HealthHIV Research and Evaluation
Key Findings Services Provided Diverse Priorities Workforce Challenges Status Neutral Continuum HIV Criminalization Conclusion Appendix

Introduction

HealthHIV administered the Fifth Annual State of HIV Care™ National Survey to identify barriers and facilitators influencing the state of HIV services across the care continuum from the perspective of HIV prevention and treatment providers.

The survey’s insights will be used to optimize the education and training of the HIV care workforce, and to better inform HIV prevention, treatment, advocacy, education, research, and training activities.

In 2021, there was a 7% decline in new HIV diagnoses in the U.S., with 32,100 new diagnoses reported, reflecting substantial efforts to address HIV nationwide and meet the Centers for Disease Control and Prevention (CDC) goal to End the HIV Epidemic in the U.S. (EHE).1, 2 This initiative aims to reduce new HIV infections by 75% by 2025 and by 90% by 2030, necessitating comprehensive interventions along every stage of the HIV care continuum — including increasing PrEP coverage, reducing new HIV infections, increasing knowledge of HIV status, and increasing the percentage of people with diagnosed HIV who are linked to medical care and virally suppressed.2 However, progress towards each of these goals remains slow. HIV providers offer an invaluable perspective on the current state of HIV care and the resources and training that could empower the workforce to overcome the significant challenges they face.

When asked what the state of HIV care is in one word, respondents primarily stated: “improving,” followed by the “better,” “progressing,” and “evolving,” suggesting that most agreed that despite improvements, there is still room for growth.

Key Findings and Implications

The Fifth Annual State of HIV Care National Survey engaged 1,031 diverse and representative healthcare providers, spanning a broad spectrum of racial, ethnic, and sexual identities and hailing from various geographic, educational, and income backgrounds. Notably, the demographics of the survey participants closely mirrored the current composition of healthcare professionals in the United States.

Key findings from this report provide an overview of the insights gained by the survey, presenting current challenges, successes, and areas of improvement in HIV prevention and care.

  • Burnout Persistent Among HIV Workforce: Strategies such as flexible scheduling, manageable workloads, and adequate staffing to combat burnout and its related workforce shortage should be prioritized.
  • Providers Indicate PrEP Awareness and Outreach Top Priority: Efforts to enhance PrEP uptake along the continuum, focusing on awareness and promotion of PrEP, especially in racial and ethnic minorities and among unstably housed individuals are needed to reduce new HIV infections.
  • Limited Familiarity with Status-Neutral Care Delays Integration of Prevention and Treatment Settings: Only 30% of participants were aware of this framework, underscoring the necessity for enhanced education and promotion to foster better connections between prevention and treatment environments.
  • Prescribers Most Concerned About Managing HIV Treatment with Competing Priorities Including Aging, Comorbidities, and Behavioral Health: Complexities in care underscore the importance of integrated services to effectively address the multifaceted needs of individuals with HIV.
  • Retention in HIV Care Challenging Due to Mental Health Issues, Substance Use, and Housing Instability: Developing targeted interventions to address social determinants of health is needed to improve overall patient engagement and outcomes.
  • Lack of Awareness of the Effect of HIV Criminalization on Underserved Communities: Promoting public awareness, educating lawmakers and law enforcement officials, and advocating for public health approaches are key steps to address this issue and its impact on people living with HIV.

These implications should guide healthcare organizations, policymakers, and advocacy groups in developing targeted strategies and initiatives to advance HIV care, reduce disparities, and ultimately work towards the goal of ending the HIV epidemic in the United States.

Healthcare Services Provided

HIV programs offer a range of comprehensive services — including primary care, HIV prevention, sexual and reproductive health, behavioral health, and social support services — which provides a vital opportunity to reach underserved communities.

Primary Care Services

Most respondents offer primary care services such as health screenings, immunizations, and medication management. Less than half (41.1%) offer frailty screening for older adult patients.



HIV Prevention Services

Nearly all respondents offer HIV prevention education including condom distribution, and HIV testing. Respondents were more likely to indicate their organization offers pre-exposure prophylaxis (PrEP) compared to post-exposure prophylaxis (PEP) services.



Social Support Services

Most respondents offer screenings for social support services and provide social support services. However, while 69.5% screen for housing insecurity, less than half offer housing services (44.6%).



