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Open Access Publications from the University of California

Scholarly Works (14 results)

  • Thesis
  • Peer Reviewed
UC Berkeley Electronic Theses and Dissertations (2013)

Over the past decade, myriad social and economic factors have fueled a burgeoning population of people who inject heroin in sub-Saharan Africa, creating an urgent need for HIV prevention and treatment services tailored to this marginalized group. While the epidemic in the region remains largely driven through heterosexual risk behavior, a higher probability of disease acquisition per exposure can lead to rapid transmission among people who inject drugs (PWID). Stigma and discrimination isolates PWID from accessing available HIV care services designed for the general population and has contributed to HIV prevalence in PWID up to four times greater than country averages. To address this crisis, a few trailblazing governments with support from international HIV/AIDS funders have begun to develop and in the case of Tanzania, implement, comprehensive national harm reduction services for people who use and inject drugs. This dissertation contributes to the growing body of implementation science literature on medication assisted treatment programs (MAT) for PWID in sub-Saharan Africa.

This dissertation takes a three-paper model to identify programmatic and policy strategies to enroll, retain and support patients in MAT programs, focusing on Tanzania. The first paper, a systematic review of the literature on methadone as an HIV prevention intervention, describes evidence-based best practices and applies key findings to make recommendations about service delivery in a limited resource setting. Results suggest that enhanced outreach and increased dosing can help maximize service utilization. The second and third papers delve into the experiences of the first MAT program on mainland sub-Saharan Africa, located at Muhimbili National Hospital in Dar es Salaam, Tanzania. The program has successfully implemented a continuum of harm reduction care, culminating in methadone treatment for PWID. However, monitoring and evaluation data highlight a gender disparity in service utilization, with women comprising less than 10% of clients. Relying on in-depth interviews and observational data collected over three field visits from July 2011 to February 2013, the last two articles look at ongoing service needs for women in treatment and identify strategies to bring more women into care. Results suggest that women face distinct hardship in treatment, needing increased psychosocial support services and economic development interventions to help them heal histories of sexual trauma and regain custody of their children. Additionally, outreach tailored to women can help increase treatment enrollment. Findings from this dissertation have implications for MAT programs in Tanzania and in other areas in the region with similar epidemiological and cultural environments.

    Cover page: Providing Medication Assisted Treatment (MAT) as an HIV Prevention Intervention: Programmatic Strategies to Maximize Service Utilization in Dar es Salaam, Tanzania
    • Article
    • Peer Reviewed
    UC San Francisco Previously Published Works (2022)

    Purpose

    The primary purpose of this study was to characterize the health care experiences of diverse patients with nonbinary gender identities across a range of geographic locations. A secondary aim was to use the qualitative findings to inform recommendations for clinics and providers to create gender-affirming health care environments for nonbinary patients.

    Methods

    We conducted 3 focus group discussions with 7-9 participants, for a total of 24 unique participants. To be eligible, participants were required to be 18 years of age or older, live in the United States, speak English, have the ability to access Zoom in a private room, have a nonbinary gender identity, and be able to attend one of three scheduled focus groups.

    Results

    Participants reported frequent negative health care experiences, including misgendering, invalidation, and pathologization, even within clinics that signaled alliance with transgender communities. Participants described strategies they use to cope with negative experiences, including health care avoidance, identity concealment, and seeking out providers that are matched in terms of gender minority status and/or race.

    Conclusion

    Recommendations for the provision of gender-affirming health care for nonbinary patients include nonbinary-inclusive intake forms and electronic health records, having providers be proactive in eliciting preferred names and pronouns, and requiring education for providers and staff at all levels on the provision of nonbinary-inclusive gender-affirming health care.
      Cover page: Health Care Experiences of Patients with Nonbinary Gender Identities
      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2016)

      Background

      Strong evidence supports the effectiveness of methadone-assisted therapy (MAT) to treat opioid dependence, reduce the risk of HIV transmission, and improve HIV related health outcomes among people who inject drugs (PWID). HIV prevalence reaches 71% in women who inject drugs (WWID) in Dar es Salaam, Tanzania; creating an urgent need for access to MAT. Despite the availability and potential benefits of treatment, few women have enrolled in services. This formative research sought to identify programmatic strategies to increase women's participation in outreach and their subsequent enrollment in MAT.

      Methods

      We conducted twenty-five, in-depth interviews with patients and their providers at a MAT clinic. Open-ended interviews explored enrollment experiences, with a focus on contextual barriers and facilitators unique to women. Ethnographic observations of harm reduction education at outreach sites and the MAT clinic enriched interview data. Trust/mistrust emerged as an overarching theme cross cutting patient and provider accounts of the connective process to enroll PWID in the methadone program. We explore trust and mistrust in relationship to the interrelated themes of family loss, social isolation, vehement discrimination and motivation for treatment.

