A survey of barriers and facilitators to the adoption of buprenorphine prescribing after implementation of a New Jersey-wide incentivized DATA-2000 waiver training program.

BACKGROUND: Opioid-involved overdose deaths continue to rise in the US, despite availability of highly effective treatments for opioid use disorder (OUD), in part due to the insufficient number of treatment providers. Barriers include the need for providers to gain expertise and confidence in providing MOUD to their patients who need these treatments. To mitigate this barrier, New Jersey sponsored a buprenorphine training program with financial incentives for participation, which met the then existing requirement for the DATA-2000 waiver. In a 2019 follow-up survey, participants reported on barriers and facilitators to subsequent buprenorphine prescribing. METHODS: Participants in the training program completed a 10-min electronic survey distributed via email. The survey addressed demographics, practice characteristics, current buprenorphine prescribing, and barriers and facilitators to adoption and/or scale up of buprenorphine prescribing. RESULTS: Of the 440 attendees with a valid email address, 91 individuals completed the survey for a response rate of 20.6%. Of the 91 respondents, 89 were eligible prescribers and included in the final analysis. Respondents were predominantly female (n = 55, 59.6%) and physicians (n = 55, 61.8%); representing a broad range of specialties and practice sites. 65 (73%) of respondents completed the training and DEA-registration, but only 31 (34.8%) were actively prescribing buprenorphine. The most frequently cited barriers to buprenorphine prescribing were lack of access to support services such as specialists in addiction, behavioral health services, and psychiatry. The most frequently reported potential facilitators were integrated systems with direct access to addiction specialists and psychosocial services, easier referral to behavioral health services, more institutional support, and improved guidance on clinical practice standards for OUD treatment. CONCLUSION: More than half (52.3%) of those who completed incentivized training and DEA registration failed to actively prescribe buprenorphine. Results highlight provider perceptions of inadequate availability of support for the complex needs of patients with OUD and suggest that broader adoption of buprenorphine prescribing will require scaling up support to clinicians, including increased availability of specialized addiction and mental health services.

Disturbance type and species life history predict mammal responses to humans.

Human activity and land use change impact every landscape on Earth, driving declines in many animal species while benefiting others. Species ecological and life history traits may predict success in human-dominated landscapes such that only species with "winning" combinations of traits will persist in disturbed environments. However, this link between species traits and successful coexistence with humans remains obscured by the complexity of anthropogenic disturbances and variability among study systems. We compiled detection data for 24 mammal species from 61 populations across North America to quantify the effects of (1) the direct presence of people and (2) the human footprint (landscape modification) on mammal occurrence and activity levels. Thirty-three percent of mammal species exhibited a net negative response (i.e., reduced occurrence or activity) to increasing human presence and/or footprint across populations, whereas 58% of species were positively associated with increasing disturbance. However, apparent benefits of human presence and footprint tended to decrease or disappear at higher disturbance levels, indicative of thresholds in mammal species' capacity to tolerate disturbance or exploit human-dominated landscapes. Species ecological and life history traits were strong predictors of their responses to human footprint, with increasing footprint favoring smaller, less carnivorous, faster-reproducing species. The positive and negative effects of human presence were distributed more randomly with respect to species trait values, with apparent winners and losers across a range of body sizes and dietary guilds. Differential responses by some species to human presence and human footprint highlight the importance of considering these two forms of human disturbance separately when estimating anthropogenic impacts on wildlife. Our approach provides insights into the complex mechanisms through which human activities shape mammal communities globally, revealing the drivers of the loss of larger predators in human-modified landscapes.

Preexposure Prophylaxis Outcomes in an Urban Community in North Carolina: Discontinuation of Care and Sexually Transmitted Infections.

