Relationship Between Patient Portal Tool Use and Medication Adherence and Viral Load Among Patients Living with HIV.

BACKGROUND: Patient portals play an increasingly critical role in engaging patients in their health care. They have the potential to significantly impact the health of those living with chronic diseases, such as HIV, for whom consistent care engagement is both critical and complex. OBJECTIVE: The primary aim was to examine the longitudinal relationships between individual portal tool use and health-related outcomes in patients living with HIV. DESIGN: Retrospective cohort study using electronic health record data to examine the relationship between patient portal tool use and key HIV-specific, health-related outcomes in patients engaged in care in the Veterans Health Administration (VA) through the application of marginal structural models. PARTICIPANTS: A national sample of patients living with HIV (PLWH) active in VA care who were registered to use the VA's patient portal, My HealtheVet (MHV; n = 18,390) between 10/1/2012 and 4/1/2017. MAIN MEASURES: The MHV tools examined were prescription refill (including prescription refill of an antiretroviral (ART) medication and any medication), secure messaging, view appointments, and view labs. Primary outcomes were viral load test receipt, viral load suppression, and ART medication adherence (measured as proportion of days covered). KEY RESULTS: The use of prescription refill for any medication or for ART was positively associated with ART adherence. Secure messaging was positively associated with ART adherence but not with viral load test receipt or viral load suppression. The use of view appointments was positively associated with ART adherence and viral load test receipt but not viral load suppression. The use of view labs was positively associated with viral load suppression but not ART adherence or viral load test receipt. CONCLUSIONS: These findings highlight the valuable role patient portals may play in improving health-related outcomes among PLWH and have implications for patients living with other types of chronic disease.

Implementation of Direct-to-Patient Mobile Teledermatology in VA.

BACKGROUND: Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective. OBJECTIVE: We evaluated Department of Veterans Affairs' (VA's) implementation of My VA Images, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person. DESIGN /PARTICIPANTS/APPROACH: Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app's implementation using qualitative and quantitative data consisting of encounter data from VA's corporate data warehouse; app usage from VA's Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff. KEY RESULTS: Implementation policies and practices included VA's vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process. CONCLUSIONS: Considerable heterogeneity existed in implementing mobile teledermatology, despite VA's common mission, integrated healthcare system, and stakeholders' broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier. CLINICAL TRIALS REGISTRATION: NCT03241589.

Harm reduction stories: leveraging graphic medicine to engage veterans in substance use services within the VA.

BACKGROUND: Harm reduction strategies can decrease morbidity and mortality associated with substance use. Various barriers limit conversation around substance use between clinicians and patients. Graphic medicine techniques can inform and encourage patient-centered conversations about substance use. We describe the co-development of a harm reduction-focused graphic medicine comic that depicts the infectious risks associated with injection drug use and patient-centered approaches to providing education about potential risk mitigation strategies. METHODS: We formed a co-design group of veterans with lived experience with substance use, physicians, health services researchers, and community-based harm reduction leaders. Over the course of ten sessions, the co-design team developed a storyline and key messages, reviewed draft content and worked with a graphic designer to develop a comic incorporating the veterans' input. During each session, co-design leads presented drafts of the comic and invited feedback from the group. The comic was edited and adapted via this iterative process. RESULTS: The comic depicts a fictionalized clinical vignette in which a patient develops an injection-related abscess and presents to their primary care provider. The dialogue highlights key healthcare principles, including patient autonomy and agency, and highlights strategies for safer use, rather than emphasizing abstinence. Feedback from co-design group participants highlights lessons learned during the development process. DISCUSSION: Graphic medicine is ideally suited for a patient-centered curriculum about harm reduction. This project is one of several interventions that will be integrated into VA facilities nationally to support incorporation of harm reduction principles into the care of persons who inject drugs.

Organizational Readiness for Patient-Facing Mobile Teledermatology to Care for Established Veteran Patients in the United States.

