Projecting the Clinical and Economic Impacts of Changes to HIV Care Among Adolescents and Young Adults in the United States: Lessons From the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, many US youth with HIV (YHIV) used telehealth services; others experienced disruptions in clinic and antiretroviral therapy (ART) access. METHODS: Using the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-Adolescent HIV microsimulation model, we evaluated 3 scenarios: 1) Clinic: in-person care; 2) Telehealth: virtual visits, without CD4 or viral load monitoring for 12 months, followed by return to usual care; and 3) Interruption: complete care interruption with no ART access or laboratory monitoring for 6 months (maximum clinic closure time), followed by return to usual care for 80%. We assigned higher 1-year retention (87% vs 80%) and lower cost/visit ($49 vs $56) for Telehealth vs Clinic. We modeled 2 YHIV cohorts with non-perinatal (YNPHIV) and perinatal (YPHIV) HIV, which differed by mean age (22 vs 16 years), sex at birth (85% vs 47% male), starting CD4 count (527/µL vs 635/µL), ART, mortality, and HIV-related costs. We projected life months (LMs) and costs/100 YHIV over 10 years. RESULTS: Over 10 years, LMs in Clinic and Telehealth would be similar (YNPHIV: 11 350 vs 11 360 LMs; YPHIV: 11 680 LMs for both strategies); costs would be $0.3M (YNPHIV) and $0.4M (YPHIV) more for Telehealth than Clinic. Interruption would be less effective (YNPHIV: 11 230 LMs; YPHIV: 11 620 LMs) and less costly (YNPHIV: $1.3M less; YPHIV: $0.2M less) than Clinic. Higher retention in Telehealth led to increased ART use and thus higher costs. CONCLUSIONS: Telehealth could be as effective as in-person care for some YHIV, at slightly increased cost. Short interruptions to ART and laboratory monitoring may have negative long-term clinical implications.

Cardiovascular Risk Assessment Among Adolescents and Youths Living With HIV: Evaluation of Electronic Health Record Findings and Implications.

BACKGROUND: The HIV epidemic remains a major public health concern, particularly among youths living with HIV. While the availability of antiretroviral therapy has significantly improved the health outcomes of people living with HIV, there is growing evidence that youths living with HIV may be at increased risk of cardiovascular disease. However, the underlying mechanisms linking HIV and cardiovascular disease among youths living with HIV remain poorly understood. One potential explanation is that HIV-related biomarkers, including detectable viral load (VL) and low cluster of differentiation 4 (CD4) lymphocyte counts, may contribute to increased cardiovascular risk. Despite the potential importance of these biomarkers, the relationship between HIV-related biomarkers and cardiovascular risk among youths living with HIV has been understudied. OBJECTIVE: To address this gap, we examined whether detectable VL and low CD4 lymphocyte counts, both of which are indications of unsuppressed HIV, were associated with cardiovascular risk among youths living with HIV. METHODS: We analyzed electronic health record data from 7 adolescent HIV clinics in the United States (813 youths living with HIV). We used multivariable linear regression to examine the relationship between detectable VL and CD4 lymphocyte counts of ≤200 and cardiovascular risk scores, which were adapted from the gender-specific Framingham algorithm. RESULTS: In our study, nearly half of the participants (366/766, 47.8%) had detectable VL, indicating unsuppressed HIV, while 8.6% (51/593) of them had CD4 lymphocyte counts of ≤200, suggesting weakened immune function. We found that those with CD4 lymphocyte counts of ≤200 had significantly higher cardiovascular risk, as assessed by Cardiac Risk Score2, than those with CD4 lymphocyte counts of >200 (P=.002). After adjusting for demographic and clinical factors, we found that for every 1000-point increase in VL copies/mL, the probability of having cardiovascular risk (Cardiac Risk Score2) increased by 38%. When measuring the strength of this connection, we observed a minor effect of VL on increased cardiovascular risk (ß=.134, SE 0.014; P=.006). We obtained similar results with Cardiac Risk Score1, but the effect of CD4 lymphocyte counts of ≤200 was no longer significant. Overall, our findings suggest that detectable VL is associated with increased cardiovascular risk among youths living with HIV, and that CD4 lymphocyte counts may play a role in this relationship as well. CONCLUSIONS: Our study highlights a significant association between unsuppressed HIV, indicated by detectable VL, and increased cardiovascular risk in youths living with HIV. These findings emphasize the importance of implementing interventions that address both VL suppression and cardiovascular risk reduction in this population. By tailoring interventions to meet the unique needs of youths, we can promote overall well-being throughout the HIV care continuum and across the life span. Ultimately, these efforts have the potential to improve the health outcomes and quality of life of youths living with HIV. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/11185.