BACKGROUND: Few studies have examined long-term outcomes among persons who initiate preexposure prophylaxis (PrEP) in the South, including PrEP discontinuation and sexually transmitted infection (STI) rates. METHODS: Care discontinuation (>6 months without a PrEP appointment) and incident STIs were evaluated for patients at 2 PrEP clinics in Durham, NC. We tested for predictors of discontinuation as a binary variable using logistic regression. Model covariates included age, race/ethnicity, sex, known HIV-positive partner, commercial sex work, men who have sex with men (MSM) versus not MSM, type of insurance, and clinic site. A similar analysis was completed for STI incidence, controlling for days in the study. RESULTS: Among 271 patients, mean age was 33.2 years, 46.9% were Black and 11.1% were Latino, 81.2% were MSM, and 32% were uninsured. Preexposure prophylaxis was discontinued in 47%, and another 11% had intermittent care. Sexually transmitted infection incidence was 45.4/100 person-years, and 5 patients were diagnosed with HIV at baseline or in follow-up. Men who have sex with men were less likely to discontinue PrEP relative to non-MSM (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.10-0.64). Baseline STI was associated with a higher likelihood of incident STI (OR, 8.19; 95% CI, 3.69-19.21), whereas care discontinuation was associated with a lower likelihood of STI (OR, 0.28; 95% CI, 0.11-0.65). CONCLUSIONS: Preexposure prophylaxis programs in the Southern United States are reaching uninsured and predominantly Black and Latino MSM, but discontinuation rates are high despite elevated rates of incident STI and HIV. Further work is required to elucidate causes of PrEP discontinuation and encourage persistence in care.

Public Awareness of HIV Pre-Exposure Prophylaxis in Durham, North Carolina: Results of a Community Survey.

BACKGROUND Adoption of HIV pre-exposure prophylaxis (PrEP) remains limited among populations at greatest risk for HIV acquisition. This study aims to assess awareness of PrEP among individuals in Durham, North Carolina, which has one of the highest rates of HIV diagnoses in the state.METHOD In 2015-2016, we administered a survey including questions to assess PrEP awareness to individuals at multiple venues throughout Durham, North Carolina.RESULTS A total of 139 respondents were surveyed. The majority were male (66%) and black/African American (75%); 21% were Hispanic/Latino. There were an estimated 53 men who have sex with men (MSM), of which 18 (33%) were black MSM M 24 years of age. Overall, only 53/138 (38%) respondents were aware of PrEP. Awareness was reported among 33/52 (63%) MSM respondents, 29/46 (63%) black MSM, and 10/17 (59%) black MSM M 24 years of age. In multivariate analysis, non-heterosexual orientation, health-insured status, and prior HIV testing were significantly associated with PrEP awareness. Ninety-four (69%) of 137 respondents reported prior HIV testing.LIMITATIONS Limitations include non-random sampling and limited sample size. Further research needs to be done in other areas of North Carolina, and assessment of PrEP acceptability and uptake needs to be performed.CONCLUSION This study reveals low overall awareness of PrEP in Durham, North Carolina, indicating that expanded outreach is necessary to increase public awareness and encourage adoption of PrEP among all demographics at risk for HIV.

Best Practices in Videoconferencing-Based Telemental Health April 2018.

Telemental health, in the form of interactive videoconferencing, has become a critical tool in the delivery of mental health care. It has demonstrated the ability to increase access to and quality of care, and in some settings to do so more effectively than treatment delivered in-person. This article updates and consolidates previous guidance developed by The American Telemedicine Association (ATA) and The American Psychiatric Association (APA) on the development, implementation, administration, and provision of telemental health services. The guidance included in this article is intended to assist in the development and delivery of effective and safe telemental health services founded on expert consensus, research evidence, available resources, and patient needs. It is recommended that the material reviewed be contemplated in conjunction with APA and ATA resources, as well as the pertinent literature, for additional details on the topics covered.

Implementing standardized substance use disorder screening in primary care.