Behavioral Health Services

The majority (84.2%) of respondents indicated that their organization offers some form of behavioral health services. Among organizations offering behavioral health services, more than half (57.7%) provide individual psychotherapy/counseling, but only about one-third facilitates group counseling and peer-led support groups. Only 35.8% offer outpatient medicine management.

People Living with HIV (PLWH) face an increased risk of complex behavioral health challenges, especially substance use disorder, mental illness, and housing instability. PLWH have higher rates of past or current substance use, yet studies have indicated that HIV care clinics lack sufficient screening procedures for early detection and intervention.3 Those with co-occurring mental health disorders face even higher rates of substance use disorder, emphasizing the need for integrated care and routine screening in HIV care settings.4

Sexual and Reproductive Health Services

Of those who provide sexual and reproductive health services (61.5%), most reported that routine STI testing is common practice.

Most respondents offer comprehensive STI testing, with 79.2% indicating they provide site-specific testing (e.g. including pharyngeal and rectal sites) for gonorrhea and chlamydia depending on sexual behavior. Many respondents (57.9%) incorporate STI testing into each visit to the health center.

Of respondents who are involved in PrEP care, nearly all (90.5%) indicated they provide STI testing services, including gonorrhea, chlamydia, and syphilis testing during each PrEP appointment.

The CDC recommends all persons prescribed PrEP should receive follow-up appointments and testing for HIV infection every three months, and general STI screening every six months.5

80.2% of respondents indicated that they are very comfortable taking a comprehensive sexual history, showcasing their readiness to engage in this vital aspect of care. However, 66.8% of respondents indicated they obtain a comprehensive sexual history from patients/clients, asking questions about partners, practices, protection, pregnancy intentions, STIs, and screen for interpersonal violence.

Discussing a person’s sexual health offers the opportunity for counseling and sharing information about behaviors that may increase STI risk. For this reason, the CDC recommends that a sexual history be taken as part of routine healthcare, in addition to when there are signs and symptoms of STIs.6

Key Populations

More than 90% of providers reported providing HIV services to people experiencing homelessness and people with substance use disorders.

Diverse Priorities in HIV Care: Perspectives from Providers

Understanding Varied Priorities Based on Professional Backgrounds

Across the board, providers noted behavioral health, aging with HIV, and stigma and discrimination as the most crucial HIV care topics facing the workforce today.

However, respondents also demonstrated distinct HIV care priorities in accordance with professional background. Survey respondents were grouped by provider type in order to identify themes in their stated priorities, with clinical providers encompassing prescribers, mental health professionals, nurses, medical assistants, and allied health professionals, and non-clinical providers including administrators, health educators, social workers and case managers, patient supporters and navigators, program coordinators and managers, and outreach workers.

In addition to aging and behavioral health, clinical providers emphasized the importance of HIV and comorbidities, while nonclinical providers highlighted stigma and discrimination and harm reduction.

Homelessness Presents Major Hurdle in Mental and Behavioral Health Service Engagement

80% of respondents indicated that homelessness poses the greatest challenge in maintaining engagement with mental and behavioral health services.

One in five PLWH are unstably housed, increasing the likelihood of poor health outcomes, specifically poor retention in care and adherence to ART.7 Unhoused PLWH are more likely than housed PLWH to report mental illness including depression and anxiety.8

Workforce Challenges: Burnout, COVID-19, Public Trust, and Training Needs

Insights into staff burnout, workforce shortages, and organizational responses amid the COVID-19 pandemic.

Workforce Burnout and Shortages

Staff burnout and workforce shortages were key issues for respondents.

More than one-third (34.8%) of respondents reported high levels of burnout — defined here as feeling emotionally drained from work at least once a week or more – and 55.2% had considered quitting their job in the preceding six months. No significant differences in burnout scores were noted between rural and urban providers, clinical and non-clinical providers, and length of time in practice–suggesting burnout is a near universal issue in healthcare. Conversely, two thirds of respondents indicated they frequently accomplish worthwhile things in their job.

