Antiretroviral therapy (ART) prevented premature mortality and improved the quality of life among people living with the human immunodeficiency virus (PLWH), such that now more than half of PLWH in the United States are 50 years of age and older. Increased longevity among PLWH has resulted in a significant rise in chronic, comorbid diseases. However, the implementation of guideline-based interventions for preventing, treating, and managing such age-related, chronic conditions among the HIV population is lacking. The PRECluDE consortium supported by the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute catalyzes implementation research on proven-effective interventions for co-occurring heart, lung, blood, and sleep diseases and conditions among PLWH. These collaborative research studies use novel implementation frameworks with HIV, mental health, cardiovascular, and pulmonary care to advance comprehensive HIV and chronic disease healthcare in a variety of settings and among diverse populations.

Background-People living with HIV (PLWH) often experience decreases in HIV viral suppression (VS) after release from jail. The Linking Inmates to Care in LA (LINK LA) peer navigation intervention helped maintain VS 12 months after release from jail compared to standard of care. In this study, we analyzed correlates of substance use and tested whether substance use was an independent correlate of decreased VS in LINK LA participants. Methods: We analyzed LINK LA data collected at baseline, 3, and 12 months. We defined high-risk drug use as any reported methamphetamine, cocaine, or opioid use in the 30 days prior to a study visit (or jail entry at baseline). We used generalized linear mixed models to test associations of sociodemographic variables with type of substance used, and we tested correlates of VS while controlling for time, the intervention, and their interaction. Results: At baseline (n = 356), 71% of participants reported high-risk drug use: 58%, methamphetamine; 17%, cocaine; 7%, heroin; and 4%, prescription opioids. Non-Hispanic Whites and those younger than 35 were most likely to use methamphetamine; Blacks were most likely to use cocaine; people who inject drugs were most likely to use opioids. Participants who used high-risk drugs had 53% lower adjusted odds than non-users of maintaining VS (AOR 0.47, 95% CI 0.31-0.70, p < 0.001). Conclusion: High-risk drug use, dominated by methamphetamine use, independently correlated with decreased VS among recently incarcerated PLWH. Improving HIV care continuum outcomes among populations leaving jail requires attention to efforts to address high-risk drug use.

Background Cardiovascular disease is emerging as a major cause of morbidity and mortality among patients with HIV. We compared use of national guideline‐recommended cardiovascular care during office visits among HIV‐infected versus HIV‐uninfected adults. Methods and Results We analyzed data from a nationally representative sample of HIV‐infected and HIV‐uninfected patients aged 40 to 79 years in the National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey, 2006 to 2013. The outcome was provision of guideline‐recommended cardiovascular care. Logistic regressions with propensity score weighting adjusted for clinical and demographic factors. We identified 1631 visits by HIV‐infected patients and 226 862 visits by HIV‐uninfected patients with cardiovascular risk factors, representing ≈2.2 million and 602 million visits per year in the United States, respectively. The proportion of visits by HIV‐infected versus HIV‐uninfected adults with aspirin/antiplatelet therapy when patients met guideline‐recommended criteria for primary prevention or had cardiovascular disease was 5.1% versus 13.8% (P=0.03); the proportion of visits with statin therapy when patients had diabetes mellitus, cardiovascular disease, or dyslipidemia was 23.6% versus 35.8% (P<0.01). There were no differences in antihypertensive medication therapy (53.4% versus 58.6%), diet/exercise counseling (14.9% versus 16.9%), or smoking cessation advice/pharmacotherapy (18.8% versus 22.4%) between HIV‐infected versus HIV‐uninfected patients, respectively. Conclusions Physicians generally underused guideline‐recommended cardiovascular care and were less likely to prescribe aspirin and statins to HIV‐infected patients at increased risk—findings that may partially explain higher rates of adverse cardiovascular events among patients with HIV. US policymakers and professional societies should focus on improving the quality of cardiovascular care that HIV‐infected patients receive.

In the United States, little is known about interventions that rely on mobile phones and/or text messaging to improve engagement in HIV care for vulnerable populations. Domestic studies using these technologies as part of the National Institute on Drug Abuse "Seek, Test, Treat, Retain" research initiative were queried regarding intervention components, implementation issues, participant characteristics, and descriptive statistics of mobile phone service delivery. Across five studies with 1,135 predominantly male, minority participants, implementation challenges occurred in three categories: (1) service interruptions; (2) billing/overage issues, and; (3) the participant user experience. Response rules for automated text messages frequently frustrated participants. The inability to reload minutes/texting capacity remotely was a significant barrier to intervention delivery. No study encountered confidentiality breaches. Service interruption was common, even if studies provided mobile phones and plans. Future studies should attend to the type of mobile phone and service, the participant user experience, and human subjects concerns.

