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Peer interventions have demonstrated efficacy with improving HIV health outcomes. Yet, little is known about factors associated with their uptake into the clinic setting. Three urban sites in the US were funded to adapt, implement and evaluate a peer intervention to improve HIV health outcomes for 173 out of care and newly diagnosed women of color. Peers worked with cis and transgender women of color for four months to achieve the goals of linkage and retention in HIV case management and medical care. Results were 96% of women were linked to medical care, 73% were retained in care and 81% were virally suppressed post 12 months. The average duration of the peer intervention was seven months. Women who received four peer encounters had a 10% increase in retention in care and viral suppression. The findings highlight key elements such as dose and duration of client interaction for peer staff as part of the health care team.

While public and medical perceptions of HIV and those living with HIV have shifted to be more accepting, many individuals still report stigmatizing experiences in clinical and non-clinical settings. Interviews with 40 people living with HIV, homelessness, substance use, and mental illness participating in a patient-centered medical home (PCMH) were conducted in seven sites across the U.S. to assess experiences with stigma in social and clinical spheres. The most salient themes of the study were: 1) how current and past experiences of stigma-in interactions with friends, family, and providers-informed clients' relationships with disclosure, and 2) how, through coordinated and confidential systems of care, the PCMH minimized the necessity to disclose HIV status, thereby reducing the anxiety associated with it.

Community health workers (CHWs) integrated in human immunodeficiency virus (HIV) care teams undertake a variety of tasks to help patients navigate health care, develop care plans, and address social needs. Given the broad role of CHWs in HIV care, we sought to understand which client attributes are associated with various dimensions of CHW satisfaction using a sample of 204 people with HIV (PWH) from various geographic regions across the United States. Multivariable linear regressions were used to determine which client attributes were associated with complete satisfaction with CHWs using 10 validated measures. The mean age of participants was 40.6 years old (SD = 12.8) and over 70% were Black or African American. Adjusted models reveal clients who were female, have marginal health literacy, or have a substance use disorder diagnosis were more likely to not be completely satisfied across multiple dimensions (p ≤ .05). Conversely, being housed and having a mental health diagnosis were associated with being more likely to be completely satisfied (p ≤ .04). Clients’ sociodemographic characteristics and health conditions may be indicative of unique needs, leading to differing expectations of CHWs. CHW training modalities should consider the complex interplay of care needs based upon different client backgrounds and experiences among PWH. Addressing unique needs resulting from social determinants of health and that arise from conditions co-occurring with HIV, such as substance use disorders, should be incorporated into CHW service delivery.

The Trump Administration instituted a series of restrictive policies including the expansion of the public charge ruling, which created barriers to healthcare access for immigrant communities. This study examined immigrants’ knowledge, attitudes, and health-seeking practices as a result of the public charge proposal. Thirty semi-structured interviews were conducted in English or Spanish with foreign-born adults at an urban safety-net hospital in Boston from May 2019 to August 2019. Thematic content analysis identified barriers and facilitators of healthcare access and usage. Approximately half of participants were aware of the public charge proposal. Six participants expressed concern about its implications, but only two discontinued benefits. Barriers to care included fear of deportation, interaction with law enforcement, and competing socioeconomic needs. Facilitators of care included supportive communities, immigrant-friendly environment, and personal beliefs. Hospitals can develop community-centered services for immigrant patients that offset the barriers to healthcare access resulting from adverse federal immigration policies.

Persons living with HIV (PLWH) with socio-economic vulnerabilities are especially vulnerable to HIV stigma and adverse HIV outcomes. Stigma related to HIV may intersect with marginalized socio-economic conditions to negatively affect social networks. HIV stigma may limit the ability of individuals to sustain social relationships. This study examined the potential cross-sectional and longitudinal associations between HIV stigma and the quality and quantity of social networks for PLWH. PLWH (n = 1,082) who were experiencing housing, employment, and medical care-related difficulties were recruited to participate in a one-year navigation and system coordination intervention to improve housing stability and employment. Neither stigma reduction nor social networks were the main components of the intervention. A series of latent growth curves were estimated to assess the cross-sectional and longitudinal relationships among internalized and anticipated HIV stigma and social networks. Anticipated HIV stigma predicted social networks both cross-sectionally and longitudinally. Internalized HIV stigma predicted social networks cross-sectionally but not longitudinally in this population. These data support the HIV Stigma Framework and suggest that anticipated stigma seems to have a strong association with social networks. As anticipated stigma decreases over time, social network scores increase. Interventions to decrease anticipated HIV stigma as a mechanism of improving social networks warrants further investigation.

