HIV Primary Care Research Articles

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions.

IntroductionLittle is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.MethodsData were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient‐reported outcomes and measures (PROs) of syndemic conditions – depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use – were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.ResultsPatients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within‐patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between‐syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).ConclusionsEstimated HIV transmissions among PLWH receiving care in well‐resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.

HIV-Adapted Group Prenatal Care: Assessing Viral Suppression and Postpartum Retention in Care.

Viral suppression and postpartum retention in care have far-reaching health implications for pregnant women living with HIV and their children, yet remain public health challenges. Prenatal care presents a unique opportunity to engage pregnant women in care. The purpose of this study is to evaluate whether group prenatal care is effective in impacting these outcomes for pregnant women living with HIV. A retrospective cohort study was performed of all women living with HIV who obtained prenatal care from a community-based health center between 2013 and 2019. Women who spoke English or Spanish, remained within the system, and had not participated in group prenatal care previously were included. Women self-selected a prenatal care model: 85 selected group care and 109 elected individual care. Group prenatal care followed a standard Centering Pregnancy® curriculum with the addition of HIV-related topics. The primary outcomes of the study were viral suppression (viral load <20 copies/mL) and postpartum retention in care (attending at least one or two visits with HIV primary care within 12 months postpartum). After adjusting for potential confounding factors, women who participated in group prenatal care were significantly more likely to have at least one HIV primary care visit postpartum {adjusted odds ratio (aOR) = 2.71 [95% confidence interval (CI 1.14-6.46)]; p = 0.024}, and had a trend for achieving viral suppression by the time of delivery [aOR = 2.29 (95% CI 0.94-5.55); p = 0.068]. We have demonstrated that group prenatal care for pregnant women living with HIV is feasible and effective, with positive impacts on retention in care and viral suppression, factors that affect long-term outcomes from patients living with HIV.

Application of the Consolidated Framework for Implementation Research to Facilitate Delivery of Trauma-Informed HIV Care.

The high prevalence of trauma and its negative impact on health among people living with HIV underscore the need for adopting trauma-informed care (TIC), an evidence-based approach to address trauma and its physical and mental sequelae. However, virtually nothing is known about factors internal and external to the clinical environment that might influence adoption of TIC in HIV primary care clinics. We conducted a pre-implementation assessment consisting of in-depth interviews with 23 providers, staff, and administrators at a large urban HIV care center serving an un-/under-insured population in the southern United States. We used the Consolidated Framework for Implementation Research (CFIR) to guide qualitative coding to ascertain factors related to TIC adoption. Inner setting factors perceived as impacting TIC adoption within HIV primary care included relative priority, compatibility, available resources, access to knowledge and information (ie, training), and networks and communications. Relevant outer setting factors included patient needs/resources and cosmopolitanism (ie, connections to external organizations). Overall, the HIV care center exhibited high priority and compatibility for TIC adoption but displayed a need for system strengthening with regard to available resources, training, communications, cosmopolitanism, and patient needs/resources. Through identification of CFIR inner and outer setting factors that might influence adoption of TIC within an HIV primary care clinic, our findings begin to fill key knowledge gaps in understanding barriers and facilitators for adopting TIC in HIV primary care settings and highlight implementation strategies that could be employed to support successful TIC implementation.

Practice Transformation in HIV Primary Care: Perspectives of Coaches and Champions in the Southeast United States

Introduction/Objectives:Across the United States, and particularly in the South, there is an urgent need to improve health outcomes for people with HIV. In response, the Southeast AIDS Education & Training Center (AETC) conducted a 4-year Practice Transformation (PT) initiative (2015-2018) in 12 mostly primary care clinics across 4 states in the region. Drawing on the leadership of PT facilitators (“coaches”) from AETC partner sites throughout the region and specific clinic staff members (“champions”), clinics worked toward self-selected organizational goals to increase their HIV care capacity and improve HIV health outcomes.Methods:To explore coaches’ and champions’ experiences and perspectives of PT, we conducted 2 focus group sessions, 1 tailored for coaches (n = 5) and another for champions (n = 9).Results:Content analysis of qualitative data revealed 4 major themes around coaches’ and champions’ experiences and perspectives of PT. These themes include Challenges, Facilitators, Successes, and Suggestions for PT Improvement.Conclusion:Primary care and infectious diseases/HIV clinics can help improve HIV Care Continuum outcomes through increasing their capacity to serve the needs of their clients, as facilitated through coaches and clinic champions. Since no single clinic or clinic patient population is alike, it is important work within organizations to address specific needs and leverage unique skillsets. Future PT initiatives can learn from experiences of this PT program to optimize the effectiveness of their programs.

