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The HIV preexposure prophylaxis optimization intervention (PrEP-OI) study evaluated the efficacy of a panel management intervention using PrEP coordinators and a web-based panel management tool to support healthcare providers in optimizing PrEP prescription and ongoing PrEP care.The PrEP-OI study was a stepped-wedge randomized clinical trial conducted across 10 San Francisco Department of Public Health primary care sites between November 2018 and September 2019. Each month, clinics one-by-one initiated PrEP-OI in random order until all sites received the intervention by the study team.The primary outcome was the number of PrEP prescriptions per month. Secondary outcomes compared pre- and postintervention periods on whether PrEP was discussed and whether PrEP-related counseling (e.g., HIV risk assessment, risk reduction counseling, PrEP initiation/continuation assessment) was conducted. Prescription and clinical data were abstracted from the electronic health records. We calculated incidence rate ratios (IRR) and risk ratios (RR) to estimate the intervention effect on primary and secondary outcomes.The number of PrEP prescriptions across clinics increased from 1.85/month (standard deviation [SD] = 2.55) preintervention to 2.44/month (SD = 3.44) postintervention (IRR = 1.34; 95% confidence interval [CI] = 1.05-1.73; P = 0.021). PrEP-related discussions during clinic visits (RR = 1.13; 95% CI = 1.04-1.22; P = 0.004), HIV risk assessment (RR = 1.40; 95% CI = 1.14-1.72; P = 0.001), and risk reduction counseling (RR = 1.16; 95% CI = 1.03-1.30; P = 0.011) increased from the pre- to the postintervention period. Assessment of PrEP initiation/continuation increased over time during the postintervention period (RR = 1.05; 95% CI = 0.99-1.11; P = 0.100).A panel management intervention using PrEP coordinators and a web-based panel management tool increased PrEP prescribing and improved PrEP-related counseling in safety-net primary care clinics.

HIV stigma is comprised of several beliefs, including transmission fears and moral judgments against affected communities. We examined the relationships among HIV-related stigma beliefs, endorsement of coercive measures for people living with HIV (PLWH), and intentions to discriminate. We sought to understand to what degree the different stigma beliefs shape support for restrictive policies and discriminatory intentions. Data were drawn from the baseline assessment of DriSti, a cluster randomized controlled trial of an HIV stigma reduction intervention in Indian healthcare settings (NCT02101697). Participants completed measures assessing transmission fears and moral judgments of HIV, endorsement of coercive measures against PLWH (public disclosure of HIV status, refusal of healthcare services, marriage and family restrictions, required testing, and sharing of HIV information in a clinic), and intentions to discriminate against PLWH in professional and personal settings. We utilized multivariate regression modeling with backward elimination to identify the coercive measures and behavioral intentions most strongly associated with moral judgments. 1540 ward staff members completed the assessment. Participants had relatively high perceptions of transmission fears (M = 1.92, SD = 0.79) and moral judgments (M = 1.69, SD = 0.83); endorsed more intentions to discriminate in professional (M = 6.54, SD = 2.28) than personal settings (M = 2.07, SD = 1.49), and endorsed approximately half of all coercive measures (M = 9.47, SD = 2.68). After controlling for transmission fears, perceptions of stronger moral judgments against PLWH were significantly associated with higher endorsement of coercive measures related to refusing services (β = 0.10, t = 4.14, p β = 0.07, t = 3.04, p = 0.002), as well as with stronger behavioral intentions to discriminate in professional settings (β = 0.05, t = 2.20, p = 0.022). HIV stigma interventions for hospital-based ward staff in India need to focus on both transmission fears and moral judgments that underlie prejudicial beliefs. While the moral judgments are not technically related to risk in a hospital setting, our findings suggest that personnel will continue to discriminate in their professional work so long as these beliefs bear on their decisions and actions.

We examine the efficacy of short message service (SMS) and SMS with peer navigation (SMS + PN) in improving linkage to HIV care and initiation of antiretroviral therapy (ART).I-Care was a cluster randomized trial conducted in primary care facilities in North West Province, South Africa. The primary study outcome was retention in HIV care; this analysis includes secondary outcomes: linkage to care and ART initiation.Eighteen primary care clinics were randomized to automated SMS ( n = 7), automated and tailored SMS + PN ( n = 7), or standard of care (SOC; n = 4). Recently HIV diagnosed adults ( n = 752) were recruited from October 2014 to April 2015. Those not previously linked to care ( n = 352) contributed data to this analysis. Data extracted from clinical records were used to assess the days that elapsed between diagnosis and linkage to care and ART initiation. Cox proportional hazards models and generalized estimating equations were employed to compare outcomes between trial arms, overall and stratified by sex and pregnancy status.Overall, SMS ( n = 132) and SMS + PN ( n = 133) participants linked at 1.28 [95% confidence interval (CI): 1.01-1.61] and 1.60 (95% CI: 1.29-1.99) times the rate of SOC participants ( n = 87), respectively. SMS + PN significantly improved time to ART initiation among non-pregnant women (hazards ratio: 1.68; 95% CI: 1.25-2.25) and men (hazards ratio: 1.83; 95% CI: 1.03-3.26) as compared with SOC.Results suggest SMS and peer navigation services significantly reduce time to HIV care linkage in sub-Saharan Africa and that SMS + PN reduced time to ART initiation among men and non-pregnant women. Both should be considered candidates for integration into national programs.NCT02417233, registered 12 December 2014; closed to accrual 17 April 2015.

Travelers may adapt HIV risk-reduction practices based on perceived destination-specific norms. We examined the association between perceived condom norms and condomless anal sex (CAS) during international and domestic travel and in the home environment among men who have sex with men. Men who traveled internationally in the past 12 months were recruited by respondent-driven sampling (N = 501). Not knowing destination-specific condom norms was significantly associated with less CAS during international travel and in the home environment but not during domestic travel. Perceiving home environment condom norms to expect use of condoms was significantly associated with less CAS during domestic but not international travel. Men were less likely to engage in CAS during international travel when destination-specific condom norms were unknown. Unfamiliarity with the environment and culture may influence some men to refrain from higher-risk behaviors. During domestic travel, some men appeared to apply home environment condom norms, which may be erroneous in some situations and pose an HIV risk.