OBJECTIVE Women of color (WoC) have lower retention in care and higher HIV/AIDS-related morbidity, compared with other populations. Barriers to care include lack of family support, inadequate HIV/AIDS services, and stigma, and women may face greater unmet needs for services including housing and employment. This descriptive study explores the unmet needs of WoC participating in the Health Resources and Services Administration's Special Projects of National Significance (SPNS) Program, Dissemination of Evidence Informed Interventions (HRSA/SPNS DEII) Initiative. SETTING Six urban health clinics across the United States. PARTICIPANTS Eligible participants were cis- or transgender women who were newly diagnosed with HIV/AIDS in the past 12 months, out of care for at least 6 months, or not virally suppressed. Participants enrolled from November 2016 to November 2018. MAIN OUTCOMES Our primary outcome of interest was unmet needs at enrollment for 6 core services: housing, transportation, benefits, mental health or substance use treatment, medication assistance, and medical care. We examined differences in unmet needs stratified by participant characteristics and used multivariate regression to identify the social and health risk factors associated with higher unmet needs. RESULTS Among the 529 WoC, the most frequently reported expressed needs were transportation (50.1%), housing (41.2%), benefits (28.2%), medication assistance (24.5%), and substance use or mental health treatment (24.3%). Participants with a significantly higher number of overall unmet needs included those who were older (40 years or older), were unstably housed, had a history of incarceration, identified as a transgender woman, were US born, had no caregiver responsibilities, and did not have a case manager at enrollment. CONCLUSIONS Our findings indicate the importance of screening for and developing focused strategies to address the unmet needs for WoC if viral suppression is to be achieved.

The study examines the reliability and validity of a 3-item self-report adherence measure among people with HIV (PWH) experiencing homelessness, substance use, and mental health disorders. 336 participants were included from nine sites across the US between September 2013 and February 2017. We assessed the validity of a self-report scale for adherence to antiretroviral therapy by comparing it with viral load (VL) abstracted from medical records at baseline, 6, 12, and 18 months. The items had high internal consistency (Cronbach’s alpha coefficients at each time point were > 0.8). The adherence scale scores were higher in the group that achieved VL suppression compared to the group that did not. The c-statistic for the receiver-operating characteristic curves pooled across time points was 0.77 for each adherence sub-item and 0.78 for the overall score. The self-report adherence measure shows good internal consistency and validity that correlated with VL suppression in homeless populations.

To assess the impact of a Community Health Worker (CHW) intervention within HIV primary care on patient outcomes. We evaluated a 10-site initiative integrating CHWs into HIV care, examining changes...

Background: People with HIV (PWH) have complex needs, and those with limited health literacy consistently have poorer HIV-related knowledge and health outcomes. One strategy to facilitate better outcomes for PWH is the inclusion of community health workers (CHWs) in care teams. This study examines the effect of health literacy on clinical outcomes and utilization of CHW services among PWH enrolled in a CHW intervention. The secondary aim is to characterize most common purposes of CHW encounters. Methods: Individuals (n=209) enrolled in a CHW intervention with completed 6-month follow-up evaluation visits were included. Health literacy level was measured at baseline with the BRIEF tool and categorized into inadequate, marginal, and adequate health literacy. Adjusted logistic regressions assessed the effect of health literacy on viral load suppression, HIV primary care visits at 6-month follow-up, CHW utilization and purpose of CHW encounter. Purpose of CHW encounters included logistical support, accompany to appointment, transportation coordination, concrete services, coaching, and emotional support. Linear regression assessed the association between purpose of CHW encounters and CHW utilization. Results: Individuals with inadequate health literacy were more likely to receive coaching from CHWs, and individuals with marginal health literacy were more likely to have an HIV primary care visit at 6 months. Individuals receiving transportation coordination, concrete services, coaching, and emotional support had more total CHW encounters. Conclusions: PWH often receive coaching from CHWs, particularly those with lower health literacy. The purpose of CHW encounter was associated with frequency of CHW encounters, indicating these types of services require more assistance from CHWs.