Respondents indicated one of the top ways the COVID-19 pandemic impacted healthcare delivery was by increasing staff burnout (50.4%). Relatedly, burnout was ranked as the second most significant workforce issue facing responding organizations (52.1%) along with workforce shortage (53.4%) and increased workload (51.1%). Workforce shortage in particular was noted by participants as a significant issue or barrier in various areas, including access to care, providing care, and linkage to treatment along with contributing to burnout.

Organizations are enacting efforts to address workforce issues that are directly targeted at these areas including allowing flexible schedules, supporting manageable workloads, and ensuring adequate staffing.

Burnout is a syndrome often characterized by high emotional exhaustion, high depersonalization, and a low sense of personal accomplishment from work.9 Workers with burnout are more likely to experience anxiety and depression.10

Burnout and resource shortages have disproportionately impacted women and providers of color. Burnout is associated with decreased work productivity, increased job dissatisfaction, and high provider turnover.11 Causes of burnout have included increased pressure on the healthcare delivery system combined with insufficient job resources.

COVID Impact on Service Delivery

The COVID-19 public health emergency had an immense impact on health and healthcare delivery. The impacts most commonly identified by respondents included increased need for mental health services (65.6%), increased use of telehealth (55.9%), and increased staff burnout (50.4%). Post-COVID, providers indicated feeling valued by clients/patients, colleagues, and organizational leadership.

The COVID-19 pandemic and its aftermath have put massive amounts of stress on the healthcare workforce and service delivery. A survey conducted by the HHS Office of the Inspector General in 2021 found that increased work hours, in combination with the stress of the pandemic, resulted in high levels of staff exhaustion and reports of trauma and PTSD.

Public Trust

Only about a quarter (27.4%) of respondents agreed or strongly agreed that public trust in healthcare has improved since the pandemic while 38% disagreed or strongly disagreed.

Concerns about public trust in the healthcare system were highlighted during the pandemic. During COVID-19’s peak, only one-third to one-quarter of U.S. adults trusted federal, state, and local health departments for information.12 Low levels of governmental trust were attributed to conflicting recommendations and policies that were deemed too restrictive.

Training Needs

Providers indicated training preferences, preferred locations for education, and areas of interest, offering several key insights.

The survey uncovered significant demand for education on cultural competency and humility, as well as diversity, equity, and inclusion, with 82.8% and 83.8% of respondents, respectively, reporting their organizations offered training in these areas. Additionally, preventing stigma and discrimination and addressing mental and behavioral health emerged as areas of high interest among providers, with 24.8% and 23.6% ranking these topics as their primary training needs.

Moreover, the survey delved into specialized training needs among clinical provider groups. Prescribers and providers expressed a keen interest in injectable PrEP and new HIV treatments, while mental health professionals placed importance on culturally competent PrEP care and addressing treatment resistance. Nurses and medical assistants emphasized the relevance of current HIV treatment guidelines and PrEP for key populations. Allied health professionals exhibited a strong interest in new HIV treatments, current treatment guidelines, and addressing treatment resistance, highlighting the diverse and evolving needs within the HIV provider community. These findings collectively underscore the importance of tailoring training programs to meet the specific needs of various clinical and non-clincial roles in the context of HIV care.

Status Neutral Care Continuum

Providers across the continuum call for similar interventions, highlighting the need for integrated, status neutral models of care.

The status neutral framework of HIV prevention and care offers a “one-door” approach where people with HIV and people at risk for HIV can access care in the same place.13

Therefore, a status neutral care continuum proposes that HIV care does not start with a positive test and end with viral suppression, but rather branches off from a positive or negative test, encompassing both prevention and treatment as strategies for reaching greater rates of community viral load suppression and survival. However, only 30% of survey participants have fully integrated status neutral care into their practice, while nearly 40% were not aware of status neutral care at all. This lack of knowledge relating to status neutral care points towards the disjuncture between HIV prevention settings and HIV treatment settings.

Moving to the right of the care continuum, there is a gradual decrease in the percentages of individuals at each stage. It is estimated that 87% of individuals living with HIV undergo testing, 81% are successfully linked to care, 66% are prescribed ART, 50% remain retained in care, and 57% achieve viral suppression. Similarly, moving to the left of the care continuum, the percentage of individuals who are aware of PrEP, linked to PrEP, prescribed PrEP, and retained in PrEP care declines at each respective stage.

