Factors Affecting Adherence With Follow-up Appointments in HIV Patients.

Currently, the majority of new human immunodeficiency virus (HIV) infections are transmitted by individuals with untreated HIV. In this retrospective study, we examined associations between demographic factors, viral suppression, acquired immunodeficiency syndrome (AIDS) status (CD4 count <200), and adherence to clinical follow-up in individuals living with HIV. Of the 489 patients, 135 (27.6%) were females, 235 (48.1%) were over 50 years old, 191 (39.1%) had Medicaid, Medicare, or Ryan White Insurance, 25 (5.1%) had CD4 counts below 200, and 207 (42.3%) were adherent to their clinic appointments. In univariable logistic regression analysis, age and viral load detectability were significantly associated with patient adherence to their clinic appointment. In multivariable analysis, only age remained significantly associated with clinic appointment adherence (Odds Ratio=2.1; 95% Confidence Interval=1.4, 3.1; P<0.001). Patients 50 years old or younger were half as likely to be adherent to their clinic appointments than patients over 50 years old. Gender and insurance status were not associated with viral suppression or AIDS status. The results illustrate the need for increased age-specific outreach to improve clinical adherence in younger individuals.

HIV post-exposure prophylaxis in the emergency department: An updated assessment and opportunities for HIV prevention identified.

OBJECTIVES: Research suggests nonoccupational post exposure prophylaxis (nPEP) is under prescribed for people seeking treatment within 72 h of human immunodeficiency virus (HIV) exposures in the emergency department (ED). This study is an assessment of ED prescribers' knowledge, attitudes and practices regarding administration of HIV nPEP. METHODS: This was an anonymous survey based on literature review and modified Delphi technique. We approached 153 ED participants at work over a 4-month period from 5 hospital-based and 2 freestanding EDs. There were 152 completed surveys: 80 attendings, 27 residents, and 44 physician assistants. RESULTS: The majority of those surveyed (133/149, 89.3%) believe it is their responsibility to provide HIV nPEP in the ED. Although 91% (138/151) and 87% (132/151) of participants are willing to prescribe nPEP for IV drug use and unprotected sex, respectively, only 40% (61/152) of participants felt they could confidently prescribe the appropriate regimen. Only 25% (37/151) of participants prescribed nPEP in the last year. Participants considered time (27%), connecting patients to follow-up (26%), and cost to patients (23%), as barriers to prescribing nPEP. CONCLUSIONS: This study identified perceived barriers to administration of nPEP and missed opportunities for HIV prevention in the ED. Although most ED prescribers were willing to prescribe nPEP and felt it is their responsibility to do so, the majority of prescribers were not confident in prescribing it. The most commonly cited barriers to prescribing nPEP were time and access to follow-up care.

Nodular granulomatous Pneumocystis jiroveci pneumonia consequent to delayed immune reconstitution inflammatory syndrome.

Although Pneumocystis jiroveci pneumonia (PCP) is a frequent manifestation of acquired immune deficiency syndrome (AIDS), the granulomatous form is uncommon. Here, we present an unusual case of granulomatous PCP consequent to immune reconstitution inflammatory syndrome (IRIS) after highly active antiretroviral therapy. A 36-year-old woman with human immunodeficiency virus (HIV) presented with cough and dyspnea that were attributed to typical PCP associated with AIDS. She was successfully treated with antibiotic, steroid, and antiretroviral therapies. After six months, however, she presented with consolidating lung lesions caused by bronchial obstruction from PCP granulomatous disease. Although antibiotics were ineffective, the effectiveness of steroid therapy suggested a diagnosis of granulomatous IRIS caused by persistent PCP antigens. Physicians should strongly suspect PCP in HIV-positive patients with nodular lung lesions and must remain aware that these lesions, if immune in origin, might not respond to antimicrobial therapy.

Head and neck emergencies: bacterial meningitis, encephalitis, brain abscess, upper airway obstruction, and jugular septic thrombophlebitis.

Head and neck infectious disease emergencies can be rapidly fatal without prompt recognition and treatment. Empiric intravenous (IV) antibiotics should be initiated immediately in any patient with suspected bacterial meningitis, and IV acyclovir in any patient with suspected encephalitis. Surgical intervention is often necessary for brain abscesses, epiglottitis, and Ludwig's angina. A high index of suspicion is often needed to diagnose epiglottitis, Ludwig's angina, and Lemierre's syndrome. Brain infections can have high morbidity among survivors. In this article, the causes, diagnostic tests, treatment, and prognosis are reviewed for some of the more common head and neck infectious disease emergencies.

Health-care worker vaccination for influenza: strategies and controversies.

Influenza infections cause significant morbidity and mortality throughout the world, and vaccination rates of health-care workers remain well below target goals. Strategies for increasing vaccination rates include mandatory vaccination of health-care workers, mandatory declination, employee incentives, intensive education, increased access to vaccines, and the use of social media to inform employees of the safety and efficacy of vaccination. While these strategies in combination have been shown to be effective in increasing vaccination rates, personal and religious objections, as well as the potential for infringing on individual autonomy, remain challenges in our efforts to bring health-care worker vaccination rates up to target goals.