Patient navigation is an evidence-based intervention for reducing delays in oncology care among underserved populations. In order to address the financial sustainability of this intervention, information is needed on the cost of implementing patient navigation in diverse healthcare settings. Because patient navigation programs and care settings are highly variable, this paucity of cost data creates difficulties in identifying best practices and decisions about the feasibility of implementing navigation programs within a health care system. One barrier to collecting these cost data is the lack of assessment tools available to support patient navigation programs. These tools must be relevant to the wide variety of navigation activities that exist in health care settings, and be flexible enough to collect cost data important to stakeholders in fee-for-service and value-based care environments.We present a novel approach and methods for assessing the cost of a patient navigation program implemented across six hospital systems to enhance timely entry and uptake of breast cancer care and treatment. These methods and tools were developed in partnership with breast oncology patient navigators and supervisors using principles of stakeholder engagement, with the goal of increasing usability and feasibility in the field.This methodology can be used to strengthen cost analysis and assessment tools for other navigation programs for improving care and treatment for patients with chronic conditions.NCT03514433.

Community health workers (CHWs) are members of the frontline health workforce who serve as intermediaries between health services and communities. In the United States, the role of CHWs has begun to expand as they have been shown to improve outcomes and reduce inequities in care for chronic conditions. This study used qualitative methods to explore the experiences of clients in CHW programs to inform their implementation in HIV care. Thirty clients from 6 Ryan White HIV/AIDS Program care settings across the United States participated in individual semistructured interviews to learn more about their experiences working with a CHW. Four key themes arose from the client perspective. First, CHWs embodied key qualities. Some of the qualities clients attributed to CHWs included being caring and supportive, along with capable of fostering personal connections. Second, CHWs met clients where they were. Clients described the CHW approach as more holistic compared with other care team members; they emphasized CHWs were able to focus on whatever was needed in that moment. Third, CHWs occupied a unique role in the HIV care team. Clients noted CHWs had more time to dedicate to their interactions; they also saw CHWs as representing a different level of authority. Finally, CHWs influenced how clients engaged with care and accessed resources. This included empowering clients to access resources independently in the future. Overall, clients' perceptions of CHWs in terms of their qualities, approach, role, and influence on the HIV care experience suggest they are a valuable resource on the care team.

Peer interventions have demonstrated efficacy with improving HIV health outcomes. Yet, little is known about factors associated with their uptake into the clinic setting. Three urban sites in the US were funded to adapt, implement and evaluate a peer intervention to improve HIV health outcomes for 173 out of care and newly diagnosed women of color. Peers worked with cis and transgender women of color for four months to achieve the goals of linkage and retention in HIV case management and medical care. Results were 96% of women were linked to medical care, 73% were retained in care and 81% were virally suppressed post 12 months. The average duration of the peer intervention was seven months. Women who received four peer encounters had a 10% increase in retention in care and viral suppression. The findings highlight key elements such as dose and duration of client interaction for peer staff as part of the health care team.

Memphis, Tennessee and its surrounding counties have been profoundly affected by the HIV epidemic. Using a participatory research approach this study identified from a community perspective: 1) the barriers and facilitators for providing support to achieve viral suppression to the most at-risk groups living with HIV in the Memphis Transitional Grant Area and 2) opportunities to strengthen the health care system through the use of community health workers (CHWs) to do outreach and engage with people living with HIV. Themes of barriers include intersectional stigma, HIV criminal laws, abstinence-only sex education, housing, transportation, and limited access to HIV case management and mental health services. Strategies to address these barriers included HIV education to youth in schools and community-wide campaigns, more testing sites, involving faith leaders, funding for housing options, innovative transportation services, rapid start of culturally appropriate HIV medical treatment, intensive case management services, and mental health counseling. Two opportunities to utilize CHWs to address the barriers identified in this geographic area are as policy advocates and as an integrated member of the HIV primary care team. The findings of this study can inform a strategy to build the CHW workforce which may have widespread implications for ending the HIV epidemic in this geographic area and across the United States.