The global effort to end the Severe Acute Respiratory Syndrome - Coronavirus 2 pandemic has resulted in the development of multiple highly efficacious vaccines1 at an unprecedented speed. Despite an at times rocky roll out, several high-income countries are soon likely to find themselves in a situation in which supply exceeds demand. However, we are also seeing the consequences of vaccine inequities and of the inconsistent use of multiple nonpharmaceutical prevention strategies. Between May and July 2021, India, with a

Visible signs of disease can evoke stigma while stigma contributes to depression and mental illness, sometimes manifesting as somatic symptoms. We assessed these hypotheses among Ebola virus disease (EVD) survivors, some of whom experienced clinical sequelae. Ebola virus disease survivors in Liberia were enrolled in an observational cohort study starting in June 2015 with visits every 6 months. At baseline and 18 months later, a seven-item index of EVD-related stigma was administered. Clinical findings (self-reported symptoms and abnormal findings) were obtained at each visit. We applied the generalized estimating equation method to assess the bidirectional concurrent and lagged associations between clinical findings and stigma, adjusting for age, gender, educational level, referral to medical care, and HIV serostatus as confounders. When assessing the contribution of stigma to later clinical findings, we restricted clinical findings to five that were also considered somatic symptoms. Data were obtained from 859 EVD survivors. In concurrent longitudinal analyses, each additional clinical finding increased the adjusted odds of stigma by 18% (95% CI: 1.11, 1.25), particularly palpitations, muscle pain, joint pain, urinary frequency, and memory loss. In lagged associations, memory loss (adjusted odds ratio [AOR]: 4.6; 95% CI: 1.73, 12.36) and anorexia (AOR: 4.17; 95% CI: 1.82, 9.53) were associated with later stigma, but stigma was not significantly associated with later clinical findings. Stigma was associated with select symptoms, not abnormal objective findings. Lagged associations between symptoms and later stigma substantiate the possibility of a pathway related to visible symptoms identified by community members and leading to fear of contagion.

Author(s): Steward, Wayne T; Agnew, Emily; de Kadt, Julia; Ratlhagana, Mary Jane; Sumitani, Jeri; Gilmore, Hailey J; Grignon, Jessica; Shade, Starley B; Tumbo, John; Barnhart, Scott; Lippman, Sheri A | Abstract: IntroductionFew interventions have demonstrated improved retention in care for people living with HIV (PLHIV) in sub-Saharan Africa. We tested the efficacy of two personal support interventions - one using text messaging (SMS-only) and the second pairing SMS with peer navigation (SMS+PN) - to improve HIV care retention over one year.MethodsIn a cluster randomized control trial (NCT# 02417233) in North West Province, South Africa, we randomized 17 government clinics to three conditions: SMS-only (6), SMS+PN (7) or standard of care (SOC; 4). Participants at SMS-only clinics received appointment reminders, biweekly healthy living messages and twice monthly SMS check-ins. Participants at SMS+PN clinics received SMS appointment reminders and healthy living messages and spoke at least twice monthly with peer navigators (PLHIV receiving care) to address barriers to care. Outcomes were collected through biweekly clinical record extraction and surveys at baseline, six and 12nmonths. Retention in HIV care over one year was defined as clinic visits every three months for participants on antiretroviral therapy (ART) and CD4 screening every six months for pre-ART participants. We used generalized estimating equations, adjusting for clustering by clinic, to test for differences across conditions.ResultsBetween October 2014 and April 2015, we enrolled 752 adult clients recently diagnosed with HIV (SOC: 167; SMS-only: 289; SMS+PN: 296). Individuals in the SMS+PN arm had approximately two more clinic visits over a year than those in other arms (pnln0.01) and were more likely to be retained in care over one year than those in SOC clinics (54% vs. 38%; OR: 1.77, CI: 1.02, 3.10). Differences between SMS+PN and SOC conditions remained significant when restricting analyses to the 628 participants on ART (61% vs. 45% retained; OR: 1.78, CI: 1.08, 2.93). The SMS-only intervention did not improve retention relative to SOC (40% vs. 38%, OR: 1.12, CI: 0.63, 1.98).ConclusionsA combination of SMS appointment reminders with personalized, peer-delivered support proved effective at enhancing retention in HIV care over one year. While some clients may only require appointment reminders, the SMS+PN approach offers increased flexibility and tailored, one-on-one support for patients struggling with more substantive challenges.