Evaluation of a Training Intervention to Improve Kaposi Sarcoma Care in Zimbabwe: A Prospective Community-Based Stepped-Wedge Cluster Randomised Trial

Background: Most Zimbabweans access medical care through tiered health systems, with decentralized HIV care and centralized oncology care. Local health centre staff are trained in ART administration but not in AIDS-associated Kaposi sarcoma (AIDS-KS) diagnosis or management. To improve AIDS-KS prognoses, interventions on screening, diagnosis, and treatment must be integrated into primary HIV care settings. We conducted a community-based randomized step-wedge cluster trial for a package of KS care training interventions. Methods: Interventions intended to improve KS detection and management included a standardized KS clinical evaluation tool, palliative care integration, standardized treatment, and improved consultative services. Interventions were evaluated at eight Zimbabwe primary HIV care sites by monitoring KS diagnoses and outcomes, including early diagnosis (T0 vs T1 tumor stage), patient retention, and mortality. Analyses controlled for within clinic correlations. Findings: 1102 suspected KS patients (96% HIV+) were enrolled: 47% newly diagnosed, 20% previously diagnosed, and 33% determined as not KS (incorrectly diagnosed). Diagnosis at T0 stage increased post-intervention, though not significant statistically (adjusted odds ratio (aOR)=1·48 (95% confidence interval (95%CI):0·66-3·79);p=0·37). New KS diagnosis rates increased 103% (95%CI:11%-273%);p=0·02) post-intervention, with parallel increased odds of incorrect diagnosis (aOR=2·08 (95%CI:0·33-3·24);p=0·001). Post-intervention, non-significant changes in 90-day return rates (adjusted hazard ratio (aHR)=0·69 (95%CI:0·38-1·45);p=0·21) and survival (aHR=1·36 (95%CI:0·85-2·20);p=0·20) were estimated. Interpretation: KS training interventions increased overall and incorrect KS diagnosis, but not early KS diagnosis, 90-day return rates, or survival at HIV primary care sites. Approaches to increase KS diagnosis accuracy in low-resource settings are needed. Trial Registration: Study design details are available at ClinicalTrials.gov NCT01764360. Funding: Funding was provided by the National Cancer Institute, National Institutes of Health: grant 1R01CA172050. Declaration of Interest: None to declare. Ethical Approval: The study was approved by the institutional review boards of Zimbabwe (Medical Research Council of Zimbabwe, MRCZ), University of Colorado Anschutz Medical Campus (COMIRB), and the Joint Parirenyatwa Hospital and University of Zimbabwe College of Health Sciences Research Ethics Committee (JREC).

Diagnostic aspects and in-service training in the decentralization of care to people living with HIV.

To analyze the perception of nurses on the decentralization of care to people living with HIV. Exploratory, descriptive, qualitative study conducted with primary health care nurses based on Imogene King's Open Systems Theory (personal, interpersonal, and social). The data were obtained through interviews; a sociodemographic/professional questionnaire and a semi-structured script were employed, processed by the IRAMUTEQ software and analyzed through Descending Hierarchical Classification. Study participants amounted to 32 nurses. Five classes emerged from the analysis: "diagnostic revelation process"; "professional training"; "preventive measures"; "barriers and potentials in the process of decentralization"; and "stigma and prejudice". In the process of reorganization of the healthcare model for people living with HIV in primary health care, an important contribution by nurses in strengthening the local healthcare decentralization was identified.