Background Community Health Workers (CHWs) have long been integrated in the delivery of HIV care in middle- and low-income countries. However, less is known about CHW integration into HIV care teams in the United States (US). To date, US-based CHW integration studies have studies explored integration in the context of primary care and patient-centered medical homes. There is a need for research related to strategies that promote the successful integration of CHWs into HIV care delivery systems. In 2016, the Health Resources and Services Administration HIV/AIDS Bureau launched a three-year initiative to provide training, technical assistance and evaluation for Ryan White HIV/AIDS Program (RWHAP) recipient sites to integrate CHWs into their multidisciplinary care teams, and in turn strengthen their capacity to reach communities of color and reduce HIV inequities. Methods Ten RWHAP sites were selected from across eight states. The multi-site program evaluation included a process evaluation guided by RE-AIM to understand how the organizations integrated CHWs into their care teams. Site team members participated in group interviews to walk-the-process during early implementation and following the program period. Directed content analysis was employed to examine program implementation. Codes developed using implementation strategies outlined in the Expert Recommendations for Implementing Change project were applied to group interviews (n = 20). Findings Implementation strategies most frequently described by sites were associated with organizational-level adaptations in order to integrate the CHW into the HIV care team. These included revising, defining, and differentiating professional roles and changing organizational policies. Strategies used for implementation, such as network weaving, supervision, and promoting adaptability, were second most commonly cited strategies, followed by training and Technical Assistance strategies. Conclusions Wrapped up in the implementation experience of the sites there were some underlying issues that pose challenges for healthcare organizations. Organizational policies and the ability to adapt proved significant in facilitating CHW program implementation. The integration of the CHWs in the delivery of HIV care requires clearly distinguishing their role from the roles of other members of the healthcare delivery team.

Boston Health Care for the Homeless Program, in Boston, Massachusetts, implemented an intensive telehealth case management intervention combined with emergency financial assistance for 270 homeless-experienced people living with HIV (PLWH) to reduce COVID-19 transmission and promote HIV care retention during Boston’s first pandemic peak (March 16–May 31, 2020). Our telehealth model successfully maintained prepandemic case management and primary care contact levels, highlighting the importance of such programs in supporting the care engagement of homeless-experienced PLWH and addressing the dual COVID-19 and HIV epidemics.

Background: Community Health Workers (CHWs) have long been integrated in the delivery of HIV care, in middle- and low-income countries. However, less is known about CHW integration into HIV care teams in the United States (US). To date, US based CHW integration studies have studies explored integration in the context of primary care and patient-centered medical homes.There is a need for research related to strategies that promote the successful integration of CHWs into HIV care delivery systems. In 2016, the Health Resources and Services Administration HIV/AIDS Bureau launched a three-year initiative to provide training, technical assistance and evaluation for Ryan White HIV/AIDS Program (RWHAP) recipient sites to integrate CHWs into their multidisciplinary care teams, and in turn strengthen their capacity to reach communities of color and reduce HIV inequities. Methods: Ten RWHAP sites were selected from across eight states. The multi-site program evaluation included a process evaluation guided by RE-AIM to understand how the organizations integrated CHWs into their care teams. Site team members participated in group interviews to walk-the-process during early implementation and following the program period. Directed content analysis was employed to examine program implementation. Codes developed using implementation strategies outlined in the Expert Recommendations for Implementing Change project were applied to group interviews (n=20). Findings: Implementation strategies most frequently described by sites were associated with organizational-level adaptations in order to integrate the CHW into the HIV care team. These included revising, defining, and differentiating professional roles and changing organizational policies. Strategies used for implementation, such as network weaving, supervision, and promoting adaptability, were second most commonly cited strategies, followed by training and TA strategies. Conclusions: Wrapped up in the implementation experience of the sites there were some underlying issues that pose challenges for health care organizations. Organizational policies and the ability to adapt proved significant in facilitating CHW implementation. The integration of the CHW role may present an occasion for health care delivery organizations to reassess policies that may unintentionally marginalize communities and both limit career opportunities and patient engagement.