Background In the United States, patients with HIV face significant barriers to linkage to and retention in care which impede the necessary steps toward achieving the desired clinical outcome of viral suppression. Individual-level interventions, such as patient navigation, are evidence based, effective strategies for improving care engagement. In addition, use of surveillance and clinical data to identify patients who are not fully engaged in care may improve the effectiveness and cost-effectiveness of these programs. Methods and findings We employed a pre-post design to estimate the outcomes and costs, from the program perspective, of 5 state-level demonstration programs funded under the Health Resources and Services Administration’s Special Projects of National Significance Program (HRSA/SPNS) Systems Linkages Initiative that employed existing surveillance and/or clinical data to identify individuals who had never entered HIV care, had fallen out of care, or were at risk of falling out of care and navigation strategies to engage patients in HIV care. Outcomes and costs were measured relative to standard of care during the first year of implementation of the interventions (2013 to 2014). We followed patients to estimate the number and proportion of additional patients linked, reengaged, retained, and virally suppressed by 12 months after enrollment in the interventions. We employed inverse probability weighting to adjust for differences in patient characteristics across programs, missing data, and loss to follow-up. We estimated the additional costs expended during the first year of each intervention and the cost per outcome of each intervention as the additional cost per HIV additional care continuum target achieved (cost per patient linked, reengaged, retained, and virally suppressed) 12 months after enrollment in each intervention. In this study, 3,443 patients were enrolled in Louisiana (LA), Massachusetts (MA), North Carolina (NC), Virginia (VA), and Wisconsin (WI) (147, 151, 2,491, 321, and 333, respectively). Patients were a mean of 40 years old, 75% male, and African American (69%) or Caucasian (22%). At baseline, 24% were newly diagnosed, 2% had never been in HIV care, 45% had fallen out of care, and 29% were at risk of falling out of care. All 5 interventions were associated with increases in the number and proportion of patients with viral suppression [percent increase: LA = 90.9%, 95% confidence interval (CI) = 88.4 to 93.4; MA = 78.1%, 95% CI = 72.4 to 83.8; NC = 47.5%, 95% CI = 45.2 to 49.8; VA = 54.6, 95% CI = 49.4 to 59.9; WI = 58.4, 95% CI = 53.4 to 63.4]. Overall, interventions cost an additional $4,415 (range = $3,746 to $5,619), $2,009 (range = $1,516 to $2,274), $920 (range = $627 to $941), $2,212 (range = $1,789 to $2,683), and $3,700 ($2,734 to $4,101), respectively per additional patient virally suppressed. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess patients against themselves at baseline and not against standard of care during the same time period. Conclusions Patient navigation programs were associated with improvements in engagement of patients in HIV care and viral suppression. Cost per outcome was minimized in states that utilized surveillance data to identify individuals who were out of care and/or those that were able to identify a larger number of patients in need of improvement at baseline. These results have the potential to inform the targeting and design of future navigation-type interventions., Starley Shade and co-workers study outcomes and costs associated with interventions seeking to improve engagement with HIV care in the United States., Author summary Why was this study done? ➢ The Health Resources and Services Administration’s Special Projects of National Significance Program (HRSA/SPNS) funded an initiative that implemented 5 state-level interventions which used existing surveillance and/or clinical data to identify individuals who had never entered HIV care, had fallen out of care, or were at risk of falling out of care and navigation strategies to engage patients in HIV care. ➢ This study estimates the outcomes and incremental costs of these 5 state-level interventions relative to the standard of care provided prior to implementation of the interventions. What did researchers do and find? ➢ We estimated the additional cost of interventions during the first year of implementation (2013 to 2014). Among HIV–infected patients who enrolled in each intervention during the first year of implementation, we estimate how much the number and proportion of patients with viral suppression increased from before to up to 12 months after enrollment in the intervention. Then, we estimated the additional cost per additional patient with viral suppression for each intervention. ➢ We found that these interventions had similar or lower costs than similar previous interventions ($223 to $3,631 per patient), were associated with larger increases in the proportion of patients with viral suppression than similar previous interventions (47.5% to 90.9% increase in proportion of patients with viral suppression), and had similar or lower costs per additional patient with viral suppression compared to similar previous interventions ($920 to $4,415 per additional patient with viral suppression). What do these findings mean? ➢ These results show that using existing data to identify HIV–infected patients who are out of care and patient navigation to link, reengage, or retain patients in care is associated with increased viral suppression and had similar costs per outcome compared to patient navigation alone. These results also showed that use of surveillance data to identify HIV–infected patients who are out of care does not increase costs and may improve the cost per outcome of these interventions. ➢ This study did not include a contemporaneous comparison group. Therefore, we do not know the degree to which patients would have engaged or reengaged in care and achieved viral suppression due to other changes in care that occurred during the first year of implementation of the intervention.

Background The US National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined cost-effectiveness from the health system perspective of 6 health information technology (HIT) interventions implemented during 2008 to 2012 in a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program demonstration project. Methods/findings HIT interventions were implemented at 6 sites: Bronx, New York; Durham, North Carolina; Long Beach, California; New Orleans, Louisiana; New York, New York (2 sites); and Paterson, New Jersey. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records (EHRs) to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. We employed standard microcosting techniques to estimate costs (in 2018 US dollars) associated with intervention implementation. Data from a sample of electronic patient records from each demonstration site were analyzed to compare prescription of antiretroviral therapy (ART), CD4 cell counts, and suppression of viral load, before and after implementation of interventions. Markov models were used to estimate additional healthcare costs and quality-adjusted life-years saved as a result of each intervention. Overall, demonstration site interventions cost $3,913,313 (range = $287,682 to $998,201) among 3,110 individuals (range = 258 to 1,181) over 3 years. Changes in the proportion of patients prescribed ART ranged from a decrease from 87.0% to 72.7% at Site 4 to an increase from 74.6% to 94.2% at Site 6; changes in the proportion of patients with 0 to 200 CD4 cells/mm3 ranged from a decrease from 20.2% to 11.0% in Site 6 to an increase from 16.7% to 30.2% in Site 2; and changes in the proportion of patients with undetectable viral load ranged from a decrease from 84.6% to 46.0% in Site 1 to an increase from 67.0% to 69.9% in Site 5. Four of the 6 interventions—including use of HIV surveillance data to identify out-of-care individuals, use of electronic laboratory ordering and prescribing, and development of a patient portal—were not only cost-effective but also cost saving ($6.87 to $14.91 saved per dollar invested). In contrast, the 2 interventions that extended access to EHRs to support service providers were not effective and, therefore, not cost-effective. Most interventions remained either cost-saving or not cost-effective under all sensitivity analysis scenarios. The intervention that used HIV surveillance data to identify out-of-care individuals was no longer cost-saving when the effect of HIV on an individual’s health status was reduced and when the natural progression of HIV was increased. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess sites against themselves at baseline and not against standard of care during the same time period. Conclusions These results provide additional support for the use of HIT as a tool to enhance rapid and effective treatment of HIV to achieve sustained viral suppression. HIT has the potential to increase utilization of services, improve health outcomes, and reduce subsequent transmission of HIV., Starley Shade and co-workers assess cost-effectiveness of information technology interventions in HIV care programs in the United States., Author summary Why was this study done? The Health Resources and Services Administration’s Special Projects of National Significance Program (HRSA/SPNS) funded a 4-year initiative (2007 to 2011) in 6 demonstration sites to enhance and evaluate existing health information electronic network systems for people living with HIV (PLHIV) in underserved communities. Each of the 6 demonstration sites implemented one or more health information technology (HIT) interventions to facilitate comprehensive care and enhance engagement in HIV medical services. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. This study estimates the total costs, cost-effectiveness, and potential cost-savings of these 6 interventions. What did researchers do and find? We used information on the cost of each intervention and the health status of PLHIV in each setting before and after implementation of each intervention to estimate: (1) changes in the cost of care and other services for PLHIV in each setting; and (2) changes in expected health status (measured as quality-adjusted life-years or QALYs) among PLHIV in each setting. We then used this information to estimate additional healthcare costs and QALYs gained for each intervention. Four of the interventions were associated with lower healthcare costs and better health outcomes (QALYs gained) for PLHIV in each setting. These interventions saved between $6.87 and $14.91 per dollar invested. Two interventions that provided access to medical record information to support service providers were not associated with improved health outcomes for PLHIV in these settings. These interventions were not effective or cost-effective. What do these findings mean? These results show that HIT interventions that facilitate changes in patient or provider behavior have the potential to improve the health status of PLHIV and reduce healthcare costs. HIT interventions that only provided additional information to support service providers were less successful. This study did not include a contemporaneous comparison group. Therefore, we do not know the degree to which improvements in the health status of PLHIV in these settings were due to changes in the quality of care for PLHIV over the life of the interventions.

