Implementation of Trauma-Informed Care into Clinical HIV Prevention and Care Settings: A Decade of Limited Progress.

Promotion of Research on the HIV Continuum of Care in the United States: The CFAR HIV Continuum of Care/ECHPP Working Group.

A key limiting factor in the scale up and sustainability of HIV care and treatment programmes is the global shortage of trained health care workers. This paper discusses why it is important to move beyond conceptualising health care workers simply as 'inputs' in the delivery of HIV treatment and care, and to also consider their roles as partners and agents in the process of health care. It suggests a framework for thinking about their roles and responses in HIV care, considers the current evidence base, and concludes by identifying key areas for future research on health care workers' responses in HIV treatment and care in low and middle income settings.

This AIDS supplement brings to the forefront the latest advances in family planning/HIV integration research programs and policy. It also offers insights into strategic directions for future investments in this area. Topics include: biomedical and basic science research on the relationship between reproductive health and HIV transmission and disease behavioral research examining contraceptive practices and fertility choices among women and couples affected by HIV implementation science evaluating integrated service delivery innovations and evidence-based recommendations for programming.

Steffanie Strathdee: “called” to HIV prevention

Understanding Trauma-Informed Care in the PALTC Setting

Trauma-Informed Care in Child Health Systems.

Global Action to reduce HIV stigma and discrimination

Evidence-informed and human rights-based combination prevention combines behavioural, biomedical, and structural interventions to address both the immediate risks and underlying causes of vulnerability to HIV infection, and the pathways that link them. Because these are context-specific, no single prescription or standard package will apply universally. Anchored in 'know your epidemic' estimates of where the next 1000 infections will occur and 'know your response' analyses of resource allocation and programming gaps, combination prevention strategies seek to realign programme priorities for maximum effect to reduce epidemic reproductive rates at local, regional, and national levels. Effective prevention means tailoring programmes to local epidemics and ensuring that components are delivered with the intensity, quality, and scale necessary to achieve intended effects. Structural interventions, addressing the social, economic, cultural, and legal constraints that create HIV risk environments and undermine the agency of individuals to protect themselves and others, are also public goods in their own right. Applying the principles of combination prevention systematically and consistently in HIV programme planning, with due attention to context, can increase HIV programme effectiveness. Better outcome and impact measurement using multiple methods and data triangulation can build the evidence base on synergies between the components of combination prevention at individual, group, and societal levels, facilitating iterative knowledge translation within and among programmes.

In the United States, more than half of the cumulative total of adult male AIDS cases are among men who have sex with men (MSM) (Centers for Disease Control and Prevention [CDC], 2001). Even with an increase in reported AIDS cases among injection drug users (IDUs) and heterosexual men in the past decade, MSM continue to constitute the largest proportion of annually reported AIDS cases in this country. In the most recent CDC report, a total of 31,901 adult male AIDS cases were reported. Of these, the largest proportion of cases (42%) was among MSM compared with 16% among IDUs, 9% among heterosexuals, 5% among MSM IDUs, and 28% whose risk was not reported (CDC, 2001). A similar pattern exists in HIV infection rates among males. Cumulative rates of HIV infection for MSM exceed those of IDUs and heterosexuals (CDC, 2001). Even with new HIV infections, MSM are still the largest subgroup among males (CDC, 2001). In the United States, however, the AIDS epidemic has had a disproportional impact on racial and ethnic populations. Today, it is people of color who carry the burden of this disease. In 2000, for example, the U.S. AIDS rate among non-Hispanic Blacks was 57 per 100,000, among Hispanic/Latinos the rate was 22 per 100,000, among Asian-Pacific Islanders (APIs) the rate was 3 per 100,000, and among Whites the rate was 6 per 100,000 (CDC, 2002; U.S Census Bureau, 2002). As we enter the 3rd decade of this epidemic, MSM of color represent the largest number of persons living with AIDS in this country. In communities of color, the impact of AIDS is even more uneven across ethnic groups in large urban epicenters such as Chicago, Miami, New York, San Francisco, and Los Angeles. In Chicago, for example, HIV disease disproportionately affects non-Hispanic Blacks compared with other ethnic groups. Since 1990, non-Hispanic Blacks have had the highest annual AIDS incidence rates in the city. The most recently reported AIDS rate for non-Hispanic Blacks was 54 per 100,000 compared with 18 per 100,000 for Hispanics/Latinos, and 14 per 100,000 for Whites (Chicago Department of Health, 2002). In other parts of the country, such as Miami, non-Hispanic AIDS Education and Prevention, 15, Supplement A, 1–6, 2003 © 2003 The Guilford Press