The San Francisco, California–based HIV Homeless-Health Outreach Mobile Engagement (HHOME) program aims to improve health and housing outcomes for multiply diagnosed people experiencing chronic homelessness whom the HIV care system has failed to reach. From 2014 to 2017, HHOME’s mobile multidisciplinary team served 106 clients. Viral suppression increased from 23.6% to 60%, and 73.8% obtained permanent supportive housing (n = 61). System-level changes included the adoption of city-wide standardized acuity assessment tools HIV Care Coordination Taskforce by community partners. This article highlights HHOME’s core components and its public health implications.

Objectives. To examine patterns of and factors associated with housing stability over time among people living with HIV (PLWH) experiencing homelessness with co-occurring substance use and mental health disorders enrolled in a patient-centered medical home (PCMH) intervention. Methods. Between September 2013 and February 2017, we ascertained housing trajectories among PLWH in 9 sites in the United States by conducting interviews at baseline, 6, and 12 months after and dichotomized them as improved consistently versus did not improve consistently. We identified covariates affecting housing stability using the socioecological model. Results. Forty-three percent (n = 198) experienced consistent housing improvement. Participants with history of mental health diagnosis (adjusted odds ratio [AOR] = 1.55; 95% confidence interval [CI] = 1.02, 2.35; P = .04) or trauma (AOR = 1.72; 95% CI = 1.22, 2.41; P = .006) had improved housing status; those with recent injecting drug use (AOR = 0.41; 95% CI = 0.19, 0.90; P = .03) had less consistent housing improvement. Conclusions. Improved housing stability may possibly reflect the importance of PCMH interventions that integrate housing, health, and behavioral services with patient navigators to address complex needs of PLWH experiencing homelessness.

Objectives. To examine the effect of patient navigation models on changes in housing status and its subsequent effects on HIV outcomes for 700 people living with HIV (PLWH) who were unstably housed with co-occurring substance use and psychiatric disorders across 9 demonstration sites in the United States between the years of 2013 and 2017. Methods. Self-reported housing status was collected at baseline, and at 6 and 12 months during the intervention. HIV outcomes included linkage and retention in care, antiretroviral therapy prescription, and viral suppression collected via chart review. Results. In the 12 months after the intervention, 59.6% transitioned to more stable housing. Compared with those who became or remained unstably housed, participants with greater stability achieved significantly higher rates of retention (adjusted odds ratio [AOR] = 2.12; 95% confidence interval [CI] = 1.11, 4.05), were more likely to be prescribed antiretroviral therapy (AOR = 2.06; 95% CI = 1.62, 2.63), and had higher rates of viral suppression (AOR = 1.62; 95% CI = 1.03, 2.55). Conclusions. The use of patient navigators to create a network of services for PLWH who are unstably housed can improve housing stability and lead to improvements in HIV-related outcomes.

Racial/ethnic minorities living with HIV and behavioral health co-morbidities are more likely to be disengaged from HIV primary care. Peer programs have been effective in HIV outreach and prevention but effectiveness of such programs for retention in care and viral suppression is understudied. Subjects (n = 348) were randomized in equal allocation to a peer navigation and education intervention versus standard clinical care at three urban clinics in the United States. The intervention group received seven structured interventions plus weekly contact to address medical and social needs. Primary outcomes included time-to-first 4-month gap in HIV care and viral suppression up to 12 months of follow-up. Intention-to-treat analysis showed no difference between groups on 4-month gap in HIV primary care, but subgroup analysis showed a suggestive effect of the peer intervention in reducing gaps in care among stably housed subjects. Fully compliant subjects in the peer intervention experienced significantly fewer 4-month gaps in HIV primary care (p

