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BackgroundLack of a gold standard for latent TB infection has precluded direct measurement of test characteristics of the tuberculin skin test and interferon-γ release assays (QuantiFERON Gold In-Tube and T-SPOT.TB).ObjectiveWe estimated test sensitivity/specificity and latent TB infection prevalence in a prospective, US-based cohort of 10 740 participants at high risk for latent infection.MethodsBayesian latent class analysis was used to estimate test sensitivity/specificity and latent TB infection prevalence among subgroups based on age, foreign birth outside the USA and HIV infection.ResultsLatent TB infection prevalence varied from 4.0% among foreign-born, HIV-seronegative persons aged <5 years to 34.0% among foreign-born, HIV-seronegative persons aged ≥5 years. Test sensitivity ranged from 45.8% for the T-SPOT.TB among foreign-born, HIV-seropositive persons aged ≥5 years to 80.7% for the tuberculin skin test among foreign-born, HIV-seronegative persons aged ≥5 years. The skin test was less specific than either interferon-γ release assay, particularly among foreign-born populations (eg, the skin test had 70.0% specificity among foreign-born, HIV-seronegative persons aged ≥5 years vs 98.5% and 99.3% specificity for the QuantiFERON and T-SPOT.TB, respectively). The tuberculin skin test’s positive predictive value ranged from 10.0% among foreign-born children aged <5 years to 69.2% among foreign-born, HIV-seropositive persons aged ≥5 years; the positive predictive values of the QuantiFERON (41.4%) and T-SPOT.TB (77.5%) were also low among US-born, HIV-seropositive persons aged ≥5 years.ConclusionsThese data reinforce guidelines preferring interferon-γ release assays for foreign-born populations and recommending against screening populations at low risk for latent TB infection.Trial registration number NCT01622140.

In this observational study, we assessed the extent to which a community-created pilot intervention, providing trauma-informed care for persons with HIV (PWH), affected HIV care retention and viral suppression among PWH attending an HIV Services Organization in the Southern US. PWH with trauma exposure and/or trauma symptoms (N = 166) were offered a screening and referral to treatment (SBIRT) session. Per self-selection, 30 opted-out, 29 received SBIRT-Only, 25 received SBIRT-only but reported receiving other behavioral health care elsewhere, and 82 participated in the Safety and Stabilization (S&S) Intervention. Estimates from multivariable logistic regression analyses indicated S&S Intervention participants had increased retention in HIV care (adjusted odds ratio [aOR] 5.46, 95% CI 1.70–17.50) and viral suppression (aOR 17.74, 95% CI 1.83–172), compared to opt-out participants. Some evidence suggested that PTSD symptoms decreased for intervention participants. A randomized controlled trial is needed to confirm findings.

Background Psychological trauma is a highly prevalent driver of poor health among people with HIV in the Southern United States. Trauma-informed care (TIC) has potential to advance national Ending the HIV Epidemic goals, but formative research is needed to tailor TIC implementation to complex and interdependent HIV networks. Methods We applied a community-based participatory research approach to iteratively engage personnel from high-volume HIV care institutions in Nashville, Tennessee. Current practices and potential implementation determinants were identified through participatory process mapping and key informant interviews. The Consolidated Framework for Implementation Research was applied to deductively code interview data. Personnel attending a dissemination summit developed a network-wide implementation plan. Results Data were collected with personnel from five institutions (e.g., community-based organizations, primary care clinics, public health department), via process mapping ( n  = 48), interviews ( n  = 35) and a summit ( n  = 17). Results suggest there are limited trauma screenings, assessments, and services across the network. Relevant Characteristics of Individuals included a trauma-sensitive workforce committed to continuous learning and TIC adoption. Relevant Inner Setting Factors were networks and communications, with strong tension for change, high compatibility with TIC, and need for advancing cultural responsiveness. Relevant Outer Setting Factors included patient needs and resources and cosmopolitanism, with need for better leveraged mental health services. Relevant Process domains were champions and leadership, with need to diversify championship among leaders. Relevant Intervention Characteristics included relative advantage and complexity, with need for personnel wellness initiatives and increased engagement with the community as service designers. Four recommendations included development of shared communication systems, personnel wellness campaigns, routine evaluations to inform practices, and culturally responsive care initiatives. Conclusion Modifiable TIC determinants were identified, and a community-created implementation plan was developed to guide adoption. Future research should focus on city-wide implementation and strengthening pre-implementation research in other settings.