1117. An HIV Primary Care Rotation Improved HIV and STI Knowledge, Enhanced Sexual History-Taking Skills, and Increased Interest in a Career in Infectious Diseases among Medical Students and Residents

BackgroundClinical rotations in HIV primary care provide a unique opportunity to teach trainees about the management of HIV and other sexually transmitted infections (STI), and enhance trainees’ skills in obtaining a culturally-competent sexual history. Positive educational experiences in this setting may also influence trainees’ decisions to pursue a career in HIV Medicine and Infectious Diseases (ID). However, little is known about the impact of an HIV clinic rotation on trainees’ fund of knowledge regarding HIV and STI management, confidence in obtaining a sexual history, or interest in HIV and ID as a career choice.MethodsThird year medical students and Internal Medicine residents rotate for two to four weeks in UCSD’s HIV primary care clinic. Over a six month period (September, 2019 - February, 2020) trainees were given a pre and post rotation survey to evaluate their fund of knowledge in managing patients with HIV and other STIs, their confidence in taking a sexual history, and their interest in pursuing a career in HIV and ID.ResultsTwenty-one of the 31 trainees completed both the pre- and post-rotation survey. Residents and medical students comprised 57% (12) and 43% (9) of the cohort, respectively. Fund of knowledge regarding antiretroviral management, HIV transmission, and STI diagnosis and treatment improved following the rotation (Figure. 1). Trainees’ confidence in their ability to manage patients with HIV and obtain a sexual history also improved (Figure. 2). Importantly, there was a substantial increase in the proportion of trainees interested in pursuing a career in HIV and ID after the rotation compared to beforehand (Figure. 2).Fund of Knowledge Pre and Post Rotation Self-Perceived Competency and Interest in HIV Clinical Care ConclusionClinical rotations in HIV primary care provide valuable learning experiences for trainees by improving their fund of knowledge about HIV and STIs, and their self-efficacy in obtaining a sexual history. These clinical experiences may also be important in recruiting trainees to pursue a career in HIV and ID. Given the importance of these clinical skills and the need to increase the number of trainees entering the field, additional support for educational experiences in HIV primary care clinics is warranted.Disclosures All Authors: No reported disclosures

1025. Integrating buprenorphine into an urban HIV primary care practice: Outcomes on viral load suppression and opioid use

BackgroundOpioid use disorder (OUD) is a correlate of poorer HIV outcomes among people with HIV (PWH). Research has shown promising results for buprenorphine (BUP), a medication for OUD, integrated into HIV primary care. In this study, we explored the effect of BUP on HIV outcomes in a cohort of PWH with OUD in Newark, New Jersey.MethodsWe performed a retrospective chart review of PWH on BUP attending the Rutgers NJMS Infectious Diseases Practice from January 2017 to June 2019 (n=91, median age 56, 59% male, 84% Black, median follow-up 1.5 years). Outcomes were suppressed HIV viral load measurements (VLS) or urine drug screening results (UDS). We analyzed data using descriptive statistics and multivariate logistic regression, which modeled associations of VLS or UDS with demographic, comorbid (substance use, chronic pain, HCV, psychiatric diagnosis), and social (insurance, employment, housing) factors. Results presented as odds ratio; 95% confidence interval.Results55% (n=46) of patients demonstrated BUP adherence (> 50% positivity on serial UDS) and 61% (n=51) had ongoing opioid use. Patients with a UDS positive for opioids (primarily opiates) were more likely to have other substance co-positivity on UDS (5.4; 4.0-7.3, p < 0.001), to be employed (5.4; 2.7-10.7, p=0.01), and enrolled in Medicaid (4.6; 2.5-8.5, p=0.01); and less likely to have BUP positive UDS (0.067; 0.050-0.088, p < 0.001). Conversely, BUP positive UDS was negatively associated with the presence of other substances (0.55; 0.44-0.70, p=0.01) and history of alcohol use (0.56; 0.40-0.79, p=0.05), controlling for concurrent opioid positivity and baseline VLS. At baseline, 39% (n=32) of patients did not have VLS; at 1 year follow-up, one-third (n=11) achieved new-onset suppression. VLS during follow-up was positively associated with BUP adherence (2.9; 1.2-7.1, p=0.02) and VLS at baseline (17.0; 10.4-27.8, p < 0.001), and negatively associated with housing insecurity (0.28; 0.15-0.52, p=0.04).ConclusionIntegration of BUP for OUD into HIV primary care led to a decrease in opioid use and improved outcomes in HIV care. Multidisciplinary approaches addressing other substance use and social services may help achieve even greater progress in ending the dual epidemics of HIV and OUD.Disclosures All Authors: No reported disclosures