Background: Trauma-informed care is increasingly recognized as the ideal model of care for acute psychiatric inpatient units; however, it continues to be a challenge to implement. The aims of this review are (1) to synthesize the research exploring health professionals’ experiences of providing trauma-informed care in acute psychiatric inpatient settings and (2) to examine these experiences through a gender lens, particularly relating to gender-based violence. This research will provide additional insights to facilitate implementation of trauma-informed care in acute psychiatric inpatient care. Method: A comprehensive scoping review methodology was adopted. English-language, peer-reviewed articles published between January 1998 and March 2018 were identified from seven databases. Inclusion criteria included a qualitative or mixed-method study design. Results: Eight full-text articles were found. This review highlights the importance for health professionals to have a reflective environment and a multilayered level of collaboration to adopt trauma-informed care. However, negative attitudes toward female consumers and inconsistent implementation strategies continue to hold back implementation of trauma-informed care in acute psychiatric inpatient units. Overall, limited consideration for gendered issues and gender-based violence in the implementation of trauma-informed care in acute psychiatric inpatient settings was found. Conclusion and Implications: There is a lack of research on health professionals’ experiences of providing trauma-informed care in acute psychiatric inpatient units, with even less research considerating gender-based violence. We argue that more research is needed to gain a better understanding of the experience of health professionals from acute psychiatric inpatient settings to inform future implementation of trauma-informed care.

Engagement and retention in health care is vital to sustained health among people living with HIV (PLWH), yet clinical environments can deter health-seeking behavior, particularly for survivors of interpersonal violence. PLWH face disproportionate rates of interpersonal violence; clinical interactions can provoke a re-experiencing of the sequalae of trauma from violence, called re-traumatization. Trauma-informed care (TIC) is a strengths-based approach to case that minimizes potential triggers of re-traumatization and promotes patient empowerment, increasing acceptability of care. Yet, Ryan White HIV/AIDS clinics, at which over 50% of PLWH received care, have struggled to IMPLEMENT TIC. In this analysis, we sought to (1) identify unique sub-groups of HIV clinics based on clinical attributes (i.e., resources, leadership, culture, climate, access to knowledge about trauma-informed care) and (2) assess relationships between sub-group membership and degree of implementation of TIC and trauma-responsive services offered. A total of 317 participants from 47 Ryan White Federally-funded HIV/AIDS clinics completed a quantitative survey between December 2019 and April 2020. Questions included assessment of inner setting constructs from the Consolidated Framework for Implementation Research (CFIR), perceived level of TIC implementation, and trauma-responsive services offered by each respondent's clinic. We employed latent class analysis to identify four sub-groups of clinics with unique inner setting profiles: Weak Inner Setting (n = 124, 39.1%), Siloed and Resource Scarce (n = 80, 25.2%), Low Communication (n = 49, 15.5%), and Robust Inner Robust (n = 64, 20.2%). We used multilevel regressions to predict degree of TIC implementation and provision of trauma-responsive services. Results demonstrate that clinics can be distinctly classified by inner setting characteristics. Further, inner setting robustness is associated with a higher degree of TIC implementation, wherein classes with resources (Robust Inner Setting, Low Communication) are associated with significantly higher odds reporting early stages of implementation or active implementation compared to Weak class membership. Resourced class membership is also associated with availability of twice as many trauma-responsive services compared to Weak class membership. Assessment of CFIR inner setting constructs may reveal modifiable implementation setting attributes key to implementing TIC and trauma-responsive services in clinical settings. Introduction.