Background Cardiology care may be beneficial for risk factor management in people living with HIV (PLWH), yet limited information is available about the referral process from the perspectives of HIV specialists and cardiologists. Methods We conducted 28 qualitative interviews at academic medical centers in the United States from December 2019 to February 2020 using components of the Specialty Referral Process Framework: referral decision, entry into referral care, and care integration. We analyzed the data using applied thematic analysis. Results Reasons for cardiology referral most commonly included secondary prevention, uncontrolled risk factors, cardiac symptoms, and medication management. Facilitators in the referral process included ease of referral, personal relationships between HIV specialists and cardiologists, and close proximity of the clinic to the patient’s home. Barriers included lack of transportation, transportation costs, insurance coverage gaps, stigma, and patient reluctance. Conclusions Our results will inform future studies on implementation strategies aimed at improving the specialty referral process for PLWH. Trial Registration ClinicalTrials.gov Identifier: NCT04025125 .

Client-level data from two Tennessee-based PrEP navigation demonstration projects reported to the Tennessee Department of Health from January to December 2017 were evaluated to determine the proportion of clients who accepted, were linked to, and were prescribed PrEP. Disparities by age, race, transmission risk, and geographic region as well as trends over time were examined via bivariate and multivariable modified Poisson regression models accounting for potential confounders. Among 1385 PrEP-eligible individuals, 50.5% accepted, 33.4% were linked, and 27.3% were prescribed PrEP. PrEP uptake varied by age, race, and HIV transmission risk, and most disparities persisted across Tennessee throughout evaluation period. Multivariable regression models revealed significant independent associations between age, race/ethnicity, transmission risk, and region and PrEP acceptance and linkage. While differences in PrEP acceptance by race narrowed over time, success among black MSM was limited, underscoring a significant need to improve upstream PrEP continuum outcomes for this important population.

Case Report A man in his 50s with a history of degenerative lumbar-disk and joint disease presented with headache and neck pain that had become progressively worse over the course of 8 days. The associated symptoms included nausea, malaise, fatigue, chills, and decreased appetite. The patient reported no fevers, rash, photophobia, or vision changes. Four weeks before presentation, he had received the latest in a series of epidural injections of methylprednisolone for low back pain. The patient had no history of immunosuppressing conditions and was not taking any additional immunomodulatory medications. Assessment of vital signs on presentation revealed a temperature . . .

Memphis, Tennessee is second in the nation for HIV incidence, with one in three diagnoses among youth. Psychological trauma disproportionately impacts youth with HIV, compared with HIV-negative counterparts, requiring community-led and trauma-informed solutions to address mental wellness among youth with HIV. However, a dearth of research concentrates on trauma-informed care (TIC) for this population, with little exploration among youth-centered HIV care settings or into strategies for mobilizing communities to develop solutions. Research co-production, an approach in which research beneficiaries engage in research as cooperative partners, aligns with the TIC focus on collaborative decision-making and could be an effective strategy for facilitating collaborative TIC adoption, but formative research is needed to explore this potential. We sought to explore TIC implementation determinants and contextual factors that might influence research co-production as a strategy for implementation, including appetite for evidence-based approaches, support for co-production, and resources for capacity building. We applied an exploratory sequential mixed methods design to identify potential barriers and facilitators to TIC implementation in a youth-focused clinic and contextual factors relative to co-production. All clinic personnel were purposively invited to complete semistructured interviews. Thematic analysis, via four cycles of coding, was applied using the Consolidated Framework for Implementation Research 2.0 to qualitative data. Subsequently, a steering committee of clinic personnel was invited to complete surveys, applying the Research Quality Plus for Co-Production framework to explore co-production factors. A deliberative dialog approach was applied to analyze these findings and synthesize them with Consolidated Framework for Implementation Research. A total of 20 personnel completed interviews, and 9 completed surveys. Potential facilitators included perceived clinic cohesiveness, equity focus, and prioritization or compatibility of TIC. Potential barriers included perceived disconnect between the clinic and larger hospital (in which youth with HIV were seen as stigmatized in other areas of the hospital), sustainability concerns related to a perceived lack of championing by leaders, insufficient mental health protocols, a lack of formal patient feedback procedures, and a lack of protected time for personnel activity engagement. Survey responses suggested that the clinic is likely supportive of evidence-based approaches (mean 3.6, SD 0.70) and collaborative research (mean 3.1, SD 0.31) and empowers personnel to participate (mean 3.1, SD 0.22). Conducive to co-production, the environment was seen as learning-centered, where evidence and standardized or validated approaches are prioritized, and there is an openness for innovation, with a focus on health disparities and quality improvement. Potential barriers included change-resistant staff, role silos, and underutilization of staff skills, coupled with a lack of formal research training and time constraints. Findings suggested that TIC implementation is likely to be embraced in the clinic, with co-production perceived as useful and fitting. However, greater effort is needed to integrate patient experiences and test co-production as a TIC implementation strategy.

