RESUMEN
Introduction: People with HIV (PWH), particularly those at the intersection of sexual and gender identities, face enduring obstacles to accessing HIV care, including structural stigma, structural racism and discrimination, housing instability, and limited access to health insurance. To address these challenges, Medical-Legal Partnerships (MLPs) in HIV care offer an innovative approach that integrates medical and legal services. By targeting health-harming legal needs (HHLN), MLPs aim to enhance the HIV care continuum outcomes for PWH. Methods: This study examines the benefits and challenges of MLPs within organizations serving PWH through the social-ecological model. MLP providers (n=111) identified organizational-level challenges such as funding limitations, resource integration issues, and staffing constraints. Results: MLPs demonstrated numerous benefits, including patient impact and benefits, comprehensive service provision, enhanced staff support and capacity, and potential for policy influence. Discussion: These results underscore the feasibility of MLPs while offering valuable insights into their efficacy and challenges, guiding the implementation of MLPs to address health-harming legal needs, including discrimination, and thereby improving HIV care outcomes.
RESUMEN
The widespread consolidation of health systems, hospitals, and physicians has contributed to the high price of healthcare across the United States. While federal antitrust enforcers continue to play an important role in overseeing large mergers, acquisitions, and other consolidating transactions of major healthcare providers, state oversight over healthcare markets is essential to slow consolidation more broadly and address market failures across the country. State laws govern the scope of authority held by state attorneys general and other state agencies to receive notice of, review, and approve, conditionally approve, or block healthcare provider transactions, which can significantly impact the breadth and content of oversight. While blocking potentially anticompetitive transactions can help states maintain any competitive forces that remain in the market, in some situations, approving a transaction with conditions may be the best path forward. Applying conditions to transactions may allow state officials to oversee and govern the behavior of providers post-transaction while states pursue other legislative fixes. Although the use of conditions is a relatively common practice at the state level, little research has been done to explore their use among states. Following a search in all 50 states, this paper examines decisions from state officials imposing conditions intended to address the impacts of transactions on healthcare price, access, and quality and provides recommendations for the effective use of conditions moving forward.
RESUMEN
Medical Legal Partnerships (MLPs) offer a structural integrated intervention that could facilitate improvements in medical and psychosocial outcomes among people living with HIV (PLWH). Through legal aid, MLPs can ensure that patients are able to access HIV services in a culturally sensitive environment. We conducted organizational-level qualitative research rooted in grounded theory, consisting of key informant interviews with MLP providers (n = 19) and members of the Scientific Collaborative Board (SCB; n = 4), site visits to agencies with MLPs (n = 3), and meetings (n = 4) with members of the SCB. Four common themes were identified: (1) availability and accessibility of legal and social services support suggest improvements in health outcomes for PLWH; (2) observations and experiences reveal that MLPs have a positive impact on PLWH; (3) 3 intersecting continua of care exist within MLPs: HIV care continuum; legal continuum of care; and social services continuum; and (4) engagement in care through an MLP increases patient engagement and community participation. The MLP approach as a structural intervention has the potential to alleviate barriers to HIV/AIDS treatment and care and thus dramatically improve health outcomes among PLWH.
RESUMEN
Importance: Some US states have issued COVID-19 vaccine mandates; however, the association of these mandates with vaccination rates remains unknown. Objective: To examine the association between announcing state-issued COVID-19 vaccine mandates that did not provide a test-out option for workers and the vaccine administration rates in terms of state-level first-dose vaccine administration and series completion coverage. Design, Setting, and Participants: This cross-sectional study used publicly available, state-level aggregated panel data to fit linear regression models with 2-way fixed effects (state and time) estimating vaccine coverage changes 8 weeks before and 8 weeks after a state-issued COVID-19 vaccine mandate was announced. Mandates were announced on or after July 26, 2021, and were included only if they went into effect before December 31, 2021. Data were included from 13 state-level jurisdictions with a vaccine mandate in effect as of December 31, 2021, that did not allow recurring testing in lieu of vaccination (mandate group), and 14 state-level jurisdictions that allowed a test-out option and/or did not restrict vaccine requirements (comparison group). Interventions/Exposures: The event of interest was the announcement of a state-issued COVID-19 vaccine mandate applicable to specific groups of workers. Main Outcomes and Measures: The outcome measures were state-level daily COVID-19 vaccine first-dose administration and series completion coverage, reported as mean percentage point changes. Results: Of 5â¯508â¯539 first-dose administrations in the 8-week postannouncement period, an estimated 634â¯831 (11.5%) were associated with the mandate announcement. First-dose administration coverage among 13 jurisdictions increased starting at 3 weeks after the mandate announcement, with statistically significant differences of 0.20, 0.33, 0.39, 0.45, 0.49, and 0.59 percentage points higher than the referent category coverage of 62.9%. Increases in vaccine series completion coverage were observed from 5 to 8 weeks after the announcement, but statistically significant differences from the referent category coverage of 56.3% were observed only during weeks 7 and 8 after the announcement (both differed by 0.2 percentage points; P = .05 and P = .02, respectively). Conclusions and Relevance: The findings of this cross-sectional event study suggest that the announcement of state-issued vaccine mandates may be associated with short-term increases in vaccine uptake. This observed association may be a product of both a direct outcome experienced by groups governed by the mandate as well as the spillover outcome due to a government signaling the importance of vaccination to the general population of the state.