Meaningful gains in health outcomes require successful implementation of evidence-based interventions. Organizations such as health facilities must be ready to implement efficacious interventions, but tools to measure organizational readiness have rarely been validated outside of high-income settings. We conducted a pilot study of the organizational readiness to implement change (ORIC) measure in public primary care facilities serving Bushbuckridge Municipality in South Africa in early 2019. We administered the 10-item ORIC to 54 nurses and lay counsellors in 9 facilities to gauge readiness to implement the national Central Chronic Medicine Dispensing and Distribution (CCMDD) programme intended to declutter busy health facilities. We used exploratory factor analysis (EFA) to identify factor structure. We used Cronbach alpha and intraclass correlation (ICC) to assess reliability at the individual and facility levels. To assess validity, we drew on existing data from routine clinic monitoring and a 2018 quality assessment to test the correlation of ORIC with facility resources, value of CCMDD programme, and better programme uptake and service quality. Six items from the ORIC loaded onto a single factor with Cronbach’s alpha of 0.82 and ICC of 0.23. While facility ORIC score was not correlated with implementation of CCMDD, higher scores were correlated with facility resources, perceived value of the CCMDD program, patient satisfaction with wait time, and greater linkage to care following positive HIV testing. The study is limited by measuring ORIC after programme implementation. The findings support the relevance of ORIC, but identify a need for greater adaptation and validation of the measure.

Health facility stigma impedes HIV care and treatment. Worry of contracting HIV while caring for people living with HIV is a key driver of health facility stigma, however evidence for this relationship is largely cross-sectional. This study evaluates this relationship longitudinally amongst nursing students and ward staff in India. Worry of contracting HIV and other known predictors of intent to discriminate were collected at baseline and 6 months in 916 nursing students and 747 ward staff. Using fixed effects regression models, we assessed the effect of key predictors on intent to discriminate over a 6-month period. Worry of contracting HIV predicted intent to discriminate for nursing students and ward staff in care situations with low and high-risk for bodily fluid exposure, confirming prior cross-sectional study results and underscoring the importance of addressing worry of contracting HIV as part of health facility HIV stigma-reduction interventions.

IntroductionPre-exposure prophylaxis (PrEP) has demonstrated to be a highly effective method for preventing HIV; however, many individuals with PrEP indications are not receiving PrEP. Primary care settings provide an opportunity to offer PrEP to a wide range of patients. In this paper, we describe the PrEP Optimisation Intervention (PrEP-OI), which includes a PrEP Coordinator and a web-based panel management tool (called PrEP-Rx), and is targeted at healthcare providers (HCPs) to increase PrEP uptake and persistence among those at risk for acquiring HIV.Methods and analysisThe PrEP-OI study evaluates the efficacy of the PrEP intervention (PrEP Coordinator + PrEP-Rx) to increase PrEP prescriptions through a stepped-wedge design among 10 primary care clinical sites in the San Francisco Department of Public Health. The number of PrEP initiation prescriptions constitute the primary outcome, and we hypothesise that the mean number of PrEP prescriptions written will significantly increase after the clinics initiate PrEP-OI versus before this intervention. Secondary objectives include: 1-differences in PrEP initiation, duration of use and reasons for discontinuation based on patient’s age, race/ethnicity and sex/gender, and by clinic and HCP characteristics, 2-sustainability of the intervention during a 12-month follow-up after the stepped-wedge phase, and 3-facilitators and barriers of PrEP delivery and experiences with the proposed PrEP intervention through qualitative interviews with HCPs. The results of this study can provide valuable insight into methods to reduce the burden of PrEP care on HCPs and improve PrEP continuum of care.Ethics and disseminationThis study and its protocols have been approved by the University of California, San Francisco (UCSF) Institutional Review Board. Study staff will disseminate findings locally (eg, the UCSF Centre for AIDS Prevention Studies’ Community Engagement Core), statewide (eg, the California Department of Public Health’s Office of AIDS) and nationally and internationally at conferences related to HIV.Trial registration numberNCT03532191.