Studies evaluating the association between human immunodeficiency virus (HIV) infection continuum of care outcomes [antiretroviral (ART) adherence, retention in care, viral suppression] and health literacy have yielded conflicting results. Moreover, studies from the southern United States, a region of the country disproportionately affected by the HIV epidemic and low health literacy, are lacking. We conducted an observational cohort study among 575 people living with HIV (PLWH) at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee). Health literacy was measured using the brief health literacy screen, a short tool which can be administered verbally by trained clinical personnel. Low health literacy was associated with a lack of viral suppression, but not with poor ART adherence or poor retention. Age and racial disparities in continuum of care outcomes persisted after accounting for health literacy, suggesting that factors in addition to health literacy must be addressed in order to improve outcomes for PLWH.

Objectives. To use statewide surveillance data to examine trends and disparities in mortality and progression from HIV to AIDS comprehensively in Tennessee over the past 20 years. Methods. Individuals diagnosed with HIV in Tennessee from 1996 to 2016 were identified through the Tennessee Department of Health Enhanced HIV/AIDS Reporting System. Clinical AIDS and all-cause mortality were the outcomes. Cox regression yielded adjusted hazard ratios (AHRs) for death and competing risk regression yielded adjusted subhazard ratios (SHRs) for AIDS, with death as the competing event. Results. Individuals with a history of heterosexual contact (AHR = 1.20; 95% confidence interval [CI] = 1.12, 1.29) and injection drug use (AHR = 1.27; 95% CI = 1.18, 1.38) had increased hazards of death relative to those with a history of male-to-male sexual contact. Hazards of death were lower among White (AHR = 0.79; 95% CI = 0.73, 0.85) and Hispanic (AHR = 0.50; 95% CI = 0.40, 0.63) individuals than among Black individuals. Those with heterosexual contact (SHR = 1.20; 95% CI = 1.12, 1.29) and injection drug use (SHR = 1.27; 95% CI = 1.18, 1.38) had a greater risk of AIDS than those with male-to-male sexual contact. White individuals (SHR = 0.85; 95% CI = 0.81, 0.90) had a lower risk of AIDS than Black individuals, and female individuals (SHR = 0.84; 95% CI = 0.79, 0.90) had a lower risk than male individuals. Conclusions. The trends, disparities, and outcomes assessed in our study will inform HIV testing and care linkage program design and implementation in Tennessee.

In a latent class analysis of healthcare utilization among 2120 persons with HIV (PWH), PWH who lived in high Social Deprivation Index neighborhoods were more likely to have suboptimal healthcare utilization patterns and less likely to transition to more favorable patterns. Abstract Background We previously identified 3 latent classes of healthcare utilization among people with human immunodeficiency virus (PWH): adherent, nonadherent, and sick. Although membership in the “nonadherent” group was associated with subsequent disengagement from human immunodeficiency virus (HIV) care, socioeconomic predictors of class membership remain unexplored. Methods We validated our healthcare utilization–based latent class model of PWH receiving care at Duke University (Durham, North Carolina) using patient-level data from 2015 to 2018. SDI scores were assigned to cohort members based on residential addresses. Associations of patient-level covariates with class membership were estimated using multivariable logistic regression and movement between classes was estimated using latent transition analysis. Results A total of 1443 unique patients (median age of 50 years, 28% female sex at birth, 57% Black) were included in the analysis. PWH in the most disadvantaged (highest) SDI decile were more likely to be in the “nonadherent” class than the remainder of the cohort (odds ratio [OR], 1.58 [95% confidence interval {CI}, .95–2.63]) and were significantly more likely to be in the “sick” class (OR, 2.65 [95% CI, 2.13–3.30]). PWH in the highest SDI decile were also more likely to transition into and less likely to transition out of the “sick” class. Conclusions PWH who resided in neighborhoods with high levels of social deprivation were more likely to have latent class membership in suboptimal healthcare utilization groupings, and membership persisted over time. Risk stratification models based on healthcare utilization may be useful tools in the early identification of persons at risk for suboptimal HIV care engagement.