Asunto(s)
COVID-19 , Vacunas , Humanos , Vacunas contra la COVID-19 , Estudios Transversales , District of Columbia , COVID-19/epidemiología , VacunaciónRESUMEN
OBJECTIVES: HIV scholars and practitioners have worked to expand strategies for prevention among marginalised populations who are disproportionately impacted by the epidemic, such as racial minority men who have sex with men (MSM). Given this urgency, the objective of this study was to assess interest in biomedical prevention strategies. METHODS: This exploratory and cross-sectional study investigated interest in four biomedical prevention tools-rectal douche, dissolvable implant, removable implant and injection-among a racially diverse sample of MSM from the Northeast Corridor region between Philadelphia and Trenton. Data were collected as part of screening for Connecting Latinos en Pareja, a couples-based HIV prevention intervention for Latino MSM and their partners. RESULTS: A total of 381 individuals participated in the screener and provided information about their interest in bio tools. Approximately 26% of participants identified as black, 28% as white and 42% as 'other' or multiracial; 49% identified as Latino. Majority (54%) reported some form of child sexual abuse. Of the participants who reported being in a primary relationship (n=217), two-thirds reported unprotected anal sex within that relationship over the past 90 days (n=138, 64%) and approximately half (n=117, 54%) reported unprotected anal sex outside of the relationship in this period. Majority of participants reported interest in all bio tools assessed, including dissolvable implants (60%), removable implants (64%), rectal douching (79%) and injection (79%). Although interest in bio tools was broadly unassociated with demographics and sexual risk behaviours, analyses revealed significant associations between reports of child sexual abuse and interest in implant and injection methods. CONCLUSIONS: The authors recommend investing in these prevention methods, particularly rectal douching and injection, as a means of preventing HIV among racial minority MSM. Given the interest in biomedical prevention tools, future studies should explore potential strategies for adherence.
Asunto(s)
Infecciones por VIH , Minorías Sexuales y de Género , Niño , Estudios Transversales , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Homosexualidad Masculina , Humanos , Masculino , Asunción de Riesgos , Conducta Sexual , Parejas Sexuales , Irrigación TerapéuticaRESUMEN
INTRODUCTION: Phylogenetic analyses can provide insights on HIV tansmission dynamics. Country and state-level differences in HIV criminalization and disclosure laws and advances in next generation sequencing could impact perceived study risks. METHODS: We present study opt-out rates and the reasons provided during enrollment for a study conducted in Boston (6/2017-8/2018). RESULTS: Of 90 patients approached to participate, 45 did not consent to participate. Reasons for not participating included unwillingness to discuss their HIV status, privacy and confidentiality concerns, disinterest, and lack of time. CONLUSIONS: Given low participation rates and concerns related to HIV disclosure, privacy, and confidentiality, these questions remain (1) should informed consent be required for all phylogenetic analyses, including deidentified and surveillance data? (2) what additional steps can researchers take to protect the privacy of individuals, particularly in contexts where HIV is criminalized or there have been civil/criminal cases investigating HIV transmission? And (3) what role can community members play to minimize the potential risks, particularly for those most marginalized? These questions require input from both researchers and community members living with HIV/AIDS.
INTRODUCCIÓN: Los análisis filogenéticos pueden proporcionar información sobre la dinámica de transmisión del VIH. Las diferencias a nivel nacional y estatal en las leyes de criminalización y divulgación del VIH y los avances en la secuenciación de la próxima generación podrían afectar los riesgos percibidos del estudio. MÉTODOS: Presentamos las tasas de exclusión voluntaria del estudio y las razones proveídas durante la inscripción para un estudio realizado en Boston (6/20178/2018). RESULTADOS: De los 90 pacientes que se acercaron para participar, 45 no dieron su consentimiento para participar. Las razones para no participar incluyeron la falta de voluntad para discutir su estado en relación con el VIH, preocupaciones de privacidad y confidencialidad, desinterés y falta de tiempo. CONCLUSIONES: Dadas las bajas tasas de participación y las preocupaciones relacionadas con la revelación del estado serológico con respecto al VIH, la privacidad y la confidencialidad, estas preguntas permanecen (1) ¿se debe requerir el consentimiento informado para todos los análisis filogenéticos, incluyendo la información anónima y datos vigilancia? (2) ¿qué pasos adicionales pueden tomar los investigadores para proteger la privacidad de las personas, particularmente en contextos donde el VIH es criminalizado o ha habido casos civiles / criminales que investigan la transmisión del VIH? Y (3) ¿qué papel pueden desempeñar los miembros de la comunidad para minimizar los riesgos potenciales, particularmente para los más marginados? Estas preguntas requieren aportes tanto de investigadores como de miembros de la comunidad que viven con el VIH/SIDA.
RESUMEN
BACKGROUND: Over the past two decades, we have seen a nationwide increase in the use of medical-legal partnerships (MLPs) to address health disparities affecting vulnerable populations. These partnerships increase medical teams' capacity to address social and environmental threats to patients' health, such as unsafe housing conditions, through partnership with legal professionals. Despite expansions in the use of MLP care models in health care settings, the health outcomes efficacy of MLPs has yet to be examined, particularly for complex chronic conditions such as HIV. METHODS: This on-going mixed-methods study utilizes institutional case study and intervention mapping methodologies to develop an HIV-specific medical legal partnership logic model. Up-to-date, the organizational qualitative data has been collected. The next steps of this study consists of: (1) recruitment of 100 MLP providers through a national survey of clinics, community-based organizations, and hospitals; (2) in-depth interviewing of 50 dyads of MLP service providers and clients living with HIV to gauge the potential large-scale impact of legal partnerships on addressing the unmet needs of this population; and, (3) the development of an MLP intervention model to improve HIV care continuum outcomes using intervention mapping. DISCUSSION: The proposed study is highly significant because it targets a vulnerable population, PLWHA, and consists of formative and developmental work to investigate the impact of MLPs on health, legal, and psychosocial outcomes within this population. MLPs offer an integrated approach to healthcare delivery that seems promising for meeting the needs of PLWHA, but has yet to be rigorously assessed within this population.