'Don't judge me 'til you walk through my shoes': A qualitative investigation of the experiences of women living with HIV.

OBJECTIVE: Women living with the human immunodeficiency virus (HIV) are less of a focus in the HIV literature, which tends to focus on the HIV experiences of men who have sex with men (MSMs). Hence, we conducted a qualitative study that examined: (a) the type of stigma and discrimination that women living with HIV experience related to their HIV status, (b) the source of this stigma and discrimination, (c) their responses related to this stigma and discrimination, and (d) the ways in which women living with HIV cope with these experiences of stigma and discrimination. DESIGN: Participants consisted of 14 self-identified women living with HIV that were recruited at a community organization in the Southern United States that provides services to individuals living with HIV. The participants ranged in age from 27 to 65 (M = 47.92, SD = 13.08). The sample primarily identified as Black (N = 12), followed by White (N = 1) and Multiracial (N = 1). Most women were cisgender (N = 13) with one woman identifying as transgender (N = 1). RESULTS: Fourteen women participated in one of two focus groups (seven in each focus group), which were audio recorded and transcribed. We identified 24 categories across five domains (Stigma and Discrimination, Source of Stigma and Discrimination, Response to Stigma and Discrimination, Coping with Stigma and Discrimination, and Support). CONCLUSIONS: This study identified that women living with HIV experience stigma and discrimination in a multitude of ways from different sources. Moreover, women with HIV responded to and coped in negative and positive ways. Multidimensional approaches including personal and community education may help alleviate the stigma and discrimination faced by women living with HIV.

Racial and ethnic differences in the availability of community medical services after leaving prison.

INTRODUCTION: Incarcerated individuals experience increased health problems, presenting additional challenges as they leave prison and re-enter the community. These challenges are disproportionally experienced by racial and ethnic minorities. Despite these trends, little is known regarding the availability of medical services within the communities to which incarcerated individuals return. METHODS: We examined all prison returns in the state of Florida between 2008 and 2017. We examined the odds of returning from prison to a community that is formally designated as medically underserved by the Health Resources and Services Administration. We also examined whether Florida communities with a greater proportion of racial and ethnic minority returns were more likely to be designated as medically underserved. RESULTS: Overall, each SD increase in community return rate resulted in a 20% increase in the odds of medical underservice designation. For each SD increase in the proportion of black and Latino returns, the odds of medical underservice designation increased by 50% and 14%, respectively, compared with the proportion of white returns. DISCUSSION: Within Florida, previously incarcerated individuals are more likely to return to communities with limited availability of medical services. These findings are even more pronounced for communities with more black returnees. Previously incarcerated individuals are more likely to return to communities that lack the medical infrastructure required to address their unique healthcare needs, potentially leading to worsened health, and increased racial and ethnic health disparities.

Racial inequities in emergency department wait times for pregnancy-related concerns.