HIV/AIDS-related stigma is a key factor impeding patient utilization of HIV testing services. To destigmatize HIV testing, the Centers for Disease Control and Prevention recommended an ‘opt-out’ screening strategy aimed at all patients in all clinical settings, regardless of HIV risk. This study assessed whether opt-out screening as compared to opt-in screening was associated with increased uptake of HIV testing among patients with HIV/AIDS-related stigma concerns. This study included 374 patients attending two Los Angeles ambulatory care clinics. Stigma items were grouped into three constructs: Blame/isolation, abandonment, and contagion. Individuals endorsing the blame/isolation subscale (AOR = 0.52; 95 % CI 0.29–0.92; p < 0.05) and abandonment subscale (AOR = 0.27; 95 % CI 0.13–0.59; p < 0.01) were significantly less likely to accept an HIV test. Additionally, the opt-out model did not counter the negative effects of stigma on HIV test acceptance. These findings indicate that stigma remains a barrier to HIV testing, regardless of the opt-out screening approach.

Background: Decade-long delays in successful implementation of Hepatitis B vaccines and ongoing obstacles in HPV vaccine roll-out suggest the importance of an implementation science approach to prepare for the effective translation of future HIV vaccines from clinical trials into routine practice. The objective of this study was to test HIV vaccine attitude items to develop reliable scales and to examine their association with HIV vaccine acceptability.Methods: HIV vaccine attitude items were assessed as part of the LA. VOICES survey, a large-scale study conducted among underserved residents of Los Angeles, to identify factors that may influence HIV vaccine acceptability. Participants (n = 1225) were randomly selected from public STD clinics, needle exchange sites and Latino community clinics using three-stage, venue-based time space sampling.Results: Exploratory factor analysis across 20 items revealed four distinct factors - mistrust, HIV vaccine social concerns, risk compensation, and altruistic vaccination - with acceptable reliability coefficients for each subscale (Cronbach's alpha range 0.61-0.84). We found no significant differences in reliability by gender or by vaccine acceptability. Risk compensation (odds ratio (OR) = 1.49; 95% CI= [1.18, 1.89]; p = 0.001) and altruistic vaccination (OR = 1.40; 95% CI= [1.14, 1.71]; p = 0.001) were significantly and positively associated with HIV vaccine acceptability.Conclusions: We identified four HIV vaccine attitude scales with sound internal reliability parameters. In the aftermath of the first candidate vaccine to demonstrate efficacy against HIV infection, these scales may be helpful in bridging expectable research-to-practice gaps in future HIV vaccine dissemination among populations at risk. As HIV vaccine trials progress in the United States and globally, these measures also may be useful as a tool to assess and facilitate effective responses to community concerns about HIV vaccine trials and to target interventions to support recruitment and mitigate risk compensation. (C) 2014 Elsevier Ltd. All rights reserved.

Compulsory vaccination is a frequently implemented policy option for ensuring comprehensive vaccine coverage. Ongoing controversies around human papillomavirus vaccine dissemination, and suboptimal coverage, suggest the value of assessing acceptability of compulsory vaccinations-particularly among likely target populations-in advance of their public availability to support evidence-informed interventions. With the first HIV vaccine to demonstrate partial efficacy in a large-scale clinical trial, we examined individual characteristics and attitudes associated with support for compulsory HIV vaccination policy among a diverse, representative sample of adults attending probable HIV vaccine dissemination venues in a large urban county. Participants were recruited using three-stage probability sampling from likely venues for future HIV vaccine dissemination. We used Audio-CASI to administer a 60-min structured questionnaire. Items included endorsement of compulsory HIV vaccination policy, sociodemographic characteristics, injecting drug use, vaccine attitudes and perceived HIV risk. Among 1,225 participants (mean age = 36.8 years; 55.6 % males, 37.6 % non-English speaking Hispanic, 78.8 % heterosexual, 25.7 % injection drug users), almost half (48.2 %) endorsed a compulsory HIV vaccination policy. Non-English speaking Hispanics compared to whites, participants with less than high school education, higher positive vaccine attitude scores and higher perceived HIV risk were significantly more likely, and people who inject drugs significantly less likely to endorse compulsory HIV vaccination. Public health interventions to promote positive vaccine attitudes and accurate perceptions of HIV risk among vulnerable populations, and strategies tailored for people who inject drugs, may build support for compulsory HIV vaccination policy and promote broad HIV vaccine coverage.