Objectives. To assess changes in perceived external stigma among people living with HIV (PLWH) experiencing homelessness or unstable housing diagnosed with mental health or substance use disorders following an intervention including care coordination and navigation assistance, building trusting relationships, addressing unmet needs, and reducing barriers to seeking and engaging in care. Methods. This study was part of a national multisite intervention project delivered at 6 geographically diverse sites throughout the United States from September 2013 through February 2017. Participant surveys were conducted at baseline, 6 months, and 12 months. We assessed perceived external stigma, defined as people’s beliefs about others’ attitudes toward them, related to HIV, homelessness, mental health disorders, and substance use disorders with modified stigma scales. Results. A total of 548 individuals participated. At baseline, more participants reported experiencing any perceived external HIV stigma (81%) than any stigma related to homelessness and mental health or substance use disorders (38.9%). Over time, those reporting any HIV stigma decreased significantly from baseline (81%) to 61.4% and 57.8% at 6 and 12 months, respectively. Conclusions. PLWH experiencing homelessness or unstable housing with mental health or substance use disorders are impacted by multilayered stigma. Interventions to engage them in care may help reduce stigma.

Supplemental Digital Content is Available in the Text., Context: People living with human immunodeficiency virus (HIV) (PLWH) who are most at risk for falling out of HIV primary care and detectable viral loads include homeless and unstably housed individuals and those codiagnosed with behavioral health disorders. The patient-centered medical home (PCMH) is a model that promotes provision of comprehensive, patient-centered, accessible, coordinated, and quality care for patients. This initiative provided patient navigation to HIV-positive homeless and unstably housed individuals codiagnosed with a mental health or substance use disorder as a means to create an adapted PCMH to meet the specific needs of this population. Objective: The purpose of this analysis was to characterize the roles and responsibilities of patient navigators as part of an effort to create a medical home for homeless and unstably housed PLWH with behavioral health comorbidities. Design: Eighty-one in-depth interviews with clinic staff and 2 focus groups with patient navigators were conducted. Content analysis was performed to identify key roles and responsibilities of the patient navigators. Results: Patient navigators played an important role in creating a PCMH by working with clients to schedule and complete appointments, develop comprehensive care plans, forging critical relationships with providers both within and outside of health care systems, providing holistic support to increase patient self-management, and assisting in achieving housing stability. Conclusions: It may be necessary to adapt the traditional PCMH model to effectively meet the social, behavior health, and medical needs of homeless and unstably housed PLWH with behavioral health comorbidities. A patient navigator who can invest time in supporting and connecting these patients to needed services may be a key component in creating an effective PCMH for this population. These findings highlight the roles and tasks of patient navigators that may contribute to developing a PCMH specific to homeless and unstably housed PLWH with mental health and substance use comorbidities. Implementation of such a model has the potential to improve health outcomes (such as retention in care and viral suppression) for particularly vulnerable PLWH and thereby reduce the burden of HIV infection.

Access to oral health care for vulnerable populations is one of the concerns addressed by the U.S. Health Resources and Services Administration HIV/AIDS Bureau's Community-Based Dental Partnership Program (CBDPP). The program introduces dental students and residents at several dental schools to care for vulnerable patients through didactic and clinical work in community-based dental settings. This study of the dental students and residents in this program answered three questions: 1) What are their HIV knowledge, attitudes, and behaviors? 2) How has participation in the CBDPP impacted their knowledge, attitudes, and behaviors? 3) Has the intervention affected their work placement decisions and attitudes after graduation, particularly with respect to treating people living with HIV and other underserved populations? A total of 305 first- through fourth-year dental students and first- and second-year residents at five dental schools across the United States completed surveys before and after a community-based rotation and following graduation. Response rates at each of the five schools ranged from 82.4 to 100 percent. The results showed an increase in the participants' knowledge and positive attitudes regarding treatment for patients with HIV and other vulnerable populations post-rotation compared to pre-rotation. Results after graduation found that most respondents were practicing in private settings or in academic institutions as residents but were willing to treat a diverse patient population. These findings support the role of training programs, such as the CBDPP, for expanding the dental workforce to treating vulnerable populations including people living with HIV/AIDS.