541. Rapid Migration to Telemedicine in a Boston Community Health Center is Associated with Maintenance of Effective Engagement in HIV Care

BackgroundThe COVID-19 pandemic has disrupted many health care activities. The impact of the pandemic on HIV primary care in a Boston community health center (CHC) that has specialized HIV, sexual and gender minority care is analyzed here.MethodsThe CHC has used the Centricity Practice SolutionTM electronic medical record (EMR) system since 1997. The current analyses used data abstracted from the EMR, testing for significant differences in HIV care utilization using the Student t-test for means and chi-square tests for proportions.ResultsThere were 2,016 HIV+ patients among 25,606 patients (7.9%) engaged in primary care in 2019. In 2019, HIV+ patients had between 563 and 689 in-person visits per month. On average, monthly visits for HIV care increased (p< 0.0001) in the first two months of 2020 (mean=626, sd=60.1) compared to 2019 (mean=617, sd=40.6), but dropped to 370 and 36 in person visits by HIV+ patients in March and April 2020 respectively (mean=203, sd=236.2; p< 0.0001), when statewide stay-at-home policies were recommended. There were 263 telemedicine visits by HIV+ patients in March and 751 in April, 2020. When telemedicine and in-person visits were combined, mean number of visits per month by HIV+ patients were higher compared to the same two-month period in 2019 (p< .0001). The mean number of plasma HIV RNA viral load (VL) tests performed each month was 279 in 2019 (range 257–312, sd=18.3), versus 219 in March and 274 in April 2020 (mean=246.5, sd=38.9; p< 0.0001). Among those tested, monthly rates of virological suppression ranged from 71–81% in 2019, with 11–20% having VL < 100 copies/ml. Eighty percent had an undetectable VL as their last measurement in 2019; an additional 14% had last VL detectable but < 100 copies/ml. In March and April, 2020, the rates of VL suppression were 77% and 74% and 14% and 18% had VL detectable but < 100 copies/ml, respectively (p=0.209).ConclusionThe COVID-19 pandemic has led to a significant decrease in in-person visits by HIV+ and other patients at a Boston CHC, but with a rapid migration to the use of telemedicine, patient engagement, as expressed by visits and VL suppression does not appear to be adversely affectedDisclosures All Authors: No reported disclosures

Pragmatic randomized trial of a pre-visit intervention to improve the quality of telemedicine visits for vulnerable patients living with HIV

Introduction The COVID-19 pandemic has required a shift of many routine primary care visits to telemedicine, potentially widening disparities in care access among vulnerable populations. In a publicly-funded HIV clinic, we aimed to evaluate a pre-visit phone-based planning intervention to address anticipated barriers to telemedicine. Methods We conducted a pragmatic randomized controlled trial of patients scheduled for a phone-based HIV primary care visit at the Ward 86 HIV clinic in San Francisco from 15 April to 15 May 2020. Once reached by phone, patients were randomized to either have a structured pre-visit planning intervention to address barriers to an upcoming telemedicine visit versus a standard reminder call. The primary outcome was telemedicine visit attendance. Results Of 476 scheduled telemedicine visits, 280 patients were reached by a pre-visit call to offer enrollment. Patients were less likely to be reached if virally unsuppressed (odds ratio (OR) 0.11, 95% confidence intervals (CI) 0.03–0.48), CD4 < 200 (OR 0.24, 95% CI 0.07–0.85), or were homeless (OR 0.24, 95% CI 0.07–0.87). There was no difference between intervention and control in scheduled visit attendance (83% v. 78%, OR 1.38, 95% CI 0.67–2.81). Conclusions A structured phone-based planning call to address barriers to telemedicine in a public HIV clinic was less likely to reach patients with poorly-controlled HIV and patients experiencing homelessness, suggesting additional interventions may be needed in this population to ensure access to telemedicine-based care. Among patients reachable by phone, telemedicine visit attendance was high and not improved with a structured pre-visit intervention, suggesting that standard reminders may be adequate in this population.

