HIV

Study protocol of a randomized controlled trial comparing two linkage models for HIV prevention and treatment in justice-involved persons

BACKGROUND: Persons involved in the justice system are at high risk for HIV and drug overdose upon release to the community. This manuscript describes a randomized controlled trial of two evidence-based linkage interventions for provision of HIV prevention and treatment and substance use disorder (SUD) services in four high risk communities to assess which is more effective at addressing these needs upon reentry to the community from the justice system. METHODS: This is a 5-year hybrid type 1 effectiveness-implementation randomized controlled trial that compares two models (Patient Navigation [PN] or Mobile Health Unit [MHU] service delivery) of linking justice-involved individuals to the continuum of community-based HIV and SUD prevention and treatment service cascades of care. A total of 864 justice-involved individuals in four US communities with pre-arrest histories of opioid and/or stimulant use who are living with or at-risk of HIV will be randomized to receive either: (a) PN, wherein patient navigators will link study participants to community-based service providers; or (b) services delivered via an MHU, wherein study participants will be provided integrated HIV prevention/ treatment services and SUD services. The six-month post-release intervention will focus on access to pre-exposure prophylaxis (PrEP) for those without HIV and antiretroviral treatment (ART) for people living with HIV (PLH). Secondary outcomes will examine the continuum of PrEP and HIV care, including: HIV viral load, PrEP/ ART adherence; HIV risk behaviors; HCV testing and linkage to treatment; and sexually transmitted infection incidence and treatment. Additionally, opioid and other substance use disorder diagnoses, prescription, receipt, and retention on medication for opioid use disorder; opioid and stimulant use; and overdose will also be assessed. Primary implementation outcomes include feasibility, acceptability, sustainability, and costs required to implement and sustain the approaches as well as to scale-up in additional communities. DISCUSSION: Results from this project will help inform future methods of delivery of prevention, testing, and treatment of HIV, HCV, substance use disorders (particularly for opioids and stimulants), and sexually transmitted infections for justice-involved individuals in the community. TRIAL REGISTRATION: Clincialtrials.gov NCT05286879 March 18, 2022

Clinical and Sociobehavioral Prediction Model of 30-Day Hospital Readmissions Among People With HIV and Substance Use Disorder: Beyond Electronic Health Record Data

Under the Affordable Care Act, hospitals receive reduced reimbursements for excessive 30-day readmissions. However, the Centers for Medicare and Medicaid Services does not consider social and behavioral variables in expected readmission rate calculations, which may unfairly penalize systems caring for socially disadvantaged patients, including patients with HIV. Randomized controlled trial of patient navigation with or without financial incentives in HIV-positive substance users recruited from the inpatient setting at 11 US hospitals. External validation of an existing 30-day readmission prediction model, using variables available in the electronic health record (EHR-only model), in a new multicenter cohort of HIV-positive substance users was assessed by C-statistic and Hosmer-Lemeshow testing. A second model evaluated sociobehavioral factors in improving the prediction model (EHR-plus model) using multivariable regression and C-statistic with cross-validation. The mean age of the cohort was 44.1 years, and participants were predominantly males (67.4%), non-white (88.0%), and poor (62.8%, <$20,000/year). Overall, 17.5% individuals had a hospital readmission within 30 days of initial hospital discharge. The EHR-only model resulted in a C-statistic of 0.65 (95% confidence interval: 0.60 to 0.70). Inclusion of additional sociobehavioral variables, food insecurity and readiness for substance use treatment, in the EHR-plus model resulted in a C-statistic of 0.74 (0.71 after cross-validation, 95% confidence interval: 0.64 to 0.77). Incorporation of detailed social and behavioral variables substantially improved the performance of a 30-day readmission prediction model for hospitalized HIV-positive substance users. Our findings highlight the importance of social determinants in readmission risk and the need to ask about, adjust for, and address them