Purpose: To improve patient access to skin care, the Department of Veterans Affairs (VA) developed a patient-facing asynchronous mobile teledermatology application (app), which allows patients to follow up remotely with dermatologists. To understand how the app would be received in VA, we examined Organizational Readiness for Change (ORC), an important prelude to effective implementation, which includes the shared resolve and collective ability of organizational members to implement a change. Methods: We used a mixed-methods multiple case study approach to assess ORC at three VA facilities. Data derived from a site process call, surveys, and semistructured telephone interviews of VA staff, field notes, and administrative data. Results: Participants at all three facilities supported the intervention and recognized the value of using the app to increase patients' access to dermatologists, but expressed concerns largely related to disruption of the pre-existing clinical workflow. Participants at the facility most actively using the app had the highest overall ORC score and reported the most facilitators. Facility leadership support when guided by a clinical champion minimized barriers by recognizing the complexities of health care provision at specialty clinics. Discussion: While provider buy-in remained a barrier, leadership, guided by the clinical champion, played a critical role instituting implementation strategies. The strong association between the ORC survey score and the presence of facilitators and barriers suggests that the ORC survey may be a rapid, convenient, and effective tool for health care systems to identify favorable sites for wider implementation of mobile telehealth care. Clinical Trials Identifier: NCT03241589.

Staff and Veteran Perspectives on Residential Treatment Programs' Responses to COVID-19: A Qualitative Study Guided by the WHO's After Action Review Framework.

Healthcare must rapidly and systematically learn from earlier COVID-19 responses to prepare for future crises. This is critical for VA's Mental Health Residential Rehabilitation and Treatment Programs (RRTPs), offering 24/7 care to Veterans for behavioral health and/or homelessness. We adapted the World Health Organization's After Action Review (AAR) to conduct semi-structured small-group discussions with staff from two RRTPs and Veterans who received RRTP care during COVID-19, to examine COVID-19's impact on these programs. Six thematic categories emerged through qualitative analysis (participant-checked and contextualized with additional input from program leadership), representing participants' recommendations including: Keep RRTPs open (especially when alternative programs are inaccessible), convey reasons for COVID-19 precautions and programming changes to Veterans, separate recovery-oriented programming from COVID-19-related information-sharing, ensure Wi-Fi availability for telehealth and communication, provide technology training during orientation, and establish safe procedures for off-site appointments. AAR is easily applicable for organizations to debrief and learn from past experiences.

Is the Availability of Direct-Acting Antivirals Associated with Increased Access to Hepatitis C Treatment for Homeless and Unstably Housed Veterans?

OBJECTIVE: Hepatitis C virus (HCV) treatment has experienced a rapid transformation in the USA. New direct-acting antiviral (DAA) medications make treatment easier, less toxic, and more successful (90% or greater viral cure) than prior, interferon-based HCV medications. We sought to determine whether DAAs may have improved access to HCV treatment for hard-to-reach populations such as the homeless. METHODS: In a retrospective study of VA electronic medical record data, a cohort was created of 63,586 veterans with a positive HCV RNA or genotype test taken at any point from January 1, 2012, through December 31, 2016. Patient data were examined for up to 5 years using a discrete time survival model to assess the relationship between their housing status and receipt of HCV medications in 6-month time periods in both the interferon and DAA eras. RESULTS: In the interferon era, the probability of HCV treatment in a given 6-month window among housed veterans, at 6.2% (95% CI: 5.3-7.1%) was significantly higher than among veterans who were homeless or unstably housed; for example, among currently homeless veterans, the probability of treatment initiation, in a given 6-month window, was 2.6% (95% CI: 1.9-3.3%). With the arrival of DAAs, each housing category had an increased probability of treatment initiation. For housed veterans, the probability was 8.6% (95% CI: 8.3-8.9%) while for currently homeless veterans, it was 6.3% (95% CI: 5.7-6.9%). CONCLUSIONS: We found a clear indication that the likelihood of treatment initiation was greater for all veterans in the DAA era as compared to the interferon era. However, disparities in treatment initiation rates between housed and homeless veterans that were observed in the interferon era persisted in the DAA era.