A mobile health intervention in HIV primary care: supporting patients at risk for ART non-adherence

Mobile health (mHealth) interventions that are integrated in HIV clinical settings to facilitate ongoing patient-provider communication between primary care visits are garnering evidence for their potential in improving HIV outcomes. Rango is an mHealth intervention to support engagement in HIV care and treatment adherence. This study used a single-arm prospective design with baseline and 6-month assessments for pre-post comparisons, as well as a matched patient sample for between-group comparisons to test Rango’s preliminary efficacy in increasing viral suppression. The Rango sample (n = 406) was predominantly 50 years of age or older (63%; M = 50.67; SD = 10.97, 23–82), Black/African-American (44%) or Hispanic/Latinx (38%), and male (59%). At baseline, 18% reported missing at least one dose of ART in the prior three days and chart reviews of recent VL showed that nearly 82% of participants were virally suppressed. Overall 95% of the patients enrolled in Rango returned for a medical follow-up visit. Of the 65 unsuppressed patients at baseline who returned for a medical visit, 38 (59%) achieved viral suppression and only 5% of the suppressed group at baseline had an increase in viral load at 6 months despite being at risk for ART non-adherence. While viral suppression was similar between Rango participants and patients receiving treatment as usual over the same time period, it is unknown whether those patients were similarly at risk for non-adherence. Our findings support efforts to formally test this innovative approach in addressing ART non-adherence and viral suppression particularly to reach HIV treatment goals.

Viral suppression during COVID-19 among people with HIV experiencing homelessness in a low-barrier clinic-based program.

Coronavirus disease-2019 (COVID-19) threatens to further worsen HIV outcomes among people experiencing homelessness. We conducted an interrupted time-series analysis of care engagement and viral suppression among unhoused individuals in the 'POP-UP' low-barrier, high-intensity HIV primary care program during COVID-19. Among 85 patients, care engagement and viral suppression did not decrease in the 5 months following implementation of San Francisco's 'shelter-in-place' ordinance. Low-barrier, in-person HIV care for homeless individuals may be important for maintaining HIV outcomes during COVID-19.

The HIV care cascade in Manitoba, Canada: Methods, measures, and estimates to meet local needs

Background and ObjectiveWe describe the development of the first HIV care cascade for Manitoba, Canada, detailing steps taken to establish indicator definitions for each cascade step, and derive a full complement of local estimates. MethodsManitoba is a Canadian Prairie Province with disproportionately high annual HIV incidence. In 2013, a clinical cohort of people living with HIV was established within the primary HIV care program in Manitoba. Using cohort data from 2017, we describe the creation of a set of indicator definitions and calculate estimates for each cascade step to create the first Manitoban cascade model. ResultsOf the 703 cohort participants categorized as alive and diagnosed, 638 (90.8%) were in care, 606 (86.2%) retained in care, 573 (81.5%) on treatment, and 523 (74.4%) virologically suppressed. The greatest point of leakage occurred between the first and second steps; 9.3% of those alive and diagnosed in 2017 were not in care in the same calendar year. ConclusionThis is the first comprehensive examination of HIV clinical epidemiology in Manitoba using a cascade framework, with the potential inform programming to improve service coverage within Manitoba and significantly contribute to evidence informing provincial policies to support these efforts.

The relationship between sex-related alcohol expectancies and hazardous drinking among persons with HIV disease

ABSTRACT Hazardous drinking is a clinically significant problem among persons with HIV (PWH) disease, and is associated with a number of poor outcomes. Hazardous drinking among PWH is associated with risky substance use and sexual behavior, but little work has examined factors that may be associated with greater hazardous drinking and subsequent risky sexual behaviors among PWH. Research among the general population suggests that sex-related alcohol expectancies, defined as drinking to enhance sexual experience, increase sexual risk-taking, and disinhibition of sexual behavior, are associated with greater hazardous alcohol use and risky sexual behavior, but these relations have not been explored among PWH. Therefore, the current study examined the associations of sex-related alcohol expectancies with hazardous alcohol consumption, dependence, and problems among 146 PWH (Mage = 50.99, SD = 9.41) \\ enrolled in a clinical trial examining a personalized feedback intervention to reduce hazardous drinking in primary HIV care. Results showed that only sexual disinhibition-related alcohol expectancies were significantly associated with the criterion variables, such that greater drinking alcohol for sexual disinhibition was associated with greater hazardous drinking behaviors. These results sit on the backdrop of a larger literature documenting the links between disinhibition and hazardous alcohol use and provide explanatory specificity to PWH who are hazardous drinkers.