OBJECTIVE: Emergency department care is common among US pregnant women. Given the increased likelihood of serious and life-threatening pregnancy-related health conditions among Black mothers, timeliness of emergency department care is vital. The objective of this study was to evaluate racial/ethnic variations in emergency department wait times for receiving obstetrical care among a nationally representative population. METHODS: The study used pooled 2016-2018 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of emergency department visits. Regression models were estimated to determine whether emergency department wait time was associated with the race/ethnicity of the perinatal patient. Adjusted models controlled for age, obesity status, insurance type, whether the patient arrived by ambulance, triage status, presence of a patient dashboard, and region. RESULTS: There were a total of 821 reported pregnancy-related visits in the National Hospital Ambulatory Medical Care Survey sample of emergency department visits. Of those 821 visits, 40.6% were among White women, 27.7% among Black women, and 27.5% among Hispanic women. Mean wait times differed substantially by race/ethnicity. After adjusting for potential confounders, Black women waited 46% longer than White women with emergency department visits for pregnancy problems (p < .05). Those reporting another race waited 95% longer for pregnancy problems in the emergency department than White women (p < .05). CONCLUSION: Findings from this study document significant racial/ethnic differences in wait times for perinatal emergency department care. Although inequities in wait times may emerge across the spectrum of care, documenting the factors influencing racial disparities in wait times are critical to promoting equitable perinatal health outcomes.

Impact of the COVID-19 Pandemic on the Care Continuum of Youth Living with HIV: Qualitative Study of the Scale It Up Program Clinical Sites.

The study objective was to explore the impact of COVID-19 pandemic restrictions on the clinics' ability to provide continuous healthcare services to youth (15-24 years) living with HIV (YLWH). One focused semi-structured interview was conducted with each HIV clinic site-resulting in ten interviews. Data were analyzed using thematic analysis techniques assisted by NVIVO coding software and themes indicating barriers and facilitators to providing uninterrupted healthcare were elicited. Six themes were identified that affected the care continuum of YLWH: Timeframe of clinic preparation to address COVID-19 restrictions; impact on treatment cascade monitoring data; impact on patient care; impact on staff and services offered; software use and virtual visits; community impact. With careful planning and preparation, clinics were able to successfully implement a process of care that adapted to COVID-19 restrictions. Guidance is provided on how healthcare facilities can effectively incorporate strategies to provide continued services during pandemics and natural disasters.

Feasibility of Using Electronic Health Records for Cascade Monitoring and Cost Estimates in Implementation Science Studies in the Adolescent Trials Network for HIV/AIDS Interventions.

BACKGROUND: One of the most difficult areas in the fight against HIV/AIDS is reaching out to youth aged 13 to 24 years. The proportion of youth living with HIV/AIDS on antiretroviral therapy (ART) and who are virally undetectable is low, highlighting significant challenges for reaching the Joint United Nations Program on HIV targets. OBJECTIVE: This study aimed to assess the feasibility of obtaining key clinical indicators and monitoring treatment, viral suppression, and retention components of the youth HIV treatment cascade in Adolescent Trials Network for HIV/AIDS Interventions clinics using electronic health record (EHR) downloads and to provide baseline characteristics for the study participants. METHODS: EHR data were systematically obtained from multiple clinical sites and used to meaningfully capture clinical characteristics, initiation of antiretrovirals, and retention in care, which are part of the Centers for Disease Control and Prevention's 4 continuum of care measures. In addition, this study used standard cost values attached to Current Procedural Terminology codes to estimate the cost per visit. RESULTS: Only 2 of the 4 Centers for Disease Control and Prevention treatment cascade measures were assessed using routine EHR data. EHR data are not adequate for monitoring HIV testing or linkage to care because denominator data are not available. However, the data work well for measuring ART initiation and adequately for retention in care. The sites were broadly able to provide information for the required data. However, in most cases, these data are insufficient for identifying patterns of missed appointments because such misses are not captured in the EHR system. Sites with good access to data management resources can operate more efficiently for cascade monitoring study purposes. CONCLUSIONS: Data other than EHRs are needed to measure HIV testing and linkage to youth care. EHR data are useful for measuring ART initiation and work moderately well for measuring retention in care. Site data management resources should be part of the selection process when looking for site partners for clinical studies that plan to use EHR data. Study planners should determine the feasibility of additional funding for organizations in need of additional information technology or data management resources.