OBJECTIVES: This quality improvement initiative aimed to develop and implement a protocol for an alcohol and substance use disorder screening for primary care. METHODS: The Two Item Conjoint Screen was selected and a process was piloted by care teams. Quality improvement tools were used to improve the protocol. Primary care providers (PCPs) were surveyed about their use of the screening protocol in the primary care setting. Data on total number of screenings were collected through the electronic health record. RESULTS: Implementation resulted in more than 30,000 screenings completed in 2016. PCP survey results indicated that PCPs felt screening was helpful in identifying potential substance use problems (100%) and that most providers (76%) felt that overall patient care improved after screening was initiated. CONCLUSIONS: Brief alcohol and substance use disorder screenings can be easily implemented and well integrated into primary care settings. PCPs found screenings to be valuable in caring for patients.

Linguistic and Cultural Adaptation of a Computer-Based Counseling Program (CARE+ Spanish) to Support HIV Treatment Adherence and Risk Reduction for People Living With HIV/AIDS: A Randomized Controlled Trial.

BACKGROUND: Human immunodeficiency virus (HIV) disease in the United States disproportionately affects minorities, including Latinos. Barriers including language are associated with lower antiretroviral therapy (ART) adherence seen among Latinos, yet ART and interventions for clinic visit adherence are rarely developed or delivered in Spanish. OBJECTIVE: The aim was to adapt a computer-based counseling tool, demonstrated to reduce HIV-1 viral load and sexual risk transmission in a population of English-speaking adults, for use during routine clinical visits for an HIV-positive Spanish-speaking population (CARE+ Spanish); the Technology Acceptance Model (TAM) was the theoretical framework guiding program development. METHODS: A longitudinal randomized controlled trial was conducted from June 4, 2010 to March 29, 2012. Participants were recruited from a comprehensive HIV treatment center comprising three clinics in New York City. Eligibility criteria were (1) adults (age ≥18 years), (2) Latino birth or ancestry, (3) speaks Spanish (mono- or multilingual), and (4) on antiretrovirals. Linear and generalized mixed linear effects models were used to analyze primary outcomes, which included ART adherence, sexual transmission risk behaviors, and HIV-1 viral loads. Exit interviews were offered to purposively selected intervention participants to explore cultural acceptability of the tool among participants, and focus groups explored the acceptability and system efficiency issues among clinic providers, using the TAM framework. RESULTS: A total of 494 Spanish-speaking HIV clinic attendees were enrolled and randomly assigned to the intervention (arm A: n=253) or risk assessment-only control (arm B, n=241) group and followed up at 3-month intervals for one year. Gender distribution was 296 (68.4%) male, 110 (25.4%) female, and 10 (2.3%) transgender. By study end, 433 of 494 (87.7%) participants were retained. Although intervention participants had reduced viral loads, increased ART adherence and decreased sexual transmission risk behaviors over time, these findings were not statistically significant. We also conducted 61 qualitative exit interviews with participants and two focus groups with a total of 16 providers. CONCLUSIONS: A computer-based counseling tool grounded in the TAM theoretical model and delivered in Spanish was acceptable and feasible to implement in a high-volume HIV clinic setting. It was able to provide evidence-based, linguistically appropriate ART adherence support without requiring additional staff time, bilingual status, or translation services. We found that language preferences and cultural acceptability of a computer-based counseling tool exist on a continuum in our urban Spanish-speaking population. Theoretical frameworks of technology's usefulness for behavioral modification need further exploration in other languages and cultures. TRIAL REGISTRATION: ClinicalTrials.gov NCT01013935; https://clinicaltrials.gov/ct2/show/NCT01013935 (Archived by WebCite at http://www.webcitation.org/6ikaD3MT7).

Perceived medical risks of drinking, alcohol consumption, and hepatitis C status among heavily drinking HIV primary care patients.

