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BACKGROUND: Since 2000, there have been rising rates of syphilis infections nationally with higher incidence among minorities and persons living with human immunodeficiency virus (HIV) (PLWH). The purpose of this study was to determine syphilis treatment adequacy and factors associated with treatment delay. METHODS: This was a retrospective academic-public health collaboration with the District of Columbia Department of Public Health reviewing surveillance data of all primary, secondary, and early latent syphilis cases diagnosed between January 1, 2015, and December 31, 2019. Data were analyzed using multivariable logistic regression to identify factors associated with delayed treatment >14 days from diagnosis. RESULTS: Among 1852 individuals diagnosed with early syphilis, 93% (1730/1852) were male; 48% (893/1852) were coinfected with HIV; 43% (n = 796/1852) were African American/Black, 27% (n = 492/1852) were White, and race/ethnicity was unknown for 17% (n = 318/1852) of cases. Among 679 PLWH for whom viral load (VL) was known, 41% (278/679) had a VL < 20 copies/mL, and 18% (123/679) had VL >10,000 copies/mL. Treatment adequacy overall was 96.5%. Median time to syphilis treatment was 6 days (interquartile range = 4-7). Factors associated with delay of treatment included refused/unknown race (adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.00-3.79), and HIV VL > 10,000 copies/mL (aOR, 1.97; 95% CI, 1.08-3.58). CONCLUSIONS: The factors we identified associated with delayed treatment may reflect systemic factors contributing to the increased rates of infection among key populations. This highlights the importance of targeted public health efforts with the goal of reducing transmission of both HIV and syphilis.
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Infecções por HIV , Sífilis , Humanos , Masculino , Feminino , Sífilis/diagnóstico , Sífilis/tratamento farmacológico , Sífilis/epidemiologia , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Estudos Retrospectivos , District of Columbia , TreponemaRESUMO
Pre-exposure prophylaxis (PrEP) is an effective tool for human immunodeficiency virus (HIV) prevention. The purpose of this study is to identify correlates of PrEP retention using patient data from an urban, publicly funded safety-net clinic in Washington, DC. Cox proportional hazards regression, logistical regression, and survival curves were used to assess the association of age, gender, race/ethnicity, insurance, number of partners, and sexually transmitted infection (STI) diagnosis at PrEP initiation with time on PrEP. From August 2016-December 2020, 1,126 people were prescribed PrEP - patients were mostly Black (44.8%) or Latinx (30.4%) and identified as cisgender men (84.6%). Half had no insurance (49.1%), with the remaining patients reporting private (28.9%) or public (21.5%) insurance. Age at PrEP prescription ranged from 15 to 66 with 80% being 20 to 39 years. For the 87.7% (n = 987) of patients who discontinued PrEP, mean PrEP time was 158 days and median was 28 days. The highest rates of discontinuation were observed within the first month with 44.3% discontinuing by day 30, 52.3% by 3 months, and 73.2% by 1 year. Cisgender women, transgender persons, and those younger than 30 years were more likely to discontinue PrEP. Latinx and patients with less than 3 male partners in the last 90 days were less likely to discontinue PrEP. We demonstrated a high level of PrEP uptake among populations disproportionally affected by HIV. Future analyses are needed to examine ways of reducing barriers to PrEP initiation and improving PrEP adherence.
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Fármacos Anti-HIV , Infecções por HIV , Profilaxia Pré-Exposição , Provedores de Redes de Segurança , População Urbana , Humanos , Masculino , Profilaxia Pré-Exposição/estatística & dados numéricos , Feminino , Adulto , Infecções por HIV/prevenção & controle , Pessoa de Meia-Idade , Fármacos Anti-HIV/uso terapêutico , Fármacos Anti-HIV/administração & dosagem , Adolescente , Adulto Jovem , District of Columbia/epidemiologia , Idoso , Adesão à Medicação/estatística & dados numéricos , Parceiros Sexuais , Infecções Sexualmente Transmissíveis/prevenção & controleRESUMO
BACKGROUND: Primary care clinicians play a critical role in diagnosis and treatment of migraine, yet barriers exist. This national survey assessed barriers to diagnosis and treatment of migraine, preferred approaches to receiving migraine education, and familiarity with recent therapeutic innovations. METHODS: The survey was created by the American Academy of Family Physicians (AAFP) and Eli Lilly and Company and distributed to a national sample through the AAFP National Research Network and affiliated PBRNs from mid-April through the end of May 2021. Initial analyses were descriptive statistics, ANOVAs, and Chi-Square tests. Individual and multivariate models were completed for: adult patients seen in a week; respondent years since residency; and adult patients with migraine seen in a week. RESULTS: Respondents who saw fewer patients were more likely to indicate unclear patient histories were a barrier to diagnosing. Respondents who saw more patients with migraine were more likely to indicate the priority of other comorbidities and insufficient time were barriers to diagnosing. Respondents who had been out of residency longer were more likely to change a treatment plan due to attack impact, quality of life, and medication cost. Respondents who had been out of residency shorter were more likely to prefer to learn from migraine/headache research scientists and use paper headache diaries. CONCLUSIONS: Results demonstrate differences in familiarity with migraine diagnosis and treatment options based on patients seen and years since residency. To maximise appropriate diagnosis within primary care, targeted efforts to increase familiarity and decrease barriers to migraine care should be implemented.