The following sections juxtapose PrEP and HIV care as opposite, yet interconnected ends of a greater care continuum. Challenges and facilitators noted by providers working at different points in the continuum echo each other, pointing towards several salient and widely applicable themes, including:

  • The importance of provider-initiated counseling at all stages of the continuum;
  • The need for providers across all settings to practice greater cultural humility and sensitivity to stigma in order to improve provider-client communication; and
  • The urgent demand for funding to support services and help patients/clients cover the costs of care.
Awareness of PrEP and Retention in HIV Care are the Highest Priority Steps in the Continuum

HIV Testing: The Continuum Center

Status neutral care begins with an HIV test, but testing poses many challenges to providers.

Respondents predominantly provide testing onsite at their organization's location (89.7%), community health fairs/events (66.7%), and within various community-based settings.

Providers state that patients' challenges to HIV testing include stigma or discrimination (58.5%), insufficient counseling (40.5%), and the assumption of low HIV risk (39.8%). Provider obstacles include patient refusal (68%), limited staff/workforce shortages (57.6%), and limited testing resources (42.4%).

The HIV Prevention Continuum

In 2022, CDC data showed that only 36% of people who could benefit from PrEP were prescribed it — a reality indicative of nationwide struggles to increase PrEP uptake despite PrEP’s approval for use as HIV prevention over ten years ago.2

There are stark racial and ethnic disparities in PrEP usage as well–only 13% of Black and African American people and 24% of Latino/a/x and Hispanic people who are eligible for PrEP are prescribed it compared to 94% of White people.14 Providers must be empowered by adequate training and resources to encourage PrEP uptake at each step of the PrEP continuum, a spectrum of care that ranges from PrEP promotion to long-term adherence to PrEP medications.


Aware of PrEP

Providers emphasized the need to prioritize PrEP outreach and promotion (41.9%).

Despite challenges to raising PrEP awareness, a majority of providers (64.1%) believe that initiating discussions with patients boosts PrEP uptake.


Linked to PrEP

Limited PrEP clinics/services were cited as the biggest challenge to linking people to PrEP. Discouragingly, 42.6% stated that provider discomfort discussing PrEP inhibits linkage to care.


Prescribed PrEP

Insurance constraints — including a lack of formulary options and the burden of prior authorizations — were identified as the biggest barrier to PrEP prescriptions.


Retained on PrEP

Respondents stated that PrEP is usually discontinued due to a lack of perceived risk.

To further enhance PrEP services, providers emphasized the need for improved funding (51.2%).

The HIV Treatment Continuum

Current antiretroviral therapy (ART) offers PLWH the opportunity for long-term physical health and a sustainable high quality of life.

Comprehensive treatment is also one of the most effective strategies for reducing overall community transmission since people who are virally suppressed on ART cannot transmit HIV (U=U, or undetectable equals untransmittable). Accordingly, each step in the HIV care continuum is vital, not only to caring for individuals living with HIV, but to greater efforts to end the HIV epidemic.


Linked to Care

Testing is provided at the majority (90%) of organizations’ onsite locations and over half of providers indicated the number of people their organization tested has increased in the last year.

Top challenges to linking diagnosed patients to care from the provider’s perspective were related to indirect and direct costs of care, including concerns over insurance coverage. There is also a notable administrative burden with linking patients to care such as managing patient schedules, attempting to contact the patient, and required paperwork.


Prescribed ART

Insurance continues to be a barrier for initiating ART, along with concerns over potential side effects and provider concerns about patient adherence.



Retained in Care

Organizations are implementing strategies to keep patients retained in care and the average lost to care rate of respondents was low (11%). Providers indicated that lack of transportation, mental health issues, substance use, and housing instability are the main barriers to retention in care and adherence to ART.


Virally Suppressed

Although the average viral suppression rate reported by respondents was relatively high (86.6%), significant barriers remain for achieving good health outcomes for all PLWH. Respondents reported an average lost to care rate of 10.8%, defined as patients who had not had a medical visit in the last 12 months.