Patients' and Providers' Views on Optimal Evidence-Based and Scalable Interventions for Individuals at High Risk of HIV Treatment Failure: Sequential Explorations Among Key Stakeholders in Cape Town, South Africa.

To support translation of evidence-based interventions into practice for HIV patients at high risk of treatment failure, we conducted qualitative research in Cape Town, South Africa. After local health officials vetted interventions as potentially scalable, we held 41 in-depth interviews with patients with elevated viral load or a 3-month treatment gap at community clinics, followed by focus group discussions (FGDs) with 20 providers (physicians/nurses, counselors, and community health care workers). Interviews queried treatment barriers, solutions, and specific intervention options, including motivational text messages, data-informed counseling, individual counseling, peer support groups, check-in texts, and treatment buddies. Based on patients' preferences, motivational texts and treatment buddies were removed from consideration in subsequent FGDs. Patients most preferred peer support groups and check-in texts while individual counseling garnered the broadest support among providers. Check-in texts, peer support groups, and data-informed counseling were also endorsed by provider sub-groups. These strategies warrant attention for scale-up in South Africa and other resource-constrained settings.

Real-time Feedback to Improve HIV Treatment Adherence in Pregnant and Postpartum Women in Uganda: A Randomized Controlled Trial.

We assessed an intervention aimed at improving adherence to antiretroviral therapy (ART) among pregnant and postpartum women living with HIV (PPWLH). We randomized 133 pregnant women initiating ART in Uganda to receive text reminders generated by real time-enabled electronic monitors and data-informed counseling through 3 months postpartum (PPM3) or standard care. Intention-to-treat analyses found low adherence levels and no intervention impact. Proportions achieving ≥95% adherence in PPM3 were 16.4% vs. 9.1% (t = -1.14, p = 0.26) in intervention vs. comparison groups, respectively; 30.9% vs. 29.1% achieved ≥80% adherence. Additional analyses found significant adherence declines after delivery, and no effect on disease progression (CD4-cell count, viral load), though treatment interruptions were significantly fewer in intervention participants. Per-protocol analyses encompassing participants who used adherence monitors as designed experienced better outcomes, suggesting potential benefit for some PPWLH. The study was registered on ClinicalTrials.Gov (NCT02396394).

Applying after action review to examine residential treatment programs' responses to COVID-19.

Resurgences of COVID-19 cases are a grave public health concern. Hence, there is an urgent need for health care systems to rapidly and systematically learn from their responses to earlier waves of COVID-19. To meet this need, this article delineates how we adapted the World Health Organization's After Action Review (AAR) framework to use within our health care system of the United States Department of Veterans Affairs. An AAR is a structured, methodical evaluation of actions taken in response to an event (e.g., recent waves of COVID-19). It delivers an actionable report regarding (i) what was expected, (ii) what actually happened, (iii) what went well, and (iv) what could have been done differently, and thus what changes are needed for future situations. We share as an example our examination of Mental Health Residential Rehabilitation and Treatment Programs in Massachusetts (a COVID-19 hotspot). Our work can be further adapted, beyond residential treatment, as a consistent framework for reviewing COVID-19 responses across multiple health care programs. This will identify both standardized and tailored preparations that the programs can make for future waves of the pandemic. Given the expected resurgences of COVID-19 cases, the time to apply AAR is now.