Objectives: To explore the barriers and facilitators from the perspective of family physicians on the implementation of a pilot trauma-informed care (TIC) initiative to promote resilience, with particular emphasis on asking about adverse childhood experiences (ACEs), in a maternity care clinic.Methods: Using an exploratory qualitative design, in-depth semi-structured interviews were conducted with family physicians who were practicing in a maternity clinic in a large Canadian city. Interviews were audio-recorded and transcribed verbatim. Transcripts were reviewed by three coders and themes were extracted using thematic analysis.Results: The analysis of 10 interviews yielded six thematic domains. Three domains pertained to perceived barriers to obtaining an ACEs history including: (1) concern about time management, (2) initial lack of physician comfort with TIC, and (3) cultural limitations of using the ACEs questionnaire. Three themes pertained to perceived facilitators of obtaining an ACEs history including: (1) the importance of a physician champion, (2) a supportive and flexible clinic environment, and (3) improved patient-physician relationships.Implications: In the context of a broader TIC initiative within a maternity care setting, asking patients about ACEs was generally perceived positively by physicians. Ensuring a supportive clinic environment and adequate staff training may be critical factors that contribute to successful implementation. Future research focused on diverse physician experiences in different settings are needed.

HIV care and treatment settings provide an opportunity to reach people living with HIV/AIDS (PLHIV) with prevention messages and services. Population-based surveys in sub-Saharan Africa have identified HIV risk behaviors among PLHIV, yet data are limited regarding HIV risk behaviors of PLHIV in clinical care. This paper describes the baseline sociodemographic, HIV transmission risk behaviors, and clinical data of a study evaluating an HIV prevention intervention package for HIV care and treatment clinics in Africa. The study was a longitudinal group-randomized trial in 9 intervention clinics and 9 comparison clinics in Kenya, Namibia, and Tanzania (N = 3538). Baseline participants were mostly female, married, had less than a primary education, and were relatively recently diagnosed with HIV. Fifty-two percent of participants had a partner of negative or unknown status, 24% were not using condoms consistently, and 11% reported STI symptoms in the last 6 months. There were differences in demographic and HIV transmission risk variables by country, indicating the need to consider local context in designing studies and using caution when generalizing findings across African countries. Baseline data from this study indicate that participants were often engaging in HIV transmission risk behaviors, which supports the need for prevention with PLHIV (PwP).Trial RegistrationClinicalTrials.gov NCT01256463

Tremendous biomedical advancements in HIV prevention and treatment have led to aspirational efforts to end the HIV epidemic. However, this goal will not be achieved without addressing the significant mental health and substance use problems among people living with HIV (PLWH) and people vulnerable to acquiring HIV. These problems exacerbate the many social and economic barriers to accessing adequate and sustained healthcare, and are among the most challenging barriers to achieving the end of the HIV epidemic. Rates of mental health problems are higher among both people vulnerable to acquiring HIV and PLWH, compared with the general population. Mental health impairments increase risk for HIV acquisition and for negative health outcomes among PLWH at each step in the HIV care continuum. We have the necessary screening tools and efficacious treatments to treat mental health problems among people living with and at risk for HIV. However, we need to prioritize mental health treatment with appropriate resources to address the current mental health screening and treatment gaps. Integration of mental health screening and care into all HIV testing and treatment settings would not only strengthen HIV prevention and care outcomes, but it would additionally improve global access to mental healthcare.

To evaluate the initial application of a recently published three-step framework for implementing trauma-informed care (TIC) in a pediatric health care network by applying Framework for Spread. In steps 1 and 2 of the framework, we established commitment from the health care network leadership and initial interest in TIC among clinical providers (step 1), set evidence-based training goals and created the associated TIC training content (step 2). In step 3, 440 health care professionals (from 27 health care teams) participated in single-session, 1-hour training that covered the psychological impact of injury- and illness-related trauma, identification of traumatic stress symptoms, and how to respond to children exposed to potentially traumatic events. A concomitant quality improvement project allowed us to assess potential changes in training participants' favorable attitudes toward the integration of TIC and confidence in delivering TIC. Compared with pretraining, participants demonstrated increases in attitude toward TIC, t(293) = 5.8, P < .001, Cohen's d = 0.32, and confidence in delivering TIC, t(293) = 20.9, P < .001, Cohen's d = 1.09. Trainings were effective in achieving proximal goals targeting attitudes and confidence, thereby demonstrating the feasibility and clinical relevance of TIC training when implemented according to the three-step framework. Future research should examine methods of training to reach wide audiences to promote systematic change and evaluate changes in patient outcomes associated with providers' implementation of TIC.