BACKGROUND: Heavy drinking poses significant risks to the health and survival of individuals infected with HIV, particularly those coinfected with hepatitis C virus (HCV). However, little is known about patients' perceptions of these risks, and whether these perceptions relate to their alcohol consumption. METHODS: A sample of 254 heavily drinking HIV primary care patients (78% male; 94.5% minority; 31.8% with HCV) reported on their perceptions of the medical risks of drinking and on their alcohol consumption prior to participation in a drinking-reduction intervention trial. RESULTS: In the HIV-infected sample as a whole, 62.9% reported that they had a medical problem made worse by drinking, and 64.3% reported restricting drinking to avoid future medical problems. Although patients coinfected with HIV/HCV reported greater efforts to restrict drinking to avoid future medical problems (adjusted odds ratio = 1.94), their reported drinking quantity and frequency did not differ from that of HIV mono-infected patients. Awareness of medical risk was not associated with drinking level. Effort to restrict drinking to avoid medical risk was associated with lower drinking quantity, frequency, and binge frequency (ps < 0.05), but the association with binge frequency was specific to patients without HCV. CONCLUSIONS: Over one-third of HIV patients are unaware of the medical risks of drinking, and do not restrict use, suggesting the need for intervention in this group. Patients coinfected with HIV/HCV may report more effort to restrict drinking, but their reported drinking quantity and frequency suggest that they are actually drinking just as heavily as HIV mono-infected patients. Awareness of medical risk was unrelated to drinking, which suggests the need for interventions consisting of more than simple education. However, reported effort to restrict drinking did predict less drinking, suggesting the importance of patient commitment and initiative in change.

Low rates of hepatitis screening and vaccination of HIV-infected MSM in HIV clinics.

BACKGROUND: HIV-infected men who have sex with men (MSM) are at increased risk of viral hepatitis because of similar behavioral risk factors for acquisition of these infections. Our objective was to estimate adherence to HIV management guidelines that recommend screening HIV-infected persons for hepatitis A, B, and C infection, and vaccinating for hepatitis A and B if susceptible. METHODS: We evaluated hepatitis prevention services received by a random sample of HIV-infected MSM in 8 HIV clinics in 6 US cities. We abstracted medical records of all visits made by the patients to the clinic during the period from 2004 to 2007, to estimate hepatitis screening and vaccination rates overall and by clinic site. RESULTS: Medical records of 1329 patients who had 14,831 visits from 2004 to 2006 were abstracted. Screening rates for hepatitis A, B, and C were 47%, 52%, and 54%, respectively. Among patients who were screened and found to be susceptible, 29% were vaccinated for hepatitis A and 25% for hepatitis B. The percentage of patients screened and vaccinated varied significantly by clinic. CONCLUSIONS: Awareness of hepatitis susceptibility and hepatitis coinfection status in HIV-infected patients is essential for optimal clinical management. Despite recommendations for hepatitis screening and vaccination of HIV-infected MSM, rates were suboptimal at all clinic sites. These low rates highlight the importance of routine review of adherence to recommended clinical services. Such reviews can prompt the development and implementation of simple and sustainable interventions to improve the quality of care.

HealthCall: technology-based extension of motivational interviewing to reduce non-injection drug use in HIV primary care patients - a pilot study.

To reduce non-injection drug use (NIDU) among HIV primary care patients, more than a single brief intervention may be needed, but clinic resources are often too limited for extended interventions. To extend brief motivational interviewing (MI) to reduce NIDU, we designed and conducted a pilot study of "HealthCall," consisting of brief (1-3 minutes) daily patient calls reporting NIDU and health behaviors to a telephone-based interactive voice response (IVR) system, which provided data for subsequent personalized feedback. Urban HIV adult clinic patients reporting ≥4 days of NIDU in the previous month were randomized to two groups: MI-only (n=20) and MI+HealthCall (n=20). At 30 and 60 days, patients were assessed and briefly discussed their NIDU behaviors with their counselors. The outcome was the number of days patients used their primary drug in the prior 30 days. Medical marijuana issues precluded HealthCall with patients whose primary substance was marijuana (n=7); excluding these, 33 remained, of whom 28 patients (MI-only n=17; MI+HealthCall n=11) provided post-treatment data for analysis. Time significantly predicted reduction in "days used" in both groups (p<0.0001). At 60 days, between-group differences approached trend level, with an effect size of 0.62 favoring the MI+HealthCall arm. This pilot study suggests that HealthCall is feasible and acceptable to patients in resource-limited HIV primary care settings and can extend patient involvement in brief intervention with little additional staff time. A larger efficacy trial of HealthCall for NIDU-reduction in such settings is warranted.