Provider Perceptions of Virtual Care During the Coronavirus Disease 2019 Pandemic: A Multispecialty Survey Study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to a dramatic increase in virtual care (VC) across outpatient specialties, but little is known regarding provider acceptance of VC. OBJECTIVE: The objective of this study was to assess provider perceptions of the quality, efficiency, and challenges of VC versus in-person care with masks. DESIGN: This was a voluntary survey. PARTICIPANTS: Mental health (MH), primary care, medical specialty, and surgical specialty providers across the 8 VA New England Healthcare System medical centers. MEASURES: Provider ratings of: (1) quality and efficiency of VC (phone and video telehealth) compared with in-person care with masks; (2) challenges of VC; and (3) percentage of patients that providers are comfortable seeing via VC in the future. RESULTS: The sample included 998 respondents (49.8% MH, 20.6% primary care, 20.4% medical specialty, 9.1% surgical specialty; 61% response rate). Most providers rated VC as equivalent to or higher in quality and efficiency compared with in-person care with masks. Quality ratings were significantly higher for video versus phone (χ2=61.4, P<0.0001), but efficiency ratings did not differ significantly. Ratings varied across specialties (highest in MH, lowest in SS; all χ2s>24.1, Ps<0.001). Inability to conduct a physical examination and patient technical difficulties were significant challenges. MH providers were comfortable seeing a larger proportion of patients virtually compared with the other specialties (all χ2s>12.2, Ps<0.01). CONCLUSIONS: Broad provider support for VC was stratified across specialties, with the highest ratings in MH and lowest ratings in SS. Findings will inform the improvement of VC processes and the planning of health care delivery during the COVID-19 pandemic and beyond.

How Should We Organize Care for Patients With Human Immunodeficiency Virus and Comorbidities? A Multisite Qualitative Study of Human Immunodeficiency Virus Care in the United States Department of Veterans Affairs.

BACKGROUND: With human immunodeficiency virus (HIV) now managed as a chronic disease, health care has had to change and expand to include management of other critical comorbidities. We sought to understand how variation in the organization, structure and processes of HIV and comorbidity care, based on patient-centered medical home (PCMH) principles, was related to care quality for Veterans with HIV. RESEARCH DESIGN: Qualitative site visits were conducted at a purposive sample of 8 Department of Veterans Affairs Medical Centers, varying in care quality and outcomes for HIV and common comorbidities. Site visits entailed conduct of patient interviews (n=60); HIV care team interviews (n=60); direct observation of clinic processes and team interactions (n=22); and direct observations of patient-provider clinical encounters (n=45). Data were analyzed using a priori and emergent codes, construction of site syntheses and comparing sites with varying levels of quality. RESULTS: Sites highest and lowest in both HIV and comorbidity care quality demonstrated clear differences in provision of PCMH-principled care. The highest site provided greater team-based, comprehensive, patient-centered, and data-driven care and engaged in continuous improvement. Sites with higher HIV care quality attended more to psychosocial needs. Sites that had consistent processes for comorbidity care, whether in HIV or primary care clinics, had higher quality of comorbidity care. CONCLUSIONS: Provision of high-quality HIV care and high-quality co-morbidity care require different care structures and processes. Provision of both requires a focus on providing care aligned with PCMH principles, integrating psychosocial needs into care, and establishing explicit consistent approaches to comorbidity management.

Using Lean-Facilitation to Improve Quality of Hepatitis C Testing in Primary Care.

BACKGROUND: Lean management has been successfully employed in healthcare to improve outcomes and efficiencies. Facilitation is increasingly being used to support evidence-based practice uptake in healthcare. However, while both Lean and Facilitation are used in healthcare quality improvement, limited research has explored their integration and the sustainability of their combined effects. OBJECTIVE: To improve hepatitis C virus (HCV) screening rates among persons born between 1945 and 1965 through the design and evaluation of a multi-modal Lean-Facilitation intervention (LFI) for Department of Veterans Affairs primary care community clinics. DESIGN: We conducted a mixed methods quasi-experimental evaluation in eight clinics, guided by the integrated Promoting Action on Research Implementation in Health Services framework. PARTICIPANTS: We engaged regional and local leadership (N = 9), implemented our LFI with clinicians and staff (N = 68), and conducted summative interviews with participants (N = 13). INTERVENTION: The LFI included six implementation strategies: (1) external facilitation, (2) stakeholder engagement, (3) champion activation, (4) rapid process improvement sessions, (5) Plan-Do-Study-Act cycles, and (6) audit-feedback. MEASURES: The primary outcome was rate of new HCV screening among previously untested patients with a primary care visit. Using interrupted time series, we analyzed intervention and time effects on HCV testing rates, and administered organizational readiness surveys, conducted summative qualitative interviews, and tracked facilitation events. RESULTS: The LFI was associated with significant, immediate, and sustained increases in HCV testing. No change was detected at matched comparison clinics. Staff accepted the LFI and the philosophy of "bottom-up" solution development yet had mixed feedback on its appropriateness and feasibility. Enablers of implementation and early sustainment included lower satisfaction with baseline HCV testing processes and staff culture, while later sustainment was related to implementation climate support, measurement, and evaluation. CONCLUSIONS: High-reach and relatively low effort, but persistent intervention led to significant improvement in guideline-concordant HCV testing rates which were sustained. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02936648.