Objectives: Black men who have sex with men and women (MSMW) experience high HIV rates and may not respond to interventions targeting gay-identified men. We tested the efficacy of the Men of African American Legacy Empowering Self (MAALES), a multisession, small-group holistically framed intervention designed to build skills, address sociocultural issues, and reduce risk behaviors in black MSMW. Design: From 2007 to 2011, we enrolled 437 black MSMW into a parallel randomized controlled trial that compared MAALES to the control condition, a single, individualized HIV risk-reduction session. Methods: Participants completed surveys at baseline, 3 months, and 6 months postintervention. We used multiple regressions to compare risk behaviors at follow-up between the intervention and control groups while adjusting for baseline risk behaviors, time between assessments, other covariates, and clustering. We used inverse probability weighting (IPW) to adjust for loss-to-follow-up while carrying out these regressions with the 291 (76.4%) randomized participants who completed at least one follow-up. Results: Participants were largely low-income (55% reported monthly incomes <$1000); nearly half had previously tested HIV positive. At 6 months of follow-up, unadjusted within-group analyses demonstrated reduced risk behaviors for the MAALES but not the control group. Adjusted results indicated significant intervention-associated reductions in the numbers of total anal or vaginal sex acts [risk ratio = 0.61; 95% confidence interval (CI) 0.49–0.76], unprotected sex acts with women (risk ratio = 0.50; 95% CI 0.37–0.66), and female partners (risk ratio = 0.56; 95% CI 0.44–0.72). Near significant reductions were observed for number of male intercourse partners. Conclusion: The MAALES intervention was efficacious at reducing HIV risk behaviors in black MSMW.

Background: Electronic health record (EHR) systems are often modified through the addition of new features over time. Few studies have examined the specific effects of such changes. We examined whether implementation of a bidirectional laboratory interface for order entry and data reporting within an existing ambulatory EHR would result in more prompt responses to laboratory indications for antiretroviral therapy (ART) changes or in improved communication with HIV+ patients about relevant laboratory results. Methods: We conducted a single-arm intervention study comparing the timeliness of ART regimen changes, HIV viral load (VL) outcomes and patient-reported assessments of care before and after implementation of a laboratory data exchange interface within an existing EHR, without changing the EHR ordering or results reporting user interface. Patient data was extracted from the EHR covering the period from 1 year before to 2 years after the intervention for a cohort of 1181 patients who had received care during the baseline year. The timeliness of ART changes was represented by the days from a laboratory-result "signal" (CD4 dropping below 350 or 200 or VL increasing by a half-log or to a value over 100,000) to an ART-change "response". Patient assessments of care were collected by interviewing 100 anonymous patients at baseline and another 125 at 2 years post-intervention. Results: A total of 171 laboratory "signal" events were followed within 80 days by a change in ART therapy. The mean time from signal to therapy change (adjusted for clustering by patient) initially increased, from 37.7 days during the pre-intervention year to 48.2 days during the quarter immediately following activation of the lab intervention. It then declined to a mean of 31.4 days over the remaining 21 months of observation (P = 0.03 for the 6-day improvement from the pre-period). A majority of patients (65%) achieved undetectable VL values by the end of the observation period; faster signal-response times were not associated with greater achievement of undetectable VL. Patients rated communication about laboratory tests more highly after implementation of the interface (91 vs. 83 on a 100-point scale, P = 0.01); ratings were not higher for other aspects of care. Adding laboratory data exchange interfaces within existing EHRs holds promise for improving HIV care, both in the timeliness of responses to important laboratory results and in the quality of provider communication about lab tests. However, the benefits from this incremental change may be modest unless more extensive redesign of laboratory follow-up workflows is undertaken, with support from enhanced user interfaces that take advantage of the laboratory information delivered. Providers should also consider increased staffing to compensate for dips in follow-up performance during the initial post-implementation months. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

OBJECTIVETo assess HIV vaccine acceptability among high-risk adults in Los Angeles.STUDY SETTINGSexually transmitted disease clinics, needle/syringe exchange programs, Latino community health/HIV prevention programs.STUDY DESIGNCross-sectional survey using conjoint analysis. Participants were randomly selected using three-stage probability sampling.DATA COLLECTIONSixty-minute structured interviews. Participants rated acceptability of eight hypothetical vaccines, each with seven dichotomous attributes, and reported post-vaccination risk behavior intentions.PRINCIPAL FINDINGSParticipants (n=1164; 55.7 percent male, 82.4 percent ethnic minority, mean age=37.4 years) rated HIV vaccine acceptability from 28.4 to 88.6; mean=54.5 (SD=18.8; 100-point scale). Efficacy had the greatest impact on acceptability, followed by side effects and out-of-pocket cost. Ten percent would decrease condom use after vaccination.CONCLUSIONSFindings support development of social marketing interventions to increase acceptability of "partial efficacy" vaccines, behavioral interventions to mitigate risk compensation, and targeted cost subsidies.