Utilising Surrogate Models to Approximate Cardiac Potentials when Solving Inverse Problems via Bayesian Techniques.

Solving inverse problems is computationally expensive, if not infeasible, under specific scenarios. For example, many forward solutions are required when solving inverse problems using Bayesian techniques. In this work, a novel inference protocol is established, that can be used to infer the cardiac bidomain conductivities and the cardiac fibre rotation angle (bidomain parameters). This protocol uses a surrogate model, developed using generalised polynomial chaos techniques, to approximate cardiac potentials on a multi-electrode array. The resulting surrogate model is used in conjunction with Bayesian inference techniques to infer the bidomain parameters. A lower-order surrogate model (order three) can effectively characterise the influence of the extracellular conductivities and fibre rotation on the cardiac potentials; however, it is recommended that a higher-order surrogate model expansion of order seven be used to adequately characterise the influence of the intracellular conductivities as well. This seventh order surrogate model was successfully used to infer the extracellular conductivities and fibre rotation angle from a single set of synthetically generated noisy experimental potentials, while the intracellular conductivities were unable to be retrieved accurately under this scenario.

A modified approach to determine the six cardiac bidomain conductivities.

Accurate values for the six cardiac bidomain conductivities are crucial for meaningful computational studies of conduction in cardiac tissue, and are yet to be determined by experimental means. Although previous studies have proposed an approach using a multi-electrode array to measure potentials, from which the conductivities can be determined, it has been found that the conductivities cannot be retrieved consistently when the noise in the potentials varies. This paper presents a protocol, which not only has been shown to retrieve the conductivities to a reasonable accuracy, but does so under the presence of a more appropriate additive Gaussian noise model, while using fewer computational resources. Through repetitions of the protocol, a comparison of two pre-fabricated 128 electrode arrays, one array with a square arrangement of electrodes and the other with a rectangular arrangement, was made against a 75-electrode array proposed in previous studies. Results indicated that the two pre-fabricated arrays were generally more capable of obtaining the cardiac conductivities to a higher degree of accuracy than the 75-electrode array. The 128-electrode rectangular array was orientated such that the length of the array first ran along the direction of the fibres, then was reorientated such that the length of the array ran perpendicular to the direction of the fibres. The 128-electrode rectangular array, when orientated in this manner, was more capable of retrieving the conductivities than the remainder of the arrays tested, and thus we suggest this arrangement be used during experimental trials.

Which bidomain conductivity is the most important for modelling heart and torso surface potentials during ischaemia?

Mathematical simulations using the bidomain model, which represents cardiac tissue as consisting of an intracellular and an extracellular space, are a key approach that can be used to improve understanding of heart conditions such as ischaemia. However, key inputs to these models, such as the bidomain conductivity values, are not known with any certainty. Since efforts are underway to measure these values, it would be useful to be able to quantify the effect on model outputs of uncertainty in these inputs, and also to determine, if possible, which are the most important values to focus on in experimental studies. Our previous work has systematically studied the sensitivity of heart surface potentials to the bidomain conductivity values, and this was performed using a half-ellipsoidal model of the left ventricle. This study uses a bi-ventricular heart in a torso model and this time looks at the sensitivity of the torso surface potentials, as well as the heart surface potentials, to various conductivity values (blood, torso and the six bidomain conductivities). We found that both epicardial and torso potentials are the most sensitive to the intracellular longitudinal (along the cardiac fibres) conductivity (gil) with more minor sensitivity to the torso conductivity, and that changes in gil have a significant effect on the surface potential distributions on both the torso and the heart.

Improving Access to Hepatitis C Treatment Using Clinical Pharmacist Services in an Uninsured, At-Risk Population at a Community Health Center.

