Improving HCV Risk Assessment and Testing in a Federally Qualified Health Center Setting in Baltimore, Maryland.

Approximately 4.1 million adults in the United States have past or current hepatitis C virus (HCV) infection. Despite efforts to test at least once for the 1945-1965 birth cohort population and others identified at risk, the completion of the annual risk assessment tool and testing of these patients has been suboptimal. The aim of this project was to reduce HCV risk assessment and testing barriers and improve both these rates by 30% within a federally qualified health center setting in Baltimore, Maryland. As part of ongoing efforts to promote HCV risk screening and testing, targeted interventions of staff education, streamlined risk screening assessment, automated electronic health record alerts, push reports, and standing orders were integrated into current screening and testing practices. This study examined the risk assessment tool use and testing rates for 1 month before and after project implementation. All patients who were seen for a primary care visit during the month preceding (n = 8911) and following (n = 8228) the intervention were evaluated. A total of 2973 risk assessments and 1831 HCV tests were completed pre-intervention compared to 3708 risk assessments and 3790 tests post-intervention, demonstrating a 35% and 125% improvement respectively. Seropositivity prevalence of 2.1% pre-intervention increased to 2.9% post-intervention. Efficiencies in workflow processes and staff education successfully impacted the HCV risk screening tool completions and testing rates for the birth cohort and non-birth cohort patients. Integrating such strategies in the primary care workflow can increase HCV detection and timely follow up for vulnerable populations.

Integration of Anal Dysplasia Screening into the Primary Care of Persons Living with HIV.

Anal dysplasia can lead to anal cancer, which affects persons living with HIV (PLWH) more than people in the general population. Screening for anal dysplasia is recommended to detect anal cancer at an early stage. The aim of our process improvement project was to improve compliance and consistency in implementing anal dysplasia screening for PLWH receiving care at a Ryan White facility covering 18 counties in western North Carolina. There were 291 PLWH screened for anal dysplasia during the 9-month data-gathering period. The compliance rate significantly increased from a preintervention rate of 31.3% to 57.5% (p < .001). There were 109 (37.5%) abnormal screening results. PLWH who had abnormal screening results were more likely to be White. Gender and age were not significantly associated with abnormal screening results. Anal dysplasia screening is a simple procedure to detect precursors to cancer that can be integrated into the primary care of PLWH.

The Development of an HIV Training Program for Nurse Practitioners.

Responding to a national need for a new workforce of HIV care providers as the first generation of providers decrease their practices or retire, the Duke University School of Nursing, with funding from the Health Resources and Services Administration, developed and implemented a program to train nurse practitioners (NP) to assume the full spectrum of primary care services needed by people living with HIV infection and various co-morbidities. The 12-credit program includes course work in HIV-related epidemiology; pathogenesis; psychosocial, political, ethical, and legal issues; and pharmacology and clinical management. Students complete 392 hours of HIV-specific clinical practice in addition to clinical hours required of all NP students. The program is the only distance-based program of its kind in the United States. Online didactic instruction is complemented by campus-based sessions with interprofessional faculty. We describe the 5 overarching goals that frame the program, and challenges and progress toward achieving those goals.

Entry-Level Competencies Required of Primary Care Nurse Practitioners Providing HIV Specialty Care: A National Practice Validation Study.

In the United States, only 30% of HIV-infected persons are diagnosed, engaged in care, provided antiretroviral therapy, and virologically suppressed. Competent HIV care providers are needed to achieve optimal clinical outcomes for all people living with HIV, but 69% of Ryan White Clinics in the United States report difficulty recruiting HIV clinicians, and one in three current HIV specialty physicians are expected to retire in the next decade. Nurse practitioners who specialize in HIV and have caseloads with large numbers of HIV-infected patients have care outcomes that are equal to or better than that provided by physicians, especially generalist non-HIV specialist physicians. We designed a national practice validation study to help prepare the next generation of primary care nurse practitioners who desire to specialize in HIV. This manuscript reports the results of the national study and identifies entry-level competencies for entry-level primary care nurse practitioners specializing in HIV.

Fatigue in HIV-Infected People: A Three-Year Observational Study.