"En la Lucha": Strategies to Improve HIV Care for Puerto Ricans with Opioids Use Disorders.

BackgroundClínica Bienestar is a comprehensive HIV primary care clinic for Spanish-speaking Latinx with opioids use disorders (OUD). This article describes the barriers and trajectories to HIV viral suppression for Puerto Ricans with a transnational profile and dual diagnoses (HIV and OUD), and the strategies applied to increase retention in care.MethodsCase study methodology was used to select two patient life histories that illustrate the most common pathways to success in reducing HIV viral load to undetectable and achieving OUD long-term recovery.Results and DiscussionPatients’ major challenges included: (1) Persistent migrating while seeking substance use treatment services with limited or no support from their sending and hosting communities; (2) Intersectional stigmas; (3) Untreated trauma; (4) Language and cultural barriers. Clínica Bienestar’s service model included ten strategies to retain patients in care (e.g., Case management to identify cases with high social isolation), six emerged as central to addressing transnational challenges.

The reliability, validity and factorial structure of the Swahili version of the 7-item generalized anxiety disorder scale (GAD-7) among adults living with HIV from Kilifi, Kenya

BackgroundGeneralized Anxiety Disorder (GAD) is under-investigated in people living with HIV/AIDS from sub-Saharan Africa. In part, this is due to paucity of culturally appropriate measures for GAD which are psychometrically robust. This study aimed to evaluate the reliability, factorial structure, and validity of Swahili version of the 7-item GAD questionnaire (GAD-7) among adults living with HIV.Study designDescriptive cross-sectional study.Methods450 adults receiving comprehensive care from an HIV specialized clinic in Kilifi County, coastal Kenya, were consecutively recruited. Swahili versions of GAD-7, Patient Health Questionnaire (PHQ-9) and a 12-item HIV stigma scale were administered alongside measures of psychosocial and health-related characteristics. Internal consistency, test–retest reliability, factorial structure, convergent validity, and discriminant validity of Swahili GAD-7 were examined using Cronbach’s alpha (α), intra-class correlation coefficient (ICC), Confirmatory Factor Analysis (CFA), Pearson’s correlation, and analysis of covariance (ANCOVA), respectively.ResultsInternal consistency of Swahili GAD-7 was good, α = 0.82 (95% CI 0.78, 0.85). Its test–retest reliability (2 weeks apart) was acceptable, ICC = 0.70 (95% CI 0.55, 0.81). A confirmatory analysis of a one-factor solution indicated an excellent fit to the hypothesized structure (RMSEA = 0.00 [95% confidence interval 0.00, 0.05], CFI = 1.00, TLI = 1.00). Multi-group CFA substantiated factorial invariance for sex and age for the one-factor structure of Swahili GAD-7. Scores of GAD-7, Swahili version, significantly correlated with those of PHQ-9 (r = 0.73; p < 0.001) and the HIV stigma scale (r = 0.36; p < 0.001) suggesting good convergent validity. Statistically significant differences were observed between participants on first-line antiretroviral therapy compared to those on second-line treatment (F [1, 441] = 5.55, p = 0.02) indicative of good discriminant validity of Swahili GAD-7.ConclusionGAD-7 Swahili version retained its original unidimensional latent structure with good psychometric properties among adults living with HIV from Kilifi, Kenya. It can be used to identify symptoms of GAD in similar research settings. However, to confidently identify those in need of mental health treatment or referral services in HIV primary care clinics, more research on the validity of Swahili GAD-7 is needed especially its discriminant validity and diagnostic accuracy at different cut-off scores.

Pathways to housing stability and viral suppression for people living with HIV/AIDS: Findings from the Building a Medical Home for Multiply Diagnosed HIV-positive Homeless Populations initiative.