Background The United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS). Methods and findings Data were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014–2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37–54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p < 0.001), share-the-care (25% increase, p < 0.001), and facilitating patient engagement in HIV primary care (13% increase, p < 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02–1.04; p < 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00–1.01; p < 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02–1.04; p < 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation. Conclusions In this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes., Wayne Steward and co-workers report on implementation of practice improvement projects for HIV care in the United States., Author summary Why was this study done? The study aimed to enhance the capacity and readiness of Ryan White HIV/AIDS Program (RWHAP)-funded clinics to adapt and realign their workforce and practices to improve the provision of quality HIV care. The study aimed to identify practice transformation approaches that can improve HIV care continuum outcomes. What did the researchers do and find? We conducted organizational assessments with clinics at 14 demonstration projects to assess changes in practices and procedures before and after implementation of practice transformations. We analyzed Ryan White HIV/AIDS Program Services Report (RSR) data from clinics affiliated with all demonstration projects to examine the impact of practice transformations on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We found that demonstration project clinics made significant changes in their practices in line with practice transformation approaches to maximize the healthcare workforce involved in the care of people living with HIV (PLWH), promote team-based care, and enhance reliable engagement of clients in primary HIV care. We also found that all three practice transformation approaches were associated with improved client retention in HIV care and viral suppression outcomes. What do these findings mean? Practice transformation approaches, particularly those that maximize the HIV care workforce and enhance reliable client engagement in primary HIV care, are of potential benefit for any clinic or healthcare facility that is straining to meet the demands for HIV care with its existing workforce.

Objective Increasing access to human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) is a high priority for the Ending the HIV Epidemic Initiative. Expanding access to PrEP and PEP through a variety of health care settings, including community pharmacies, may increase access in communities most in need. California is the first state to allow community pharmacists to furnish PrEP and PEP directly to consumers. Our objective was to assess attitudes among key stakeholders about a California policy to allow community pharmacists to furnish HIV PrEP and PEP. Methods We conducted a qualitative case study with key pharmacy stakeholders. Semistructured phone interviews were audio-recorded and transcribed verbatim. We generated analytical memos for each interview and working with these analytical memos, we conducted a constant comparison across cases to identify commonalities and differences. Results We launched the study in October 2018 and interviewed pharmacists (n = 7) working in a variety of settings, including retail-, clinic-, and community-based pharmacies. We also interviewed medical providers (n = 2) working in high-volume PrEP clinics and sought input from representatives of large retail chain pharmacies (n = 2). Overall, pharmacists and medical provider informants shared similar opinions about the central benefits as well as the key challenges related to pharmacist-delivered PrEP and PEP services. Benefits included: community pharmacists are widely accessible, PrEP and PEP protocols are similar to other preventative medications, policy may lead to efficiencies in the health care workforce, and community pharmacists are authorities on medication adherence. Challenges included: implementation issues may limit pharmacist involvement, and missed opportunities to diagnose and treat other health conditions. Conclusion This study characterizes the types of benefits and challenges that can be expected when PrEP and PEP prescribing privileges are extended to community pharmacists. This information may be useful to policymakers and other stakeholders considering legislation to permit direct prescription of PrEP and PEP by pharmacists.

Lack of healthcare provider knowledge, capacity, and willingness to prescribe PrEP are barriers to PrEP delivery in clinical settings. We implemented the PrEP Optimization Intervention (PrEP-OI) combining a PrEP Coordinator with an online panel management tool to assist providers with PrEP uptake, persistence, and management in 12 San Francisco Department of Public Health Primary Care Clinics. Medical directors (N = 10) identified important factors to consider prior to implementation, including shortage of clinical space for coordinators, medical mistrust, language barriers, and limited lab hours, along with the need for education of providers and staff and patient outreach. Among 110 providers who completed a baseline survey, the majority had reservations in asking about sexual practices and having conversations about PrEP. Providers reported PrEP-OI increased their efficiency and capacity to manage PrEP patients, and served as a gateway to additional services. These results highlight the promise of a provider-based intervention to improve the PrEP continuum and maximize the impact of PrEP.

The Health Resources and Services Administration Special Projects of National Significance launched the Systems Linkage and Access to Care for Populations at High Risk of HIV Infection Initiative in 2011. Six state departments of health were funded to utilize a modified Learning Collaborative model to develop and/or adapt HIV testing, linkage to care and retention in care system-level interventions. More than 60 Learning Sessions were held over the course of the Learning Collaborative. A total of 22 unique interventions were tested with 18 interventions selected and scaled up. All interventions were created to impact services at a systems level, with standardized protocols developed to ensure fidelity. Our findings provide key lessons and present considerations for replication for use of a modified Learning Collaborative to achieve state-level systems change.

HIV stigma continues to be a barrier to physical and mental health among people living with HIV globally, especially in vulnerable populations. We examined how stigma is associated with health outcomes and quality of life among rural women living with HIV in South India (N = 600). Interviewer-administered measures assessed multiple dimensions of stigma, as well as loneliness, social support, ART adherence, time since diagnosis, and quality of life. Internalized stigma and a lack of social support were associated with a lower quality of life, while the association between internalized stigma and adherence was mediated by the use of stigma-avoidant coping strategies, suggesting that keeping one's diagnosis a secret may make it more difficult to take one's medications. These findings suggest that these women constitute a vulnerable population who need additional services to optimize their health and who might benefit from peer support interventions and stigma-reduction programs for family and community members.

Shared decision-making (SDM) is considered best practice in health care. Prior studies have explored attitudes and barriers/facilitators to SDM, with few specific to HIV care. We interviewed 53 patients in HIV primary care clinics in California to understand the factors and situations that may promote or hinder engagement in SDM. Studies in other populations have found that patients' knowledge about their diseases and their trust in providers facilitated SDM. We found these features to be more nuanced for HIV. Perceptions of personal agency, knowledge about one's disease, and trust in provider were factors that could work for or against SDM. Overall, we found that participants described few experiences of SDM, especially among those with no comorbidities. Opportunities for SDM in routine HIV care (e.g., determining antiretroviral therapy) may arise infrequently because of treatment advances. These findings yield considerations for adapting SDM to fit the context of HIV care.