CONTEXT: HIV-related fatigue remains the most frequent complaint of seropositive patients. OBJECTIVES: To describe the natural course of fatigue in HIV infection, in a sample (n=128) followed for a three-year period. METHODS: A longitudinal prospective design was used to determine what factors influenced changes in fatigue intensity and fatigue-related impairment of functioning in a community-dwelling sample of HIV-infected individuals. Participants were followed every six months for a three-year period. At each study visit, we collected data on a large number of physiological and psychosocial markers that have been shown to be related to fatigue in HIV-infected people. At three month intervals between study visits, we collected data on fatigue via mailed questionnaires. RESULTS: Fatigue in HIV infection is largely a result of stressful life events, and is closely tied to the anxiety and depression that accompany such events. Fatigue did not remit spontaneously over the course of the study, indicating the need for interventions to ameliorate this debilitating symptom. CONCLUSION: Intervening to help people who are suffering from HIV-related fatigue to deal with stressful life events may help to ameliorate this debilitating symptom.

Integrating routine HIV screening into a primary care setting in rural North Carolina.

Blacks living in the southern United States are disproportionately affected by HIV infection. Identifying and treating those who are infected is an important strategy for reducing HIV transmission. A model for integrating rapid HIV screening into community health centers was modified and used to guide implementation of a testing program in a primary care setting in a small North Carolina town serving a rural Black population. Anonymous surveys were completed by 138 adults who were offered an HIV test; of these, 61% were female and 89.9% were Black. One hundred patients (72%) accepted the test. Among those Black survey respondents who accepted an offer of testing, 58% were women. The most common reason for declining an HIV test was lack of perceived risk; younger patients were more likely to get tested. Implementation of the testing model posed challenges with time, data collection, and patient flow.

Intensity, chronicity, circumstances, and consequences of HIV-related fatigue: a longitudinal study.

HIV-related fatigue remains the most troubling complaint of seropositive people. Researchers often use tools to measure fatigue that were developed for other patient populations; thus, the measurement of fatigue specific to HIV is needed. This article describes results from the HIV-Related Fatigue Scale (HRFS) including: (a) the variability in intensity and chronicity of HIV-related fatigue, (b) the circumstances surrounding changes in fatigue, (c) the impact of fatigue on activities of daily living (ADLs), and (d) the consequences of HIV-related fatigue. We collected data every 3 months over a 3-year period from 128 people. HIV-related fatigue was chronic and did not appear to remit spontaneously; those who were the most fatigued at the beginning of the study remained the most fatigued over 3 years. Fatigue interfered more with instrumental activities of daily living than basic ADLs; it also interfered with work, family, and social life. Stress and depression increased fatigue.

Physiological and psychosocial factors that predict HIV-related fatigue.

Fatigue is one of the most common and debilitating symptoms experienced by HIV-infected people. We report the results of our longitudinal analysis of physiological and psychosocial factors that were thought to predict changes in HIV-related fatigue in 128 participants over a 1-year period, in an effort to sort out the complex interplay among a comprehensive set of physiological and psychosocial variables. Physiological measures included hepatic function (aspartate aminotransferase, alanine aminotransferase, gamma glutamyl transpeptidase, alkaline phosphatase, total bilirubin, hepatitis C status), thyroid function (thyroid stimulating hormone, thyroxine), HIV viral load, immunologic function (CD4, CD8, CD4/CD8 ratio, CD16, CD8CD38), gonadal function (testosterone, dehydroepiandrosterone), hematologic function (hemoglobin, hematocrit, serum erythropoietin), and cellular injury (lactic acid). Psychosocial measures included childhood and adult trauma, anxiety, depression, social support, stressful life events, and post-traumatic stress disorder (PTSD). Unemployment, not being on antiretroviral therapy, having fewer years since HIV diagnosis, more childhood trauma, more stressful life events, less social support, and more psychological distress (e.g., PTSD, anxiety and depression) put HIV-infected persons at risk for greater fatigue intensity and fatigue-related impairment in functioning during 1-year follow-up. Physiological variables did not predict greater fatigue. Stressful life events had both direct and indirect effects on fatigue.