Barriers and Facilitators to the Collection and Aggregation of Electronic Health Record HIV Data: An Analysis of Study Recruitment Venues Within the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN).

Electronic health record (EHR) data can be leveraged for prospective cohort studies and pragmatic clinical trials, targeting youth living with HIV (YLH). Using EHRs in this manner may minimize the need for costly research infrastructure in service to lowering disease burden. This study characterizes HIV prevention and care continua variables and identifies factors likely to impede or facilitate EHR use for research and interventions. We conducted telephone-based qualitative interviews with National Experts (n = 10) and Key Stakeholders (n = 19) from subject recruitment venues (SRVs), providing care services to YLH and youth at risk for HIV. We found 17 different EHR systems being used for various purposes (e.g., workflow management and billing). Thematic content analysis of interviews highlighted six broad categories of perspectives on barriers to and facilitators of EHR use: specific variable collection, general use barriers, and facilitators, general data collection barriers and facilitators, EHRs for surveillance and research, EHRs for personnel and resource management and capture of HIV specific variables. These findings may inform implementation strategies of future studies, in which we conduct routine monitoring of the youth HIV prevention and care continua using EHRs and test an eHealth intervention.

Racial Disparities in Healthcare Utilization Among Individuals with Cardiometabolic Risk Factors and Comorbid Anxiety Disorder.

OBJECTIVE: This study addresses racial/ethnic differences in adverse health care utilization among individuals with comorbid anxiety disorder and cardiometabolic syndrome (CMetS) risk factors. METHODS: Utilizing 2011-2015 Medical Expenditure Panel Survey (MEPS) data, logistic regression models were estimated to determine the likelihood of receiving CMetS-related medical treatment in the emergency department (ED) or via inpatient services and to determine if the likelihood is associated with race/ethnicity. Adjusted models controlled for age, sex, and insurance type. RESULTS: Significant racial-ethnic differences were observed for utilization (any emergency department and/or inpatient visit). The odds of non-Hispanic Black respondents reporting emergency department and/or inpatient utilization was 2.39 (p < 0.05) times the odds of non-Hispanic White respondents. CONCLUSION: Racial-ethnic variation in adverse healthcare utilization suggests an opportunity to improve care and outcomes for persons diagnosed with comorbid anxiety disorder and cardiometabolic syndrome. Integrated interventions could simultaneously improve mental health and facilitate CMetS disease self-management.

Cascade Monitoring in Multidisciplinary Adolescent HIV Care Settings: Protocol for Utilizing Electronic Health Records.

BACKGROUND: Past research shows that youth living with HIV (YLH) are not as engaged in the HIV treatment cascade as other HIV-positive populations. To achieve the health benefits of rapid and widespread testing and advanced pharmacologic treatment, YLH must be fully engaged in every stage of the treatment cascade. Cascade monitoring provides an opportunity to assess the youth care cascade, including engagement in care and when youth commonly drop out of care, across 10 clinical sites in the United States. Collecting electronic health record (EHR) data for prevention and care across participant recruitment venues within the Adolescent Medicine Trials Network (ATN) allows for monitoring of the prevention and care cascades within the ATN, for comparing the ATN population to large-scale surveillance, for future integration of technology-based interventions into EHRs, and for informing ATN strategic planning. OBJECTIVE: The aim of this protocol study is to examine the trends in treatment cascade, including whether patients are receiving antiretroviral therapy, adhering to regimens, attending care appointments, and maintaining suppressed viral loads, to guide new protocol development and to facilitate community engagement. This protocol is part of the ATN Scale It Up (SIU) program described in this issue. METHODS: Deidentified EHR data of YLH, aged 15 to 24 years, will be collected annually (2017 to 2022) from 10 ATN clinical sites, resulting in patient data from 2016 to 2021. These data will be transferred and stored using Dropbox Business, a Health Insurance Portability and Accountability Act-compliant site and then analyzed by the SIU analytic core. RESULTS: This study was launched in December 2017 in 10 clinical sites, with 2016's EHR data due on January 31, 2017. All 10 sites electronically uploaded their EHR data. The mandatory variables requested to monitor cascade of care include date of visit, age, gender, height, weight, race, ethnicity, viral load, and International Classification of Diseases codes for other diagnosis. In total, 70% of the sites provided data for all mandatory variables. The remaining mandatory variables were manually extracted. CONCLUSIONS: This study will provide a platform to determine how YLH across the nation progress through or drop out of the HIV treatment cascade. It will also provide a foundation for assessing impact of SIU projects on treatment cascade outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11185.