Roadblocks to PrEP: What Medical Records Reveal About Access to HIV Pre-exposure Prophylaxis.

BACKGROUND: Pre-exposure prophylaxis (PrEP) has been shown to be efficacious in preventing HIV; however, its uptake remains modest. Given that there are fewer cost barriers to receiving PrEP within VHA than via commercial insurance, VHA represents an ideal setting in which to study other barriers that may impact patients seeking PrEP. OBJECTIVE: We sought to understand potential barriers to obtaining PrEP within the Veterans Health Administration (VHA) through examination of documentation in electronic medical records. DESIGN: Retrospective structured chart review, including chart abstractions of notes, referrals, and communications; content analysis of charts from a subsample of patients receiving PrEP in VHA. PARTICIPANTS: One hundred sixty-one patients prescribed PrEP at 90 sites varying in PrEP prescribing rates. APPROACH: We extracted descriptive information and conducted a qualitative analysis of all PrEP-relevant free-text notes including who initiated the PrEP conversation (patient vs. provider), time interval between request and prescription, reasons for denying PrEP, and patient responses to barriers. KEY RESULTS: Patients initiated 94% of PrEP conversations and 35% of patients experienced delays receiving PrEP ranging from six weeks to 16 months. Over 70% of cases evidenced barriers to access. Barriers included provider knowledge gaps about PrEP, provider knowledge gaps about VHA systems related to PrEP, confusion or disagreement over clinic purview for PrEP, and provider attitudes or stigma associated with patients seeking PrEP. CONCLUSIONS: Although PrEP is recommended for HIV prevention in high-risk persons, many PrEP-eligible individuals faced barriers to obtaining a prescription. Current practices place substantial responsibility on patients to request and advocate for this service, in contrast to many other preventive services. Understanding the prevalence and content of PrEP knowledge gaps and attitudinal barriers can inform organizational interventions to increase PrEP access and decrease HIV transmission.

Retention in HIV Care Among HIV-Seropositive Pregnant and Postpartum Women in Uganda: Results of a Randomized Controlled Trial.

We tested an intervention that aimed to increase retention in antiretroviral therapy (ART) among HIV-positive pregnant and postpartum women, a population shown to be vulnerable to poor ART outcomes. 133 pregnant women initiating ART at 2 hospitals in Uganda used real time-enabled wireless pill monitors (WPM) for 1 month, and were then randomized to receive text message reminders (triggered by late dose-taking) and data-informed counseling through 3 months postpartum or standard care. We assessed "full retention" (proportion attending all monthly clinic visits and delivering at a study facility; "visit retention" (proportion of clinic visits attended); and "postpartum retention" (proportion retained at 3 months postpartum). Intention-to-treat and per protocol analyses found that retention was relatively low and similar between groups, with no significant differences. Retention declined significantly post-delivery. The intervention was unsuccessful in this population, which experiences suboptimal ART retention and is in urgent need of effective interventions.

The Connectedness of Mental Health Providers Referring Patients to a Treatment Study for Post-Traumatic Stress: A Social Network Study.