The United States (US) has experienced a surge of anti-immigrant policies and rhetoric, raising concerns about the influence on health outcomes for immigrants living in the US. We conducted qualitative interviews (n = 20) with health care and social service providers, attorneys, and legal/policy experts in California to understand how agencies were maintaining access to HIV care and prevention for immigrant clients. We conducted a thematic analysis to describe the role of medical–legal part- nerships (MLPs) and document best practices. Informants reported high demand for legal services. Referrals were facilitated by case managers, medical providers, and pre-existing relationships between clinics and legal agencies. Informants identified a need for additional funding and further guidance on screening for and supporting patients with legal needs. MLPs have the capacity to create sustainable, efficient, comprehensive structural changes that minimize barriers to HIV prevention and treatment and improve health outcomes among immigrant populations.

This cross-sectional study describes the prevalence and context of violence by sexual partners against female sex workers (FSWs, N = 589) in Andhra Pradesh and its association with alcohol use by FSWs and abusive partners. In all, 84% of FSWs reported alcohol use; 65% reported lifetime physical abuse by a sexual partner. Most abused women suffered abuse from multiple partners, often triggered by inebriation or FSW’s defiance. In multivariate logistic regressions, frequency of FSW’s alcohol use was associated with abuse by clients and primary partner, whereas partner’s alcohol use was only significant for abuse by primary partner, not clients.

Background While qualitative assessments of Ebola virus disease (EVD)-related stigma have been undertaken among survivors and the general public, quantitative tools and assessment targeting survivors have been lacking. Methods and findings Beginning in June 2015, EVD survivors from seven Liberian counties, where most of the country’s EVD cases occurred, were eligible to enroll in a longitudinal cohort. Seven stigma questions were adapted from the People Living with HIV Stigma Index and asked to EVD survivors over the age of 12 at initial visit (median 358 days post-EVD) and 18 months later. Primary outcome was a 7-item EVD-related stigma index. Explanatory variables included age, gender, educational level, pregnancy status, post-EVD hospitalization, referred to medical care and EVD source. Proportional odds logistic regression models and generalized linear mixed-effects models were used to assess stigma at initial visit and over time. The stigma questions were administered to 859 EVD survivors at initial visit and 741 (86%) survivors at follow-up. While 63% of survivors reported any stigma at initial visit, only 5% reported any stigma at follow-up. Over the 18-month period, there was a significant decrease in stigma among EVD survivors (Adjusted Odds Ratio [AOR], 0.02; 95% Confidence Interval [CI], 0.01–0.04). At initial visit, having primary, junior high or vocational education, and being referred to medical care was associated with higher odds of stigma (educational level: AOR, 1.82; 95%CI, 1.27–2.62; referred: AOR, 1.50; 95%CI, 1.16–1.94). Compared to ages of 20–29, those who had ages of 12–19 or 50+ experienced lower odds of stigma (12–19: AOR, 0.32; 95%CI, 0.21–0.48; 50+: AOR, 0.58 95%CI, 0.37–0.91). Conclusions Our data suggest that EVD-related stigma was much lower more than a year after active Ebola transmission ended in Liberia. Among survivors who screened negative for stigma, additional probing may be considered based on age, education, and referral to care., Author summary Survivors of Ebola virus disease (EVD) experienced stigma throughout the 2013–2016 West African outbreak, but post-outbreak experiences of EVD-related stigma have been limited to qualitative studies. We adapted a 7-item EVD-related stigma index from the HIV literature, which was administered to EVD survivors of the observational cohort, Ebola Natural History Study, in Liberia beginning in June 2015. While 63% of 859 EVD survivors reported any EVD-related stigma during the end of the outbreak in Liberia, only 5% of 741 survivors reported any stigma 18-months post-outbreak, suggesting that survivors experienced little to no EVD-related stigma in the absence of active Ebola virus transmission. Among survivors who screened negative for stigma, additional probing may be considered based on age, education, and referral to care.

© 2018 Springer Science+Business Media, LLC, part of Springer Nature Ensuring continuity of and retention in care after release from prison is critical for optimizing health outcomes among people living with HIV. As part of a large federal initiative, we conducted qualitative interviews (n = 24) with individuals living with HIV and recently released from prison in four states to understand their experiences in different navigation interventions to improve access to HIV care post-release. Interventions were delivered only in prison, only in the community, or in both settings. While the interventions varied by design, overall, participants appreciated the breadth of support received from interventionists, including health system navigation, case management and social support. Even when individuals leaving prison were returning to clinics that they were familiar with, systems navigation supported continuity of care. Our findings elucidate why navigational support was instrumental, and underscore the value of a variety of types of navigation programs in facilitating continuity of care and reintegration post-prison.

This manuscript describes the experiences of three state departments of health (SDoH) that successfully launched data sharing interventions involving surveillance and/or patient data collected in clinics to improve care outcomes among people living with HIV. We examined 58 key informant interviews, gathered at two time points, to describe the development and implementation of data sharing interventions. We identified three common themes across states' experiences: creating standard practices, fostering interoperability, and negotiating the policy environment. Projects were successful when state teams adapted to changing circumstances and were committed to a consistent communication process. Once implemented, the interventions streamlined processes to promote linkage and retention in care among low-income populations living with HIV. Despite using routinely collected data, key informants emphasized the labor-intensive process to develop and sustain the interventions. Lessons learned from these three state experiences can help inform best practices for other SDoH that are considering launching similar interventions.

The patient-centered medical home (PCMH) is a promising model for increasing the efficiency and quality of HIV care. We evaluated the implementation of PCMH-related demonstration projects in HIV care settings serving safety net populations. We conducted 113 qualitative interviews with key informants and patients to understand which PCMH components were perceived as best meeting patient medical and support service needs. Our results demonstrate the value and limitations of the PCMH, as currently conceived, for HIV care settings. Clinics focused on modifying workflows and improving care coordination. Patients welcomed such changes because they reinforced existing trust in the providers. Clinics dedicated less attention to promoting patient activation, such as building self-management skills, because such changes were seen as duplicative or undermined existing practices to meet patient social support needs. Research should explore how components of the PCMH could be modified to more fully meet the needs of this patient population.