Achieving viral suppression through retention in care and adherence to ART is crucial for supporting a high quality of life for PLWH and reducing community transmission. The HIV Care Continuum serves as an important framework to understanding levels of engagement of PLWH at each step of treatment and identifying strategies to better support PLWH reaching viral suppression. The CDC provides prevalence-based (diagnosed and undiagnosed) and diagnosis-based care continuum data for each reporting year from 47 states and the District of Columbia. Each step — diagnosis, linkage to care, reception of treatment, retention in care, viral suppression — poses unique barriers and has varying rates of achievement nationwide. Retention in care and viral suppression in particular are not achieved at the same rates as other steps in the continuum.

Retention in HIV Care Persists

Moderate progress despite significant interventions

Retaining PLWH in care was identified as the step along the continuum that still requires the most amount of attention.

Although 90% of respondents utilize at least one retention in care strategy, only 62.2% reported satisfaction with their retention in care efforts.

Respondents stated their organizations have implemented outreach and communication-based strategies to engage patients in care including appointment reminders, routine follow ups, and case management services. Importantly, the majority of respondents indicated their organizations are monitoring retention of all HIV patients and routinely reinforcing the value of follow-up visits.

Special Focus

Impact of HIV Criminalization

Exploring provider awareness, patient/client concerns, and a pathway to reform

More than half of U.S. states have HIV-specific criminal laws and/or sentence enhancements applicable to people living with HIV. HIV criminalization laws typically encompass the criminalization of behaviors related to HIV exposure and transmission, such as not disclosing one's HIV status to sexual partners or engaging in activities that may transmit HIV, even if transmission does not or cannot occur.

HIV criminalization laws vary from one jurisdiction to another, but most laws are counterproductive and stigmatizing. They can discourage individuals from getting tested for HIV or disclosing their status to healthcare providers or sexual partners, for fear of criminal prosecution. Additionally, many laws do not reflect current scientific knowledge about HIV transmission risk (e.g. U=U) and unfairly target PLWH.

Only 40% of HIV providers are aware of HIV criminalization policies.

Of those, 75.5% express concerns about the impact of these policies on the health of their clients/patients. Importantly, a considerable proportion (52.3%), have observed that HIV criminalization disproportionately affects marginalized communities, including people of color, LGBTQ+ individuals, and people who use drugs. However, only 8% of patients routinely express concerns about HIV criminalization.

One in four providers have counseled patients on the legal risks related to HIV criminalization, although it is not an everyday occurrence. Most (73.8%) believe that HIV criminalization has a detrimental impact on public health efforts aimed at preventing HIV transmission.

Respondents also provided insights into potential steps to mitigate the negative effects of HIV criminalization. The most supported strategies include increasing public awareness and understanding of HIV (76.8%), educating lawmakers and law enforcement officials (71.1%), and replacing criminalizing laws with public health approaches (70.5%).

Conclusion

Understanding the Complex HIV Care Landscape

This comprehensive survey offers invaluable insights into the complex landscape of HIV care, revealing the challenges and opportunities that lie ahead. The findings highlight the need for ongoing education and training initiatives to empower providers with the skills and resources required to navigate the evolving challenges of HIV care. As the healthcare community moves forward, these findings provide a roadmap for advancing care, reducing disparities, and ultimately achieving the ambitious goals set forth in ending the HIV epidemic.

Prioritizing Behavioral Health, Aging and Stigma in Education and Training

Behavioral health, aging, and stigma emerged as paramount training priorities across all provider types. This highlights not only acute provider awareness regarding the role of social determinants of health in HIV care but also echoes concerns brought to the forefront during the COVID-19 pandemic. As PLWH increasingly lead longer and healthier lives, allocating resources toward aging with HIV is critical. Recent epidemics such as COVID-19 and MPox have significantly impacted this well-being, underscoring the urgency of addressing these priorities for both healthcare providers and policymakers.

Addressing PrEP Barriers and Promoting Awareness

Efforts should be made to communicate the awareness and benefits of PrEP to individuals at risk for HIV and PLWH, as their voices can play a pivotal role in reaching community members and sexual partners who could benefit from PrEP. Stigma, lack of knowledge, bias among healthcare workers, and difficulties accessing care continue to be significant barriers to PrEP uptake. Despite these challenges, the number of PrEP users in the U.S. has steadily increased since 2012,15 reinforcing the importance of ongoing efforts to promote PrEP awareness and accessibility.