Variation in out of pocket health care costs for individuals with anxiety disorders by type of insurance coverage.

PURPOSE: Given that out-of-pocket (OOP) costs impact adherence to treatment and recent and proposed changes to the health insurance system that impact OOP costs, it is imperative to understand the OOP cost burden faced by individuals with anxiety disorders depending upon type of insurance coverage. The objective of this study was to determine the annual OOP cost burden faced by individuals with anxiety disorders and the variation of these costs by type of insurance coverage. METHODS: Using weighted nationally representative data from the 2011-2014 Medical Expenditure Panel Surveys, total OOP health care costs were assessed for all respondents who indicated that they had an anxiety disorder (N = 9985). Total OOP health care costs were also calculated separately by type of insurance. RESULTS: Average annual OOP costs among individuals with anxiety was $1152. The highest OOP cost were incurred by individuals with private fee-for-service (FFS) insurance ($1356/year, 4.1% of annual income), while individuals enrolled in HMOs with dual Medicare/Medicaid had the lowest OOP cost ($129/year, 6.8% of annual income). Individuals without insurance had high OOP cost burden ($1309/year, 12.5% of annual income). CONCLUSION: Individuals with anxiety disorders have a wide range of OOP cost depending upon their insurance coverage. Those with anxiety should carefully consider their choice of insurance coverage if interested in minimizing OOP costs.

Sociodemographic Influences of Emergency Department Care for Anxiety Disorders.

This study examines variations in content of care for anxiety-related emergency department (ED) visits in the USA across various sociodemographic strata. The 2009-2012 National Hospital Ambulatory Medical Care Survey was used to identify all visits to general hospital EDs in which an anxiety diagnosis was recorded (n = 1930). Content and equitability of care was assessed utilizing logistic regression models. There were an estimated 1,856,000 ED visits with anxiety-related discharge diagnoses in the USA annually. Content of care and disposition varied by age, race/ethnicity, and insurance status. Visits by Medicaid patients were more likely than visits by privately insured patients to include a toxicology screen (OR = 1.67, p < .05) and visits by patients with either Medicaid or Medicare were less likely to include an EKG (OR = 0.53, p < .05 and OR = 0.52, p < .05, respectively). Understanding variations in ED care for anxiety can identify opportunities for intervention, both in the ED and upstream in appropriate healthcare settings.

Epidemiology of Emergency Department Visits for Anxiety in the United States: 2009-2011.