      Results

      Narratives delineated both the generation of mistrust against PWID and the generation of mistrust in PWID against outsiders and medical institutions. In order to enroll PWID in treatment, community base organizations engaged outreach strategies to overcome mistrust and connect eligible patients to care, which varied in their success at recruiting women and men. Greater discrimination against WWID pushed them into hiding, away from outreach teams that focus on outdoor areas where men who inject drugs congregate. Building trust through multiple encounters and making a personal connection facilitated entry into care for women. Only PWID were eligible for MAT, due to resource constraints and the higher risk associated with injection drug use. Many women smoke heroin, yet still face high risk of HIV, resulting from low condom use during sex work to fund drug use.

      Conclusion

      Expanding outreach times and locations, by women peers, could increase women's enrollment in treatment. Allowing women who smoke heroin to enter the program could prevent onward transmission via sex work and reduce the chance of progressing from the lower risk smoking or sniffing to injection drug use.
        Cover page: Generating trust: Programmatic strategies to reach women who inject drugs with harm reduction services in Dar es Salaam, Tanzania
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2017)

        Introduction

        The rapid scale-up of HIV care and treatment in resource-limited countries requires concurrent, rapid development of health information systems to support quality service delivery. Mozambique, a country with an 11.5% prevalence of HIV, has developed nation-wide patient monitoring systems (PMS) with standardized reporting tools, utilized by all HIV treatment providers in paper or electronic form. Evaluation of the initial implementation of PMS can inform and strengthen future development as the country moves towards a harmonized, sustainable health information system.

        Objective

        This assessment was conducted in order to 1) characterize data collection and reporting processes and PMS resources available and 2) provide evidence-based recommendations for harmonization and sustainability of PMS.

        Methods

        This baseline assessment of PMS was conducted with eight non-governmental organizations that supported the Ministry of Health to provide 90% of HIV care and treatment in Mozambique. The study team conducted structured and semi-structured surveys at 18 health facilities located in all 11 provinces. Seventy-nine staff were interviewed. Deductive a priori analytic categories guided analysis.

        Results

        Health facilities have implemented paper and electronic monitoring systems with varying success. Where in use, robust electronic PMS facilitate facility-level reporting of required indicators; improve ability to identify patients lost to follow-up; and support facility and patient management. Challenges to implementation of monitoring systems include a lack of national guidelines and norms for patient level HIS, variable system implementation and functionality, and limited human and infrastructure resources to maximize system functionality and information use.

        Conclusions

        This initial assessment supports the need for national guidelines to harmonize, expand, and strengthen HIV-related health information systems. Recommendations may benefit other countries with similar epidemiologic and resource-constrained environments seeking to improve PMS implementation.
          Cover page: Scaling-up health information systems to improve HIV treatment: An assessment of initial patient monitoring systems in Mozambique
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2020)
          Latinxs continue to be overrepresented in the U.S. HIV epidemic. We examined the transnational practices, family relationships, and realities of life of Mexicans and Puerto Ricans living with HIV in the continental U.S. We conducted qualitative interviews with 44 persons of Mexican and Puerto Rican origin participating in HIV care engagement interventions. Framework Analysis guided our data analysis. Among participants, a strong connection to the family was intertwined with transnational practices: communication, travel to their place of origin to maintain family ties, and material and/or emotional support. Separation from their family contributed to social isolation. Many participants lacked emotional support regarding living with HIV. Transnational practices and family relationships were intrinsic to the experiences of Mexicans and Puerto Ricans living with HIV in the continental U.S.; and may help understand the points of reference, health-seeking behaviors, and support sources that influence their health, well-being and engagement in HIV care.
            Cover page: “Holidays Come, Sundays Come. It is Very Sad to be Alone”: Transnational Practices and the Importance of Family for Mexican and Puerto Rican Latinxs Living with HIV in the Continental U.S.
            • Article
            • Peer Reviewed
            UC San Francisco Previously Published Works (2019)
            Interventions aiming to improve access to and retention in HIV care are optimized when they are tailored to clients' needs. This paper describes an initiative of interventions implemented by ten demonstration sites using a transnational framework to tailor services for Mexicans and Puerto Ricans living with HIV. Transnationalism describes how immigrants (and their children) exist in their "receiving" place (e.g., continental U.S.) while simultaneously maintaining connections to their country or place of origin (e.g., Mexico). We describe interventions in terms of the strategies used, the theory informing design and the tailoring, and the integration of transnationalism. We argue how applying the transnational framework may improve the quality and effectiveness of services in response to the initiative's overall goal, which is to produce innovative, robust, evidence-informed strategies that go beyond traditional tailoring approaches for HIV interventions with Latino/as populations.
              Cover page: From Theory to Application: A Description of Transnationalism in Culturally-Appropriate HIV Interventions of Outreach, Access, and Retention Among Latino/a Populations
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2023)