Understanding the HIV Care Continuum

The HIV Care Continuum serves as a vital framework for comprehending PLWH's engagement levels at each stage of treatment and devising strategies to better support their journey toward viral suppression. While progress is seen at different steps of the continuum, retention in care and achieving viral suppression remain challenges that require special attention.

Combating HIV Criminalization

Low awareness of HIV-specific criminal laws among both patients and healthcare providers may lead to missed opportunities for counseling and perpetuate HIV-related stigma. These laws discourage testing, are not supported by scientific evidence, and are often misinterpreted by non-medical professionals.16 In some states, individuals can face enhanced sentences or charges for improper HIV status disclosure, perpetuating stigma and overlooking the complexities of HIV transmission.17 There is a clear and pressing need for comprehensive action, including raising public awareness, educating policymakers and law enforcement, and reforming existing laws to combat stigma and promote HIV testing.

Appendix: Research Strategy

Survey Methodology

Survey Development

The survey consisted of a mix of 197 open- and closed-ended survey questions. The survey was developed using a status neutral framework with an emphasis on systemic and structural barriers, so as to capture a full picture of the HIV care landscape ranging from PrEP uptake to long-term HIV care. The survey asked questions about training needs, PrEP provision, HIV treatment innovations, workforce burnout, behavioral health, and more. Internal and external advisory groups reviewed the survey to ensure the questions encompassed salient issues facing HIV care providers as described in the literature.

Participant Recruitment

The survey was administered online via Research Electronic Data Capture (REDCap)18 from May 20, 2023 - June 26, 2023. Respondents were recruited through the HealthHIV constituent relationship management (CRM) database, SalsaLabs, which includes approximately 80,000 persons who reflect a diverse cross-section of the HIV care workforce. We solicited participation from all members of the healthcare workforce with direct experience providing or supporting HIV care. No incentive was provided for participation.

Data Analysis

Basic descriptive statistics were calculated in REDCap. Additional multivariable analyses were calculated using RStudio 4.2.1 statistical software.19 Thematic content analysis was used to explore qualitative data and identify themes that captured respondent experiences.

Survey Participants

A total of 1031 providers participated in the survey. There was wide representation of racial and ethnic minorities and sexual and gender minorities, across geographic location, and educational status. Participants in this survey reflect the demographics of healthcare professionals currently working in the U.S.

Respondent Demographics

Survey participants were predominately white, cis-gender women between the ages of 35 and 54. However, there was also strong representation of Black/African American respondents (24.3%) and older people aged 55+ (28.8%). 18.6% identified as Latino/a/x.

Participants hailed from a wide range of U.S. states and geographies, with representation from 48 states and two territories, across rural, urban, suburban, and tribal areas.


Professional Backgrounds

Participation reflects a wide distribution of provider types and professional and geographic settings.

Just over two-thirds of respondents occupied non-clinical professional roles, with administrators, case managers, and community health workers being the most common.

The remaining third were clinical providers with nurse practitioners, physicians, licensed clinical social workers (LCSWs), and pharmacists as the predominant roles.


Organizational Affiliations

Respondents represented organizations in a variety of settings, but were predominantly from health departments/public health clinics, non-profit organizations, Federally Qualified Health Centers (FQHCs), and AIDS Service Organizations (ASOs).

The geographical distribution of organizations was largely urban, followed by rural and suburban areas.