People with HIV with co-occurring substance use and mental health diagnoses who are unstably housed have poorer outcomes for retention in care and viral suppression. Navigation models are a potential strategy to help this vulnerable population obtain the necessary medical and non-medical services across multiple service systems. The Health Resources and Services Administration's Special Projects of National Significance: "Building a Medical Home for Multiply-Diagnosed HIV-positive Homeless Populations initiative 2012-2017 found that navigation models may be an effective intervention to support people with HIV with unstable housing improve HIV health outcomes. However, there is limited information about the mechanisms by which this intervention works. In this article, we explore the participant and program factors for achieving stable housing at 6 months and how these factors influence HIV health outcomes. This was a prospective study of 471 unstably housed people with HIV enrolled in a navigation intervention across nine sites in the United Stated from 2013-2017. All sites provided HIV primary medical care. Eight sites were located in urban areas and one site served a predominantly rural population. Two sites were federally qualified health centers, three were city or county health departments, one site was a comprehensive HIV/AIDS service organization, and three sites were outpatient or mobile clinics affiliated with a university -based or hospital system. Data were collected via interview and medical chart review at baseline, post 6 and 12 months. Type and dose of navigation activities were collected via a standardized encounter form. We used a path analysis model with housing stability at 6 months as the mediator to examine the direct and indirect effects of participant's socio-demographics and risk factors and navigation on viral suppression and retention in care at 12 months. Housing stability at 6 months was associated with male gender, younger age, viral suppression at baseline, having a lower risk for opiate use, recent homelessness, lower risk of food insecurity, and a longer length of time living with HIV. Participants who increased self-efficacy with obtaining help by 6 months had significantly higher odds of achieving housing stability. Stable housing, fewer unmet needs, moderate to high risk for opiate use, and viral suppression at baseline had a direct effect on viral suppression at 12 months. The intensity of navigation contact had no direct effect on housing stability and a mixed direct effect on viral suppression. Recent diagnosis with HIV, women, greater social support, increased self-efficacy and higher intensity of navigation contact had a direct effect on improved retention in HIV primary care at 12 months. In this sample of people with HIV who are experiencing homelessness, housing stability had a significant direct path to viral suppression. Navigation activities did not have a direct effect on the path to housing stability but were directly related to retention in care. These results identify key populations and factors to target resources and policies for addressing the health and social unmet needs of people with HIV to achieve housing stability and HIV health outcomes.

Measuring the Effects of Childhood Trauma in HIV Primary Care

This quality improvement pilot screened 60 people living with HIV for childhood trauma using the Adverse Childhood Experience (ACE) questionnaire. Antiretroviral adherence and substance use were compared between 2 ACE scoring groups 0 to 3 and 4 to 10, because scoring 4 and higher reflects complex trauma. Higher ACE scores correlated with increased substance use and suboptimal antiretroviral adherence. This project supports the need for childhood trauma screening and implementation of a trauma-informed approach to care.

A Nurse-Led Initiative to Improve Implementation of HIV Preconception Care Services.

United States guidelines recommend preconception care (PCC) as an integral part of primary care to improve maternal and fetal/newborn outcomes and promote planned pregnancies. Persons living with HIV have additional, specialized needs for PCC. However, PCC is not reliably integrated in HIV care, and few studies have examined strategies to improve the provision of PCC services. We describe a successful, nurse-led initiative that incorporated collaborative strategic planning in conjunction with staff education and continuous quality improvement to strengthen implementation of PCC in a small urban HIV care clinic. Key features of this project included consensus building, training, and action planning with clinic staff; addressing clinic-specific barriers; and providing ongoing support/technical assistance. Continuous quality improvement reviews at 12, 18, and 36 months demonstrated improved and sustained implementation of PCC services for women and men. Our experiences serve as a model for HIV primary care clinics working to advance implementation of PCC services.

The role of dermatology in Kaposi sarcoma diagnosis across 3 regions in sub-Saharan Africa

Kaposi sarcoma (KS) remains a highly incident and morbid cancer across sub-Saharan Africa.1 KS diagnosis requires multidisciplinary coordination between dermatology, oncology, and HIV departments, which makes patients vulnerable to care coordination gaps.2 Although KS diagnosis ideally requires skin biopsy followed by prompt pathologic confirmation, in resource-limited settings, KS is often diagnosed clinically or is subject to delays in pathologic diagnosis.2,3 To better understand the role of dermatology in KS diagnosis and multidisciplinary care coordination, we conducted chart reviews and site assessments to evaluate the care cascade of patients with KS at 3 HIV primary care networks in southern, eastern, and western Africa.