Literature describing the roles and activities of peers working in HIV care is limited. Evaluations of the impact of peer-based behavior-change interventions reveal mixed results, due in part to varied program aims, structure, evaluation mechanisms, and training. Peers themselves are important resources to address these concerns and lay the groundwork for developing improved programs and evaluation strategies. This qualitative article describes peer support in HIV care and treatment from the perspective of 23 HIV-positive peers across the United States. Peers reported that peer characteristics (HIV-status, common experiences, and self-care) enable them to engage clients. Peers also required flexibility to respond to client needs, and their activities spanned four types of social support: informational, emotional, instrumental, and affiliational. We recommend peer programs and evaluations accommodate the broad scope of peer work by acknowledging the need for flexibility and activities that are not always directly related to clients' HIV care and treatment.

Engaging and retaining persons living with HIV/AIDS (PLWHA) in medical care is essential to ensure disease management and successful health outcomes. This article summarizes the results of a qualitative study of 21 staff members from seven programs aimed to engage and retain at-risk PLWHA in HIV medical care. The data revealed five domains of services provided and skills delivered: 1. finding people, 2. delivering services and practical support, 3. assistance with systems navigation and linking to services, 4. providing HIV education and information, and 5. relationship-building. These activities were implemented within a framework of client-centered care and teamwork. These findings can assist program planners and service providers with approaches to enhance staff skills that lead to better quality and service delivery for at-risk PLWHA individuals.

The secondary effect of a national, targeted, outreach initiative in reducing sexual risk behavior among newly diagnosed persons living with HIV/AIDS (PLWHA) was examined in the present study. The findings propose an optimal number of outreach program contacts associated with a change in sexual risk behavior. The primary goal of the initiative was to implement and evaluate strategies to engage and retain underserved populations (PLWHA) in HIV primary medical care. Participants from 10 sites nationwide were enrolled in outreach interventions from 2004 to 2005 that were designed to engage and retain hard-to-reach PLWH in care. The study population in the subanalysis performed was predominantly male, people of color, sexual minorities; mean age of 32, and 31% reported no visits to an HIV health provider since testing positive. The study design was prospective and nonrandomized; 116 newly diagnosed individuals reported on unprotected sex at baseline, 6-, and 12-month interviews. The proportion of individuals reporting unprotected sex postintervention was reduced significantly compared to baseline. Postbaseline, individuals were 80% less likely to report unprotected sex. Additionally, individuals with 1-3 program contacts per month were 80 times less likely to report risky sexual behavior compared to those with 2 or less contacts (adjusted odds ratio [AOR] = 0.20). Substantial risk exists for secondary HIV transmission; this study shows the promise of a supplemental intervention to ensure access to HIV care, retention in care, and risk reduction for positives.

This article examines health literacy among a group a HIV-positive persons at risk for receiving suboptimal health care due to histories of substance abuse, mental illness, incarceration, and unstable housing or homelessness. Participants receiving services from three outreach programs funded as part of a multisite demonstration project were screened for health literacy using the Test of Functional Health Literacy in Adults (TOFHLA) at program enrollment. The goal of this analysis was to identify demographics, risk factors, and health indicators associated with different levels of health literacy. Results indicated that although fewer than 30% of the sample scored in the marginal or inadequate range for health literacy, participants with these lower levels of health literacy were more likely to be African American or Latino/a, heterosexual, speak Spanish as their primary language, and have less than a high school education. The disparities in health literacy found in this study point to a need to assess level of health literacy and provide culturally sensitive health literacy interventions for persons with chronic diseases such as HIV. In addition to offering these services within HIV health care settings, health professionals can use other potential venues for health literacy assessment and intervention including substance abuse treatment and community-based social service, education, and training programs. Health care and support service providers also must become aware of the importance of health literacy when caring for all patients with HIV, particularly those most likely to have low health literacy.