We conducted a process evaluation in the context of a Hybrid Type 1 randomized controlled trial testing two treatments for post-traumatic stress, using a web-based social network survey and semi-structured interviews to illustrate the relationship between providers' influence and likelihood of referring patients to the RCT. Providers with high indegree centrality (designated by other providers as someone they seek information from) were significantly more likely to refer patients to the RCT, and serve as an influence to others' referral behavior. Interviews provided additional data to consider for future studies aimed at increasing the uptake of evidence-based practices.

Primary care provider perceptions and experiences of implementing hepatitis C virus birth cohort testing: a qualitative formative evaluation.

BACKGROUND: In 2014, the Department of Veterans Affairs (VA) adopted a screening test policy for hepatitis C virus (HCV) in all "Baby Boomers" - those born between 1945 and 1965. About 1 in 12 Veterans were estimated to be infected with HCV yet approximately 34% of the birth cohort remained untested. Early HCV diagnosis and successful antiviral treatment decrease the risk of onward transmission, cirrhosis, hepatocellular carcinoma, liver transplant, and death. Implementing evidence-based HCV screening in primary care has great potential to reduce morbidity and mortality. To inform design and implementation of a quality improvement intervention, we studied primary care provider (PCP) perceptions of and experiences with HCV birth cohort testing. METHODS: We conducted a formative evaluation using qualitative semi-structured interviews guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Twenty-two PCPs in six states across a large integrated US healthcare system were interviewed. Content analysis with a priori and emergent codes was performed on verbatim interview transcripts. RESULTS: We identified three themes related to primary care provider HCV testing and linkage practices, as mapped to i-PARIHS constructs: 1) evaluating cues to HCV testing (innovation/evidence), 2) framing HCV testing decisions (recipients), and 3) HCV testing and linkage to care in the new treatment era (context). The most frequently reported HCV testing cue was an electronic clinical reminder alert, followed by clinical markers and the presence of behavioral risk factors. Most PCPs saw testing as routine, but less urgent, leading to some reluctance. Providers largely saw themselves as performing guideline-concordant testing, yet no performance data were available to assess performance. Given the recent availability of new HCV medications, many PCPs were highly motivated to test and link patients to specialty care for treatment. CONCLUSIONS: Our results suggest a multi-component intervention around awareness and education, feedback of performance data, clinical reminder updates, and leadership support, would address both a significant need, and be deemed acceptable and feasible to primary care providers.

Experiences with interferon-free hepatitis C therapies: addressing barriers to adherence and optimizing treatment outcomes.

BACKGROUND: Millions of Americans are living with hepatitis C, the leading cause of liver disease in the United States. Medication treatment can cure hepatitis C. We sought to understand factors that contribute to hepatitis C treatment completion from the perspectives of patients and providers. METHODS: We conducted semi-structured interviews at three Veterans Affairs Medical Centers. Patients were asked about their experiences with hepatitis C treatments and perspectives on care. Providers were asked about observations regarding patient responses to medications and perspectives about factors resulting in treatment completion. Transcripts were analyzed using a grounded thematic approach-an inductive analysis that lets themes emerge from the data. RESULTS: Contributors to treatment completion included Experience with Older Treatments, Hope for Improvement, Symptom Relief, Tailored Organized Routines, and Positive Patient-Provider Relationship. Corresponding barriers also emerged, including pill burden and skepticism about treatment effectiveness and safety. CONCLUSION: Despite the improved side-effect profile of newer HCV medications, multiple barriers to treatment completion remain. However, providers and patients were able to identify avenues for addressing such barriers.

Use of testosterone in men infected with human immunodeficiency virus in the veterans healthcare system.