While published cure rates for new hepatitis C virus (HCV) treatments exceed 90%, barriers such as cost, medication access, housing or phone service instability, and substance use complicate medication adherence for uninsured, at-risk populations. Lincoln Community Health Center (LCHC) Pharmacy, in collaboration with primary care providers and care coordination professionals, implemented clinical pharmacist services to facilitate treatment of HCV infection in uninsured patients using manufacturers' patient assistance programs (PAP). Eighty-four (84) uninsured patients initiated treatment at LCHC using PAP during the first two years of the program. Nearly all patients (65/67 or 97%) who completed lab monitoring at 12 weeks post-treatment achieved undetectable viral load or a sustained virologic response (SVR-12), considered a proxy for cure. Successfully treating HCV infection in an uninsured, at-risk population may be achieved in a safety-net community health center by incorporating clinical pharmacist services into a team-based model.

STD screening of HIV-infected MSM in HIV clinics.

BACKGROUND: National guidelines for the care of human immunodeficiency virus (HIV)-infected persons recommend asymptomatic routine screening for sexually transmitted diseases (STDs). Our objective was to determine whether providers who care for HIV-infected men who have sex with men (MSM) followed these guidelines. METHODS: We abstracted medical records to evaluate STD screening at 8 large HIV clinics in 6 US cities. We estimated the number of men who had at least one test for syphilis, chlamydia (urethral and/or rectal), or gonorrhea (urethral, rectal, and/or pharyngeal) in 2004, 2005, and 2006. Urethral testing included nucleic acid amplification tests of both urethral swabs and urine. We also calculated the positivity of syphilis, chlamydia, and gonorrhea among screened men. RESULTS: Medical records were abstracted for 1334 HIV-infected MSM who made 14,659 visits from 2004-2006. The annual screening rate for syphilis ranged from 66.0% to 75.8% during 2004-2006. Rectal chlamydia and rectal and pharyngeal gonorrhea annual screening rates ranged from 2.3% to 8.5% despite moderate to high positivity among specimens from asymptomatic patients (3.0%-9.8%) during this period. Annual urethral chlamydia and gonorrhea screening rates were higher than rates for nonurethral sites, but were suboptimal, and ranged from 13.8% to 18.3%. CONCLUSIONS: Most asymptomatic HIV-infected MSM were screened for syphilis, indicating good provider adherence to this screening guideline. Low screening rates for gonorrhea and chlamydia, especially at rectal and pharyngeal sites, suggest that substantial barriers exist for complying with these guidelines. The moderate to high prevalence of asymptomatic chlamydial and gonococcal infections underscores the importance of screening. A range of clinical quality improvement interventions are needed to increase screening, including increasing the awareness of nucleic acid amplification tests for nonurethral screening.

Approaches for determining cardiac bidomain conductivity values: progress and challenges.

Modelling the electrical activity of the heart is an important tool for understanding electrical function in various diseases and conduction disorders. Clearly, for model results to be useful, it is necessary to have accurate inputs for the models, in particular the commonly used bidomain model. However, there are only three sets of four experimentally determined conductivity values for cardiac ventricular tissue and these are inconsistent, were measured around 40 years ago, often produce different results in simulations and do not fully represent the three-dimensional anisotropic nature of cardiac tissue. Despite efforts in the intervening years, difficulties associated with making the measurements and also determining the conductivities from the experimental data have not yet been overcome. In this review, we summarise what is known about the conductivity values, as well as progress to date in meeting the challenges associated with both the mathematical modelling and the experimental techniques. Graphical abstract Epicardial potential distributions, arising from a subendocardial ischaemic region, modelled using conductivity data from the indicated studies.

Differences between models of partial thickness and subendocardial ischaemia in terms of sensitivity analyses of ST-segment epicardial potential distributions.