The direct link between stigma against sexual minorities and psychological distress is well established. However, few studies have examined the potential mediating roles of avoidant and social support coping in the relationships between internalized and anticipated stigma associated with homosexuality and depressive symptoms and anxiety among Chinese men who have sex with men (MSM). We recruited a longitudinal sample of 493 MSM in Beijing, China from 2011 to 2012. Participants completed computer-based questionnaires at baseline, 6, and 12months. We found significant indirect effects of anticipated MSM stigma on symptoms of both depression and anxiety via avoidant coping: anticipated MSM stigma at baseline was significantly associated with avoidant coping (B=0.523, p&nbsp

While Medicaid eligibility expansion created health care access for millions in California, its impact on people living with HIV has been more nuanced. Newly covered people living with HIV who have behavioral health care needs now must navigate separate mental health and substance use care systems, instead of receiving them in integrated care settings as they had under the Ryan White HIV/AIDS Program. We conducted forty-seven interviews in the period April 2015-June 2016 to examine the impact of Medicaid expansion on people living with HIV in California who had behavioral health care needs. California's historical division in its Medicaid funding streams created challenges in determining which payer should cover clients' behavioral health care. Compounding these challenges were a perceived lack of cultural competence for serving this population, insufficient infrastructure to facilitate continuity of care, and unmet need for nonmedical supportive services. The multipayer model under health reform has compromised the administrative simplicity and integrated delivery of HIV and behavioral health services previously available to uninsured patients through the Ryan White HIV/AIDS Program.

Male migrant workers (MMWs) in India are vulnerable to developing alcohol-related problems and engaging in unprotected sex, putting them at risk of HIV. Research has shown that alcohol-related expectancies mediate vulnerability to alcoholism. We examined which expectancies were associated with sexual risk and drinking. We surveyed 1085 heterosexual MMWs in two South Indian municipalities, assessing expectancies, sex under the influence, and unprotected sex with female sex workers (FSW) and casual female partners in the prior 30 days. Men more strongly endorsed positive than negative expectancies (t = 53.59, p

Author(s): Vincent, Wilson; Pollack, Lance M; Huebner, David M; Peterson, John L; Steward, Wayne T; Rebchook, Gregory M; Storholm, Erik D; Kegeles, Susan M | Abstract: ObjectiveThis study examined whether the association between social support and condom self-efficacy would be moderated by (a) internalized heterosexism among and (b) enacted heterosexism experienced by young Black men who have sex with men (YBMSM), who contend with high HIV incidence, heterosexism, and low uptake of preexposure prophylaxis.MethodParticipants were 1,210 YBMSM (ages 18-29) who completed measures of social support, internalized and enacted heterosexism, and condom self-efficacy in 2 large cities in the southern United States as part of a community-level HIV-prevention study.ResultsA significant 3-way interaction between social support and both hypothesized moderators, internalized and enacted heterosexism, showed that social support was positively associated with condom self-efficacy when both internalized and enacted heterosexism were high (1 SD above the mean; b = .177, 95% confidence interval [CI: .088, .266]). However, social support was not associated with condom self-efficacy when scores were low (1 SD below the mean) on both internalized and enacted heterosexism (b = .024, 95% CI [-.054, .101]), low on internalized and high on enacted heterosexism (b = .058, 95% CI [-.061, .117]), or high on internalized and low on enacted heterosexism (b = .039, 95% CI [-.083, .161]).ConclusionsYBMSM who are high in both internalized and enacted heterosexism may see greater benefits from social support on condom self-efficacy than would YBMSM who grapple with less heterosexism. In addition to promoting social support, interventions should aim to assess and reduce multiple forms of stigma. (PsycINFO Database Record

© 2015 Taylor & Francis. We examined current challenges with patient engagement in HIV prevention and care in South Africa by assessing the procedures of eight public health clinics in the North West Province. Procedures consisted of (1) an inventory/audit of the HIV Counseling and Testing, pre-antiretroviral therapy (pre-ART), and antiretroviral therapy (ART) patient registers; (2) extraction of data from a convenience sample of 39 HIV-positive patient files; and (3) 13 key informant interviews with clinic staff to characterize retention and re-engagement practices for patients. Incomplete registers revealed little evidence of follow-up services, particularly for pre-ART patients. The more detailed examination of patient files indicated substantial disparities in the proportion of pre-ART versus ART patients retained in care. Key informant interviews contextualized the data, with providers describing multiple procedures for tracking and ensuring service delivery for ART patients and fewer procedures to retain pre-ART patients. These findings suggest that enhanced strategies are needed for ensuring continued engagement in HIV care, with a particular emphasis on improving the retention of pre-ART patients. The preventive benefits of ART scale-up may not be achieved if improvements are not made in the proportion of earlier-stage HIV-positive patients who are successfully engaged in care.

Food insecurity (FI) and its link with depression and quality of life (QOL) among people living with HIV (PLHIV) in India are not well-documented. We analyzed cohort data from 243 male and 129 female PLHIV from Bengaluru, and found 19 % of men and 26 % of women reported moderate or severe FI over a 6-month period. Women reported higher mean depression than men, and lower mean QOL. In multivariate analyses adjusting for HIV stigma and demographic covariates, both male and female PLHIV with moderate to severe FI showed lower mean QOL than those reporting mild to no FI. Male but not female food insecure participants also had higher depression scores in adjusted regression analyses. As ART has improved the physical health of PLHIV, more effort is being invested in improving their psychological well-being. Our results suggest such interventions could benefit from including nutritional support to reduce FI among PLHIV. Entre las personas que viven con el VIH en India, no se ha documentado bien la inseguridad alimentaria y su conexion con la depresion y la calidad de vida. Se analizaron datos de un cohorte de 243 hombres y 129 mujeres que viven con el VIH en Bengaluru, y se descubrieron que durante un periodo de seis meses, 19 % de los hombres y 26 % de las mujures reportaron inseguridad alimentario. Las mujeres reportaron una media de depresion mas alta que la reportado por los hombres, y una media de calidad de vida mas baja. Analisis multivariado, ajustado por el estigma y por covariables demograficos, demostro que personas que viven con el VIH – tanto hombres como mujeres – con moderada a severa inseguridad alimentaria mostraron menor calidad de vida que aquellos que se reportaron leves. Los masculinos tambien tuvieron altos niveles de depresion en analisis de regresion ajustada. Como la terapia antirretroviral ha mejorado la salud fisica de las personas que viven con el VIH, mas esfuerzos estan siendo invertidos en mejorar el bienestar sicologico. Nuestros resultados sugieren que tales intervenciones podrian beneficiar al incluir apoyo nutricional para reducir la inseguridad alimentaria entre personas que viven con el VIH.