Chronicity and remission of fatigue in patients with established HIV infection.

Fatigue is one of the most common and debilitating complaints of HIV-positive individuals, potentially leading to important functional limitations. We recruited 128 HIV-positive individuals (fatigued and nonfatigued) between March 2005 and May 2006; 66% were male, 66% were African American, 45% had greater than a high school education, 67% were unemployed, and ages ranged from 26-66 (median, 44). Every 3 months for 15 months, participants completed a 56-item self-report fatigue scale developed and validated by the authors. Participants were classified as fatigued or not fatigued at each assessment and received scores for fatigue intensity and impact of fatigue on functioning. We used linear mixed-effects models to assess longitudinal variation in fatigue scores and generalized estimating equations for binary outcomes to model predictors of fatigue remission among those fatigued at baseline. At baseline, 88% of the sample was fatigued. Fatigue measures were highly correlated across time points (rho 0.63-0.85 [intensity], 0.63-0.80 [functioning]) and showed no evidence of overall improvement, deterioration, or convergence over time. Predictors of lower fatigue scores included higher income, employment, longer time since HIV diagnosis, and antiretroviral therapy use. Those employed at baseline were likely to show improvements in fatigue while those unemployed were not. Of those fatigued at baseline, 11% experienced remission during follow-up; remission was associated with Caucasian race and employment. In summary, fatigue intensity and related functional limitations were persistent, stable, and unlikely to remit over 15 months of follow-up in this sample of patients with established HIV infection.

Daytime sleepiness, nighttime sleep quality, stressful life events, and HIV-related fatigue.

In this report, the authors describe the relationships between daytime sleepiness, nighttime sleep quality, stressful life events, and HIV-related fatigue in a sample of 128 individuals; they report the baseline results of a longitudinal observational study. They examined sleep using the Pittsburgh Sleep Quality Index (a measure of the quality of nighttime sleep), and the Epworth Sleepiness Scale, (a measure of daytime sleepiness). Recent stressful life events were measured via a methodology developed in a previous 9-year HIV study. Poor nighttime sleep was significantly correlated with fatigue intensity (r = .46, p < .05), as was daytime sleepiness (r = .20, p < .05). However, in multiple regression models, the association between stress and fatigue intensity was not explained by daytime sleepiness and was only partially explained by nighttime sleep quality. Further research is needed to better elucidate these relationships.

Demographic and illness-related variables associated with HIV-related fatigue.

Fatigue is one of the most debilitating symptoms suffered by those with HIV infection, yet little is known about its correlates. The primary aims of this study were to describe the degree to which fatigue affects daily functioning and the demographic and illness-related predictors of fatigue. The sample (n = 128) was composed of primarily poor, unemployed people of color. Fatigue most often interfered with the ability to think quickly, perform household chores, exercise, work, engage in recreational activities, walk, plan activities, and think clearly. The consequences of fatigue were highest for lowered motivation, difficulty concentrating, increased drowsiness, losing patience, and interference with work, family, and social life. Multiple linear regression analyses showed statistically significant associations of employment status, monthly income, current antidepressant use, and number of years living with HIV infection as predictors of fatigue. These must be better understood to develop interventions to successfully ameliorate HIV-related fatigue.

Physiological correlates of HIV-related fatigue.

Our primary aim is to describe the relationship of multiple physiological variables and HIV-related fatigue. We report baseline data collected from 128 human immunodeficiency virus (HIV)-positive individuals. The HIV-Related Fatigue Scale was used to measure several aspects of fatigue. Blood was drawn for the following physiological variables: hepatic function, thyroid function, HIV viral load, immunologic function, gonadal function, hematologic function, serum cortisol, and cellular injury. In bivariable analyses, free testosterone (p=0.03) and CD8 (p=0.07) were negatively correlated with fatigue intensity, and nonlinear relationships were observed between fatigue intensity and total testosterone (p=0.02), thyroxine (p=0.01), hematocrit (p=0.06), and total bilirubin (p=0.06). However, none of these associations persisted in multivariable models. It is possible that fatigue suffered by seropositive people is better predicted by other variables, which must be better understood to develop interventions to successfully ameliorate HIV-related fatigue.