Notes

  1. Centers for Disease Control and Prevention. Expanding PrEP Coverage in the United States to Achieve EHE Goals. Centers for Disease Control and Prevention. Published October 17th, 2023. https://www.cdc.gov/nchhstp/dear_colleague/2023/dcl-101723-prep-coverage.html.
  2. Centers for Disease Control and Prevention. EHE Progress: Ending the HIV Epidemic in the U.S. Initiative. Published August 14, 2023. https://www.cdc.gov/endhiv/ehe-progress/index.html
  3. Substance Abuse and Mental Health Services Administration. The Case for Behavioral Health Screening in HIV Care Settings. U.S. Department of Health and Human Services; 2016. https://store.samhsa.gov/sites/default/files/d7/priv/sma16-4999.pdf.
  4. Remien RH, Stirratt MJ, Nguyen N, Robbins RN, Pala AN, Mellins CA. Mental health and HIV/AIDS: the need for an integrated response. AIDS. 2019;33(9):1411. https://doi.org/10.1097/QAD.0000000000002227.
  5. Centers for Disease Control and Prevention, U.S. Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States — 2021 Update – A Clinical Practice Guideline. Published online 2021. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf.
  6. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (U.S.), Centers for Disease Control and Prevention. A Guide to Taking a Sexual History. Published online August 5, 2021. https://stacks.cdc.gov/view/cdc/108651/cdc_108651_DS1.pdf
  7. Marcus R, Tie Y, Dasgupta S, et al. Characteristics of Adults With Diagnosed HIV Who Experienced Housing Instability: Findings From the Centers for Disease Control and Prevention Medical Monitoring Project, United States, 2018. The Journal of the Association of Nurses in AIDS Care: JANAC 2022;33(3):283-294. https://doi.org/10.1097/JNC.0000000000000314.
  8. Padilla M, Frazier EL, Carree T, Shouse RL, Fagan J. Mental Health, Substance Use and HIV Risk Behaviors among HIV-Positive Adults Who Experienced Homelessness in the United States — Medical Monitoring Project, 2009–2015. AIDS Care. 2020;32(5):594-599. https://doi.org/10.1080/09540121.2019.1683808.
  9. National Academy of Medicine. National Plan for Health Workforce Well-Being. The National Academies Press; 2022. https://doi.org/10.17226/26744.
  10. Centers for Disease Control and Prevention. Support for Public Health Workers and Health Professionals. Centers for Disease Control and Prevention. Published April 27, 2023. Accessed September 5, 2023. https://www.cdc.gov/mentalhealth/public-health-workers/index.html.
  11. Health Resources and Services Administration, John Snow, Inc. HRSA Health Center Workforce Survey Literature Review Summary. Published online 2020. https://publications.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=24050&lid=3.
  12. SteelFisher GK, Findling MG, Caporello HL, et al. Trust In US Federal, State, And Local Public Health Agencies During COVID-19: Responses And Policy Implications: Study reports the results of a survey of public trust in US federal, state, and local public health agencies’ performance during the COVID-19 pandemic. Health Aff (Millwood). 2023;42(3):328-337. https://doi.org/10.1377/hlthaff.2022.01204.
  13. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention and Centers for Disease Control and Prevention, “Issue Brief: Status Neutral HIV Care and Service Delivery.” Published November 29, 2022. https://www.cdc.gov/hiv/policies/data/status neutral-issue-brief.html.
  14. Centers for Disease Control and Prevention. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data — United States and 6 Dependent Areas, 2019. 2021;26(2). https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.
  15. AIDSVu. AIDSVu Releases New Data Showing Significant Inequities in PrEP Use Among Black and Hispanic Americans. AIDSVu. Published July 29, 2022. Accessed August 25, 2023. https://aidsvu.org/prep-use-race-ethnicity-launch-22/.
  16. The Center for HIV Law and Policy. HIV Criminalization in the United States: A Sourcebook on State and Federal HIV Criminal Law and Practice, CHLP (updated February 2022). Published February 27, 2022. Accessed September 6, 2023. https://www.hivlawandpolicy.org/resources/hiv-criminalization-united-states-sourcebook-state-and-federal-hiv-criminal-law-and.
  17. Harsono D, Galletly CL, O’Keefe E, Lazzarini Z. Criminalization of HIV Exposure: A Review of Empirical Studies in the United States. AIDS and Behavior. 2017;21(1):27-50. https://doi.org/10.1007/s10461-016-1540-5.
  18. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomdical Informatics. 2009;42(2):377-381. https://doi.org/10.1016/j.jbi.2008.08.010.
  19. RStudio Team. RStudio: Integrated Development for R. Published online 2020. https://www.rstudio.com/.

HealthHIV Research and Evaluation

State of Aging With HIV

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HealthHIV Research and Evaluation conducts regular national surveys to better inform ongoing advocacy, education, research, and training activities. These "State Of" surveys provide unique insight into patient and provider issues in order to optimize primary and support services for diverse communities. The regular reports offer the ability to study multi-year trend analyses illustrating changes, challenges, and opportunities to address the needs of providers and patients. HealthHIV, HealthHCV and the National Coalition for LGBTQ Health conduct State of surveys addressing HIV care, HCV care, LGBTQ healthcare, and aging with HIV.

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