OBJECTIVE: The purpose of this study was to describe the epidemiology of anxiety-related emergency department (ED) visits in the United States and assess the care provided during those visits. METHODS: Data from the 2009-2011 National Hospital Ambulatory Medical Care Survey were used to identify all ED visits in which the patient received a primary anxiety diagnosis or declared anxiety as the reason for the visit (N=1,029). Patient characteristics, treatment provided, and dispositions of these nationally representative visits were assessed. RESULTS: There were an estimated 1,247,000 anxiety-related ED visits annually, representing .93% of all ED visits. The proportion of total ED visits that were anxiety related was higher among women than men (1.05% versus .77%) and among nonelderly adults (1.28%) versus other age groups, non-Hispanic whites (1.06%) versus other racial-ethnic groups, and self-pay visits (1.20%) versus other forms of insurance. Among anxiety-related visits, a small percentage (9.6%) involved admission to the hospital, and approximately 67% involved a referral back to the patient's medical care professional. Regarding content of care, most visits for anxiety involved diagnostic or screening services, and one-fourth involved medical procedures. Anxiolytics and benzodiazepines were prescribed most often when drug therapy was offered during anxiety visits in the ED. CONCLUSIONS: EDs were frequently used by patients experiencing anxiety symptoms. In the vast majority of visits, follow-up visits with providers were planned. The most common treatment provided during these ED visits was benzodiazepines, which can offer immediate anxiety symptom relief but are potentially dangerous because of risk of overdose and addiction.

Patterns of information behavior and prostate cancer knowledge among African-American men.

The purposes of this study are to explore cancer information acquisition patterns among African-American men and to evaluate relationships between information acquisition patterns and prostate cancer prevention and control knowledge. A random sample of 268 men participated in a statewide interviewer-administered, telephone survey. Men classified as non-seekers, non-medical source seekers, and medical source seekers of prostate cancer information differed on household income, level of education, and beliefs about personal risk for developing prostate cancer. Results from multiple regression analysis indicated that age, education, and information-seeking status were associated with overall levels of prostate cancer knowledge. Results from logistic regression analyses indicated that men who included physicians as one of many information resources (medical source seekers) had superior knowledge over non-seekers and non-medical source seekers on 33% of individual knowledge details. The findings emphasize the need to connect lower-income and lower-educated African-American men to physicians as a source of prostate cancer control information.

Gender differences in financial hardships of medical debt.

Women are more likely than men to forgo, delay, and ration medical care because of medical debt. Using 2003-04 Community Tracking Study Household Survey data, this study examined gender differences in five financial hardships associated with medical debt. Regression analyses accounting for predisposing, enabling, and need factors of health services use indicated women were less likely to report being contacted by a collection agency (b=-0.15, p<.05), using savings (b=-0.23, p<.005), or having any financial hardships associated with medical debt (b=-0.24, p<.05). There were no significant gender differences in putting off major purchases, borrowing money, and problems paying for necessities. Similarly, there were positive and negative relationships between medical debt financial hardships and income, insurance, and health status. Findings suggest that making health care affordable and equitable is critically important for both men and women. Research is needed to understand the differential impact of medical debt, especially among disadvantaged populations.

Applicability of a video intervention to increase informed decision making for prostate-specific antigen testing.

PURPOSE: To evaluate the applicability of an evidence-based video intervention to promote informed decision making for prostate cancer screening among African American men with different levels of health literacy. METHODS: Forty nine African American men participated in interviewer-administered, pretest and posttest interviews between January and March 2008. Health literacy status was assessed with the Test of Functional Health Literacy in Adults. Repeated measures analysis of covariance (ANCOVA), McNemar or binomial distributions were computed to assess pretest and posttest differences in knowledge. Descriptive statistics were produced to describe participants' perceptions of the information presented in the video. RESULTS: Results indicated that men with functional health literacy had higher mean levels of prostate cancer screening knowledge at baseline than men with inadequate health literacy. The between-group (F2,44= 4.84; p = .013) and within-group (F1,44 = 5.16; p = .028) test results from repeated-measures ANCOVA indicated that preexisting group differences in prostate cancer knowledge had lessened after intervention exposure. Nearly all men rated the information presented in the video as credible (98%), trustworthy (96%), interesting (100%), understandable (94%), and complete (96%). CONCLUSIONS: Results from this exploratory study suggest that the video intervention is suitable for use with African American men with different health literacy characteristics in 2 counties in the greater Florida panhandle region. More research is recommended to evaluate the impact of the intervention on men's intentions to undergo screening and actual screening behavior.