Mathematical modelling is a useful technique to help elucidate the connection between non-transmural ischaemia and ST elevation and depression of the ECG. Generally, models represent non-transmural ischaemia using an ischaemic zone that extends from the endocardium partway to the epicardium. However, recent experimental work has suggested that ischaemia typically arises within the heart wall. This work examines the effect of modelling cardiac ischaemia in the left ventricle using two different models: subendocardial ischaemia and partial thickness ischaemia, representing the first and second scenarios, respectively. We found that it is possible, only in the model of subendocardial ischaemia, to see a single minimum on the epicardial surface above the ischaemic region, and this only occurs for low ischaemic thicknesses. This may help to explain the rarity of ST depression that is located over the ischaemic region. It was also found that, in both models, the epicardial potential distribution is most sensitive to the proximity of the ischaemic region to the epicardium, rather than to the thickness of the ischaemic region. Since proximity does not indicate the thickness of the ischaemic region, this suggests a reason why it may be difficult to determine the degree of ischaemia using the ST segment of the ECG.

The effect of including increased arterial stiffness in the upper body when modelling Coarctation of the Aorta.

Coarctation of the Aorta is a congenital narrowing of the aorta and diagnosis can be difficult. Treatments result in idiopathic sequelae including hypertension. Untreated patients are known to develop increased arterial stiffness in the upper body, which worsens with time. We present results from simulations with a one-dimensional mathematical model, about the effect of stiffness, stenting, surgery and coarctation severity on blood pressure, Pulsatility and Resistivity Index. One conclusion is that increased stiffness may explain both hypertension in treated patients and why diagnosis can be difficult.

Advancing the HIV Pre-Exposure Prophylaxis Continuum: A Collaboration Between a Public Health Department and a Federally Qualified Health Center in the Southern United States.

Uptake of pre-exposure prophylaxis (PrEP) has been limited among black and Latino men who have sex with men (MSM), especially in the southern United States. Public health departments and federally qualified health centers (FQHCs) serving predominantly uninsured populations are uniquely positioned to improve access. We evaluated a novel PrEP collaboration between a public health department and an FQHC in North Carolina (NC). In May 2015, a PrEP program was initiated that included no-cost HIV/sexually transmitted infection screening at a public health department, followed by referral to a colocated FQHC for PrEP services. We profiled the PrEP continuum for patients entering the program until February 2018. PrEP initiators and noninitiators were compared using Wilcoxon rank-sum test for continuous variables and chi-square or Fisher's exact tests for categorical variables. Of 196 patients referred to the FQHC, 60% attended an initial appointment, 43% filled a prescription, 38% persisted in care for >3 months, and 30% reported >90% adherence at follow-up. Among those presenting for initial appointments (n = 117), most were MSM (n = 95, 81%) and black (n = 62, 53%); 21 (18%) were Latinx and 9 (8%) were trans persons. Almost half (n = 55) were uninsured. We found statistically significant differences between PrEP initiators versus noninitiators based on race/ethnicity (p = 0.02), insurance status (p = 0.05), and history of sex work (p = 0.05). In conclusion, this collaborative model of PrEP care was able to reach predominantly black and Latino MSM in the southern United States. Although sustainable, program strategies to improve steps along the PrEP care continuum are vital in this population.

A solution method for the determination of cardiac potential distributions with an alternating current source.

A recently presented solution method for the bidomain model (Johnston et al. 2006), which involves the application of direct current for studying electrical potential in a slab of cardiac tissue, is extended here to allow the use of an applied alternating current. The advantage of using AC current, in a four-electrode method for determining cardiac conductivities, is that instead of using 'close' and 'wide' electrode spacings to make potential measurements, increasing the frequency of the AC current redirects a fraction of the current from the extracellular space into the intracellular space. The model is based on the work of Le Guyader et al. (2001), but is able to include the effects of the fibre rotation between the epicardium and the endocardium on the potentials. Also, rather than using a full numerical technique, the solution method uses Fourier series and a simple one dimensional finite difference scheme, which has the advantage of allowing the potentials to be calculated only at points, such as the measuring electrodes, where they are required. The new alternating current model, which includes intracellular capacitance, is used with a particular four-electrode configuration, to show that the potential measured is affected by changes in fibre rotation. This is significant because it indicates that it is necessary to include fibre rotation in models, which are to be used in conjunction with measuring arrays that are more complex than those involving simply surface probes or a single vertical probe.