              Background

              Uptake of HIV pre-exposure prophylaxis (PrEP) remains low among transgender people as compared to other subgroups, despite high rates of HIV acquisition. In California, Latinx people comprise 40% of the population and Latina transgender women experience some of the highest burden of HIV of any subgroup, indicating a critical need for appropriate services. With funding from the California HIV/AIDS Research Programs, this academic-community partnership developed, implemented, and evaluated a PrEP project that co-located HIV services with gender affirming care in a Federally Qualified Heath Center (FQHC). Trans and Latinx staff led intervention adaptation and activities.

              Methods

              This paper engages qualitative methods to describe how a PrEP demonstration project- Triunfo- successfully engaged Spanish-speaking transgender Latinas in services. We conducted 13 in-depth interviews with project participants and five interviews with providers and clinic staff. Interviews were conducted in Spanish or English. We conducted six months of ethnographic observation of intervention activities and recorded field notes. We conducted thematic analysis.

              Results

              Beneficial elements of the intervention centered around three intertwined themes: creating trusted space, providing comprehensive patient navigation, and offering social support "entre nosotras" ("between us women/girls"). The combination of these factors contributed to the intervention's success supporting participants to initiate and persist on PrEP, many of whom had previously never received healthcare. Participants shared past experiences with transphobia and concerns around discrimination in a healthcare setting. Developing trust proved foundational to making participants feel welcome and "en casa/ at home" in the healthcare setting, which began from the moment participants entered the clinic and continued throughout their interactions with staff and providers. A gender affirming, bilingual clinician and peer health educators (PHE) played a critical part in intervention development, participant recruitment, and patient navigation.

              Conclusions

              Our research adds nuance to the existing literature on peer support services and navigation by profiling the multifaced roles that PHE served for participants. PHE proved instrumental to empowering participants to overcome structural and other barriers to healthcare, successfully engaging a group who previously avoided healthcare in clinical settings.
                Cover page: “Entre Nosotras:” a qualitative study of a peer-led PrEP project for transgender latinas
                • Article
                • Peer Reviewed
                UC San Francisco Previously Published Works (2016)
                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.
                  • Article
                  • Peer Reviewed
                  UC San Francisco Previously Published Works (2019)
                  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.
                    Cover page: "I don't have to do this all by myself": Systems Navigation to Ensure Continuity of HIV Care for Persons Leaving Prison.
                    • Article
                    • Peer Reviewed
                    UC San Francisco Previously Published Works (2017)

                    Introduction

                    Breastfeeding is recommended exclusively for the first 6 months after birth, with continued breastfeeding for at least 2 years. Yet prevalence of these recommendations is low globally, although it is an effective and cost-effective way to prevent serious infections and chronic illness. Previous studies have reported that social support greatly influences breastfeeding, but there is little evidence on perceived social norms in Mexico and how they affect actual behavior.

                    Objective

                    Our objective was to investigate breastfeeding intention, practices, attitudes, and beliefs, particularly normative, among low-resource communities in central and southern Mexico.

                    Methods

                    We performed a secondary analysis using the theory of planned behavior with cross-sectional data, which included semi-structured individual interviews with fathers (n 10), 8 focus groups with mothers (n 50), and 8 focus groups with women community leaders (n 44) with a total of 104 participants. Our data also included a quantitative survey among pregnant women and mothers (n 321).

                    Results

                    Women reported supplementing breast milk with water and teas soon after birth, as well as introducing small bites of solid food a few months after birth. Social norms appeared to support breastfeeding, but not exclusive breastfeeding or breastfeeding for periods longer than about a year. This may be partially explained by: a) behavioral beliefs that for the first 6 months breast milk alone is insufficient for the baby, and that water in addition to breast milk is necessary to hydrate an infant and b) normative beliefs related to the appropriateness of breastfeeding in public and as the child gets older.

                    Conclusions

                    Future strategies should focus on positively influencing social norms to support recommended practices, and emphasize the specific reasons behind the recommendations. Future efforts should take a multi-pronged approach using a variety of influences, not only directed at healthcare providers but close family members, including fathers.
                      Cover page: Breastfeeding practices, beliefs, and social norms in low-resource communities in Mexico: Insights for how to improve future promotion strategies
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