US Latino adults are disproportionately affected by the HIV epidemic and experience disparities in access to HIV care. However, relatively little is known about how acculturation affects perceived barriers to engagement in care among Latinos. This article examines factors that may be associated with engaging HIV-infected persons in primary care by using interview data from 651 Latino and non-Latino adults presenting for services at five agencies that participated in a multisite demonstration project Latinos (n=219) were more likely than non-Latino Whites (n=117) to be male, recently diagnosed with HIV, less educated, without health insurance, not on Medicaid, taking HIV medications, and in better physical health. In addition, Latinos were more likely to report facing numerous structural barriers, stigma-related worries/concerns, and belief barriers than were non-Latino Whites. Upon closer examination of the Latino subsample, acculturation (based on language) was associated with reported structural barriers, worry/concern barriers, and belief barriers. In the final multivariate model that controlled for site, Spanish language was significantly associated with experiencing stigma-related worries/concerns that impact HIV status.

OBJECTIVE:To examine whether having a case manager is associated with better physical and mental health scores. BACKGROUND:HIV/AIDS is a condition characterized by a variety of medical and social needs that vary between individuals and over time. Case management has been advocated as a means to improve problems of access, cost and outcomes of HIV/AIDS care. METHODS:We analyzed data from a nationally representative sample of 2,251 HIV-positive persons receiving care in the in the HIV Costs and Services Utilization Study (HCSUS). Participants were interviewed at baseline and approximately 18 months later. Data were collected on use of case management, sociodemographics, antiretroviral therapy and health-related quality of life. We examined bivariate and multivariate associations of case management at baseline with change in self-reported physical health and mental health at follow-up. RESULTS:We found that having contact with a case manager at baseline significantly predicted improvement in physical health (regression coefficient=1.02, p<0.05) among those not receiving HAART. We found no association of case management with mental health among those not receiving HAART and those receiving HAART in multivariate analysis. CONCLUSIONS:Our findings support a beneficial relationship between case managers and physical health for patients with HIV but only among those not already receiving recommended treatment with HAART.

This research brief describes findings from HIV Costs and Services Utilization Study surveys on the prevalence of mental health and substance abuse problems for persons with HIV, access to appropriate care, and ability to adhere to treatment.

Approximately 28% of HIV-infected people in treatment in the United States report using illicit drugs. Illicit drug users have poorer course of HIV disease than non-drug users, which is thought to be due to their irregular use of HIV medical services. We examined associations between type (cocaine versus opioids) and pattern of drug use (drug use at baseline, 6-month follow-up, both periods, and nonuse) and health care utilization for a large sample of HIV-infected individuals drawn from a multisite project that evaluated the impact of medical outreach interventions for populations at risk of poor retention in HIV care. Across all types and patterns of drug use, drug users were more likely to have suboptimal ambulatory care, miss scheduled appointments, use the emergency department, have unmet support services needs, and were less likely to take antiretroviral medications. Additionally, while people who started using drugs during the follow-up period and consistently used drugs across both periods differed from nonusers on missed appointments (odds ratio [OR] = 2.20 for starters versus nonusers, OR = 2.92 for consistent users versus nonusers), emergency department use (OR = 4.93 for starters versus nonusers, OR = 2.24 for consistent users versus nonusers), and antiretroviral medication use at follow-up (OR = 0.23 starters versus nonusers, OR = 0.19 for consistent users versus nonusers), those who stopped using drugs after the baseline period did not differ from nonusers. We conclude that health care utilization is poorer for people who use illicit drugs than those who do not, and stopping drug use may facilitate improvements in health care utilization and HIV outcomes for this population.

To benefit from HIV treatment advances individuals must utilize ambulatory primary care services. Few studies focus on marginalized populations, which tend to have poor health care utilization patterns. This study examined factors associated with health care utilization in hard-to-reach marginalized HIV-infected individuals. As part of a multisite initiative evaluating outreach programs that target underserved HIV-infected individuals, 610 participants were interviewed about their HIV disease, health services utilization, substance use, mental health, and case management. Primary outcomes included ambulatory, emergency department, and inpatient visits. Generalized estimating equations were used in logistic regression analyses. On regression analyses ambulatory visits were associated with having insurance (adjusted odds ratio [AOR] = 2.46), mental health medications (AOR = 7.46), and case management (AOR = 4.81). Emergency department visits were associated with having insurance (AOR = 1.74), homelessness (AOR = 2.23), poor health status (AOR = 2.02), length of HIV infection (AOR = 2.02), mental health care (AOR = 1.47), mental health medications (AOR = 1.59), and heavy alcohol intake (AOR = 1.46). Hospitalizations were associated with high school education (AOR = 1.57), having insurance (AOR = 10.45), homelessness (AOR = 2.18), poor health status (AOR = 2.64), length of HIV infection (AOR = 2.03), and mental health medications (AOR = 1.87). In hard-to-reach marginalized HIV-infected individuals, having insurance, case management and mental health care were associated with increased ambulatory visits. These findings support HIV multidisciplinary care with marginalized populations. Understanding factors associated with health care utilization is essential for outreach programs to facilitate engagement in HIV care.