The substance abuse treatment and HIV health care systems have different treatment approaches, and many HIV-infected substance users fall through the cracks between systems. Providers are often challenged by the difficulty of engaging and retaining HIV-infected substance users in care and working across disciplines to coordinate services. A Kaleidoscope of Careis a cross-disciplinary curriculum in HIV and substance use, designed to train HIV health care and substance abuse treatment professionals in providing better care to the clients they share in common. It applies adult learning principles to engage diverse professionals in building skills to promote health and adherence, engagement and retention in care, harm reduction, and interdisciplinary collaboration. Early evaluation of the curriculum indicates that it has enhanced knowledge and built skills in serving HIV-infected substance users among providers from multiple disciplines.

Access to oral health care for vulnerable populations is one of the concerns addressed by the U.S. Health Resources and Services Administration HIV/AIDS Bureau's Community-Based Dental Partnership Program (CBDPP). The program introduces dental students and residents at several dental schools to care for vulnerable patients through didactic and clinical work in community-based dental settings. This study of the dental students and residents in this program answered three questions: 1) What are their HIV knowledge, attitudes, and behaviors? 2) How has participation in the CBDPP impacted their knowledge, attitudes, and behaviors? 3) Has the intervention affected their work placement decisions and attitudes after graduation, particularly with respect to treating people living with HIV and other underserved populations? A total of 305 first- through fourth-year dental students and first- and second-year residents at five dental schools across the United States completed surveys before and after a community-based rotation and following graduation. Response rates at each of the five schools ranged from 82.4 to 100 percent. The results showed an increase in the participants' knowledge and positive attitudes regarding treatment for patients with HIV and other vulnerable populations post-rotation compared to pre-rotation. Results after graduation found that most respondents were practicing in private settings or in academic institutions as residents but were willing to treat a diverse patient population. These findings support the role of training programs, such as the CBDPP, for expanding the dental workforce to treating vulnerable populations including people living with HIV/AIDS.

This qualitative study explored the impact on oral health-care knowledge, attitudes, and practices among 39 people living with HIV/AIDS (PLWHA) participating in a national initiative aimed at increasing access to oral health care. Personal values and childhood dental experiences, beliefs about the importance of oral health in relation to HIV health, and concerns for appearance and self-esteem were found to be determinants of oral health knowledge and practice. Program participation resulted in better hygiene practices, improved self-esteem and appearance, relief of pain, and better physical and emotional health. In-depth exploration of the causes for these changes revealed a desire to continue with dental care due to the dental staff and environmental setting, and a desire to maintain overall HIV health, including oral health. Our findings emphasize the importance of addressing both personal values and contextual factors in providing oral health-care services to PLWHA.

We provide an overview of the Health Resources and Services Administration HIV/AIDS Bureau's Special Projects of National Significance Innovations in Oral Health Care Initiative, describe the models developed by the 15 demonstration sites and associated evaluation center, and present initial descriptive data about the characteristics of the multisite evaluation study sample.Baseline data were collected from May 2007-August 2009 for 2,469 adults living with HIV/AIDS who had been without dental care, except for emergency care, for 12 months or longer. Variables included sociodemographic characteristics, HIV status, medical care, history of dental care and oral health symptoms, oral health practices, and physical and mental health quality of life. Descriptive statistics of baseline variables were calculated.The study sample included 2,469 adults who had been HIV-positive for a decade; most were engaged in HIV care. The majority (52.4%) of patients had not seen a dentist in more than two years; 48.2% reported an unmet oral health-care need since testing positive for HIV, and 63.2% rated the health of their teeth and gums as "fair" or "poor."This study is the largest to examine oral health care among people living with HIV/AIDS in more than a decade. The need for access to oral health care among members of this HIV-positive patient sample is greater than in the general population, following previous trends. Findings from our study reinforce the necessity for continued federal and statewide advocacy and support for oral health programs targeting people living with HIV/AIDS; findings can be extended to other vulnerable populations.