Antiretroviral therapy (ART) could curtail the HIV epidemic, but its impact is diminished by low uptake. We developed a peer navigation program to enhance engagement in HIV care, ART adherence, and behavioral prevention. In preparation for a randomized controlled trial, the program was piloted over four months at two primary health clinics in South Africa's North West Province. Newly diagnosed, HIV-positive clients met regularly with navigators to address barriers to care, adherence, and prevention. To assess program acceptability and feasibility and characterize the mechanisms of action, we surveyed 25 clients who completed navigation services and conducted interviews with 10 clients, four navigators, and five clinic providers. Clients expressed near universal approval for the program and were satisfied with the frequency of contact with navigators. HIV stigma emerged as a primary driver of barriers to care. Navigators helped clients overcome feelings of shame through education and by modeling how to live successfully with HIV. They addressed discrimination fears by helping clients disclose to trusted individuals. These actions, in turn, facilitated clients' care engagement, ART adherence, and HIV prevention efforts. The findings suggest peer navigation is a feasible approach with potential to maximize the impact of ART-based HIV treatment and prevention strategies.

Objective We examined the mediating roles of coping, depression, anxiety, and encountering difficult sexual situations in explaining the association between stigma against men who have sex with men (MSM) and HIV risk. Methods We conducted path analyses using longitudinal data collected from 493 Chinese MSM in Beijing at baseline, 6 months, and 12 months from 2011 to 2013. Results MSM stigma, specifically anticipations of stigma, had a marginally significant, protective total effect on unprotected anal intercourse at 12 months. This overall association, however, was the byproduct of 5 significant, indirect associations (3 risk enhancing, 2 protective) that routed through coping, anxiety, and difficult sexual situations. Of note, heavier use of avoidant coping principally had a protective effect on risk behavior by decreasing difficult sexual situations. Conclusions Interventions to reduce avoidant coping would be an important tool for improving the emotional well-being of Chinese MSM. Such interventions, however, must be paired with biomedical or behavioral HIV prevention strategies to ensure that their benefit is not undermined by unintended increased HIV transmission risk in response to reduced social isolation among MSM.

In 2011, the Health Resources and Services Administration launched the Systems Linkage and Access to Care for Populations at High Risk of HIV Infection Initiative. Six state Departments of Health were funded to develop and implement HIV testing, linkage-to-care, and retention-in-care interventions over a four-year period. We conducted qualitative interviews with stakeholders (n = 68) involved in intervention development and/or implementation in order to characterize and compare the interventions; assess factors shaping the implementation of different interventions; and identify barriers to and facilitators of linkage and retention interventions. Our findings provide important lessons learned for achieving a more coordinated state-level response to the HIV epidemic.

Purpose The purpose of this article is to describe how comprehensive HIV care is delivered within Ryan White Program (RWP)-funded clinics and to characterize proposed health information exchange (HIE) interventions, which employ technology to exchange information among providers, designed to improve the quality and coordination of clinical and support services. Methods We use HIV patient care quality and coordination indicators from electronic data systems to describe care delivery in six RWP demonstration sites and describe HIE interventions designed to enhance that care. Results Among patients currently in care, 91% were retained in care in the previous six months (range across sites: 63–99%), 79% were appropriately prescribed antiretroviral therapy (54–91%) and 52% had achieved undetectable HIV viral load (16–85%). To facilitate coordination of care across clinical and support services, sites designed HIE interventions to access a variety of data systems (e.g. surveillance, electronic health records, laboratory and billing) and focused on improving linkage and retention, quality and efficiency of care and increased access to patient information. Discussion Care quality in RWP settings can be improved with HIE tools facilitating linkage, retention and coordination of care. When fully leveraged, HIE interventions have the potential to improve coordination of care and thereby enhance patient health outcomes.

HIV infection remains highly stigmatized throughout sub-Saharan Africa despite the increasing availability of treatment. HIV-related stigma is commonly described to be highly prevalent in East Africa, but none of these studies have employed validated scales for measurement. We used data from 456 people living with HIV/AIDS in rural Uganda to validate the six-item Internalized AIDS-Related Stigma Scale. The scale demonstrated acceptable internal consistency (Cronbach's alpha = 0.73) and time stability. Exploratory factor analysis indicated the presence of a single factor. Construct validity was supported by observations that the scale was correlated with related constructs such as depression and mental health-related quality of life. The scale was able to discriminate between groups of persons who were different in terms of treatment status and their experience of HIV-related self-blame. Taken together, these findings suggest that the Internalized AIDS-Related Stigma Scale may be a useful tool for socio-behavioral HIV research.

Background: Stigma shapes the lives of people living with HIV and may affect their willingness to seek medical care. But treatment delays can compromise health and increase the risk of transmission to others. Purpose: To examine whether the 4 stigma manifestations— enacted (discrimination), vicarious (hearing stories of discrimination), felt normative (perceptions of stigma’s prevalence), and internalized (personal endorsement of stigma beliefs)—were linked with delays in seeking care among HIV-infected people in India. Methods: A cross-sectional survey was conducted with 961 HIV-positive men and women in Mumbai and Bengaluru. Results: Enacted and internalized stigmas were correlated with delays in seeking care after testing HIV positive. Depression symptoms mediated the associations of enacted and internalized stigmas with care-seeking delays, whereas efforts to avoiding disclosing HIV status mediated only the association between internalized stigma and care-seeking delays. Conclusion: It is vital to develop stigma reduction interventions to ensure timely receipt of care.