Ending The HIV Epidemic Using National HIV Behavioral ... - PLOS

Discussion

The network visualization here addresses some of the utility of the NHBS as a survey mechanism, which has the capacity to recruit and test people who are at high risk of HIV using a social network strategy. Generalized testing strategies have become less effective in HIV diagnoses and the NHBS was implemented in jurisdictions to reach the “hidden” population (i.e., those for whom no sampling frame exists or whose members engage in stigmatized or illegal activities, making them reticent to divulge information that may compromise their privacy) [6]. There have been several analyses based on the NHBS data, unfortunately none of them address the success of the network implementation to find HIV diagnoses, which lies at the core of the implementation. Based on our network analysis we strongly recommend other jurisdictions employ network visualizations to evaluate the efficacy in reaching their own hidden populations. However, the structure of the social network data may offer little more than visualization. Still, visualizations often prove to be powerful tools. We recommend implementing CDC’s Social Network strategy to recruit hidden population through community-based organizations. The network visualization shows evidence of some recruitment clustering for HIV positives. We recommend re-evaluating the NHBS recruitment strategy to expand to areas that include more diverse populations in D.C.

This analysis identifies valuable results that can play an important role in HIV prevention-intervention planning and future data collection efforts. The HIV recruitment sample maps identify 24 positives residing in four zip codes, which suggests spatial clusters of HIV and supports previous studies that have identified HIV clusters in D.C. [19, 20]. That said, these recruits were primarily from High-Risk Areas (HRA) identified based on poverty and HIV diagnoses maps provided by the Health Department and were found based on spatially biased data. Three zip codes 20019, 20020, and 20032 had the highest number of recruits in the networks (see Table 1).

As part of the evaluation process our analysis helps to understand the impact of demographic, behavioral, and prevention efforts on peoples’ HIV status. It is reported that Black women aren’t always aware of their higher risk for HIV which stems from lack of public health awareness [20], we recommend higher recruitment and testing of Black women including strategies for PrEP awareness. Black communities traditionally have a high degree of social mixing between higher and lower risk individuals, which means that they are more likely to have a partner with a history of higher risk [20, 21]. Black women are relatively more susceptible to poverty, unstable housing, and unemployment, potentially increasing the likelihood of participation in sex trade, and making them more vulnerable to HIV [22]. We acknowledge that these situations are likely the result of structural racism. Black women also have a higher likelihood of experiencing violence or trauma. This is an important finding for D.C.’s EHE plan where increased engagement of Black women with HIV services and PrEP. We strongly recommend that the plan prioritizes Black women and their access to health care.

Among this HET sample we found that association of education did not change the HIV outcomes with behavior or interventions. The sample analysis also showed that crack cocaine, jail time, and a larger number of partners increased the risk of HIV for HETs in D.C. These behavioral issues may be significant as DC shapes the plan to end the HIV epidemic (EHE). As a part of the opioid use disorder and harm reduction initiative, has been planning and implementing several programs which include the Opioid Learning Institute led by the HealthHIV, opioid awareness campaign and education, and as well as Medication Assisted Treatment (MAT) and Substance Use Disorder Treatment (SUD). It is well established that substance use, including crack cocaine, can create a cycle in which people quickly exhaust their resources and turn to other ways to acquire the drug, including trading sex for drugs or money. This increases HIV risk, yet we lack programs that help mitigate it. We recommend collaboration with the Department of Behavioral Health (DBH) to develop behavioral treatment guidelines for people at risk or with HIV. The guidelines will assist providers with helping patients initiate abstinence and avoid relapse to cocaine use. These guidelines should include contingency management, cognitive behavioral therapy, and motivational interviewing. We also recommend integrating behavioral health screening for people who may be at risk of HIV and being prescribed PrEP.

Our results support that incarceration increases the risk of HIV. Unfortunately, this well-documented outcome often ignores the racial aspect. In the United States, Black and Latino/Hispanic men of lower socio-economic status are disproportionately incarcerated [23]. We recommend programs that may assist incarcerated individuals with prevention and treatment adherence in collaboration with the Metropolitan Police Department Detention Center. D.C. plans to incorporate programs to evaluate and monitor HIV treatment adherence among incarcerated individuals through the returning citizens program.

NHBS is planning on implementing home-based testing post COVID-19. Jurisdictions across the U.S. are considering home-based HIV testing, which will be shipped to those at-risk following completion of an online form. These jurisdictions must be aware of the digital divide that may have a significant impact on HIV outcomes, particularly during the current pandemic. We recommend that for prevention and intervention, we continue to engage with traditional community-based organizations and Disease Intervention Specialists in these areas of lower internet access.