Testosterone supplementation has been widely used in those infected with human immunodeficiency virus (HIV) for hypogonadism, and wasting. But with effective antiretroviral therapy and increasing recognition of atherosclerotic disease and adults infected with HIV, the risks of inappropriate testosterone use in HIV-infected patients are far better recognized than previously. Testosterone use has expanded among U.S. males, but few studies have examined prescribing in those infected with HIV. In a national cohort of males with at least one outpatient prescription in the Veterans Health Administration (VHA), we examined 9475 HIV-infected males, including 2484 who had received testosterone and a randomly selected 6991 who had not. For comparison, we identified 1,387,241 uninfected males (189,369 had received testosterone and a randomly selected 1,197,872 had not). We determined rates of new and prevalent testosterone use, and also examined the adequacy of the diagnostic evaluation that had preceded testosterone initiation among our HIV-infected and uninfected testosterone groups. Our main results were as follows. HIV-infected men had higher rates of initiation (0.8% vs. 0.4% in FY09; p < 0.001) and prevalence of testosterone use (2.2% vs. 0.8% in FY08; p < 0.001) compared to the uninfected men across the entire period. Trends of prescribing for both groups followed a similar pattern, rising from FY08, reaching a peak in FY13, and then dipping in FY 14. Only 1.1% of HIV-infected patients had a fully guideline-concordant workup before starting testosterone therapy, compared to 3.5% of uninfected patients (p < 0.001). In conclusion, testosterone use among HIV-infected patients in the VHA system rose to a peak in FY13 and has decreased somewhat since. Only a small minority of HIV-infected patients who receive testosterone therapy from VHA have undergone an appropriate workup before starting therapy, suggesting an opportunity for improvement.

The relationship between gastrointestinal symptom attribution, bothersomeness, and antiretroviral adherence among adults with HIV.

Patients who attribute their symptoms to HIV medications, rather than disease, may be prone to switching antiretrovirals (ARVs) and experience poor retention/adherence to care. Gastrointestinal (GI) symptoms (e.g., nausea/vomiting) are often experienced as a side effect of ARVs, but little is known about the relationship of symptom attribution and bothersomeness to adherence. We hypothesized that attribution of a GI symptom to ARVs is associated with a reduction in adherence, and that this relationship is moderated by the bothersomeness of the symptom. Data for our analysis come from the pre-randomization enrollment period of a larger study testing an adherence improvement intervention. Analyses revealed that patients with diarrhea who attributed the symptom to ARVs (compared to those who did not) had significantly worse adherence. We did not find a significant moderating effect of bothersomeness on this relationship. Incorporating patient beliefs about causes of symptoms into clinical care may contribute to improved symptom and medication management, and better adherence.

"Where's My Choice?" An Examination of Veteran and Provider Experiences With Hepatitis C Treatment Through the Veteran Affairs Choice Program.

BACKGROUND: The Department of Veterans Affairs (VA) is the country's largest provider for chronic hepatitis C virus (HCV) infection. The VA created the Choice Program, which allows eligible veterans to seek care from community providers, who are reimbursed by the VA. OBJECTIVES: This study aimed to examine perspectives and experiences with the VA Choice Program among veteran patients and their HCV providers. RESEARCH DESIGN: Qualitative study based on semistructured interviews with veteran patients and VA providers. Interview transcripts were analyzed using rapid assessment procedures based in grounded theory. SUBJECTS: A total of 38 veterans and 10 VA providers involved in HCV treatment across 3 VA medical centers were interviewed. MEASURES: Veterans and providers were asked open-ended questions about their experiences with HCV treatment in the VA and through the Choice Program, including barriers and facilitators to treatment access and completion. RESULTS: Four themes were identified: (1) there were difficulties in enrollment, ongoing support, and billing with third-party administrators; (2) veterans experienced a lack of choice in location of treatment; (3) fragmented care led to coordination challenges between VA and community providers; and (4) VA providers expressed reservations about sending veterans to community providers. CONCLUSIONS: The Choice Program has the potential to increase veteran access to HCV treatment, but veterans and VA providers have described substantial problems in the initial years of the program. Enhancing care coordination, incorporating shared decision-making, and establishing a wide network of community providers may be important areas for further development in designing community-based specialist services for needy veterans.