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Pressure injuries are localized damage to skin or soft tissue. They commonly occur over bony prominences and often present as an intact or open wound. Pressure injuries are common and costly, and they significantly impact patient quality of life. Comprehensive skin assessments are crucial for evaluating pressure injuries. Staging of pressure injuries should follow the updated staging system of the National Pressure Injury Advisory Panel. Risk assessments allow for appropriate prevention and care planning, and physicians should use a structured, repeatable approach. Prevention of pressure injuries focuses on assessing and optimizing nutritional status, repositioning the patient, and providing appropriate support surfaces. Treatment involves pressure off-loading, nutritional optimization, appropriate bandage selection, and wound site management. Pressure injuries and surrounding areas should be cleaned, with additional debridement of devitalized tissue and biofilm if necessary. All injuries should be monitored for local infection, biofilms, and osteomyelitis. Appropriate wound dressings should be selected based on injury stage and the quality and volume of exudate.
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Osteomielite , Úlcera por Pressão , Humanos , Úlcera por Pressão/diagnóstico , Úlcera por Pressão/prevenção & controle , Qualidade de Vida , Bandagens , Estado NutricionalRESUMO
Pre-exposure prophylaxis (PrEP) for HIV prevention is underutilized by cisgender women at risk for HIV in the USA. Published research on PrEP initiation among cisgender women at risk for HIV focuses on identifying barriers and facilitators associated with intention to initiate, but few apply a behavioral theoretical lens to understand the relative importance of these diverse factors. This study provides a theoretically grounded view of the relative importance of factors associated with intention to initiate PrEP. We conducted an anonymous, cross-sectional survey of 1437 cisgender women seeking care at family planning and sexual health clinics to evaluate hypothesized barriers and facilitators of PrEP initiation. We categorized cisgender women with ≥ 3 behavioral risk-factors as "high-risk" for HIV acquisition; 26.9% (N = 387) met high-risk criterion. Among cisgender women in the high-risk sample, the majority were Black and single. Perceived risk of HIV acquisition was low and 13.7% reported intention to initiate PrEP. Positive attitudes toward PrEP, self-efficacy, perceived support from medical providers and social networks, and prior discussion about PrEP with medical providers were associated with intention to initiate PrEP; stigma was negatively associated. Background characteristics (other than age), risk factors for HIV acquisition, prior awareness of PrEP, and perceived risk of HIV were not associated with uptake intention. These findings support interventions that center on the role of providers in the provision of PrEP and on social networks in destigmatization of PrEP use.
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Infecções por HIV , Profilaxia Pré-Exposição , Estudos Transversais , District of Columbia , Feminino , Infecções por HIV/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Humanos , IntençãoRESUMO
Elimination of chronic hepatitis C (HCV) will require scaling up treatment, including possible HCV treatment by primary care providers. The District of Columbia (DC) has a substantial population living with untreated hepatitis C, and treatment expansion would benefit the resident population. The aim of this study was to assess the knowledge, attitudes, and behaviors of primary care providers and specialists related to hepatitis C screening and treatment. We conducted a prospective, online survey of physicians and nurse practitioners (n = 153) in DC on their knowledge, attitudes, and behaviors related to hepatitis C screening and treatment, as well as referral patterns, interest in learning, and preferred learning modalities. We compared responses by provider type. Key findings indicated that HCV screening and treatment knowledge was higher among specialty physicians as compared to primary care providers. The most common reported facilitators of HCV screening included a prompt in the electronic medical record (63%), patient education (57%), and support staff (41%). While 71% reported that HCV treatment was important in the community they serve, only 26% indicated that access to HCV specialist expertise and consultation was a major area of need. Additionally, 59% reported that they refer all HCV patients to specialists for treatment. Primary care providers in DC had moderate interest in learning how to treat chronic hepatitis C, but they need additional training. Patients are typically referred to gastroenterology, infectious diseases, and hepatology specialists who may have limited capacity to expand treatment.
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Atitude do Pessoal de Saúde , Pessoal de Saúde , Hepatite C/diagnóstico , District of Columbia , Registros Eletrônicos de Saúde , Feminino , Hepacivirus , Hepatite C Crônica , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Profissionais de Enfermagem , Médicos , Estudos Prospectivos , Encaminhamento e Consulta , Inquéritos e QuestionáriosRESUMO
More than 750,000 persons in the United States inject opioids, methamphetamine, cocaine, or ketamine, and that number is increasing because of the current opioid epidemic. Persons who inject drugs (PWID) are at higher risk of infectious and noninfectious skin, pulmonary, cardiac, neurologic, and other causes of morbidity and mortality. Nonjudgmental inquiries about current drug use can uncover information about readiness for addiction treatment and identify modifiable risk factors for complications of injection drug use. All PWID should be screened for human immunodeficiency virus infection, latent tuberculosis, and hepatitis B and C, and receive vaccinations for hepatitis A and B, tetanus, and pneumonia if indicated. Pre-exposure prophylaxis for human immunodeficiency virus infection should also be offered. Naloxone should be prescribed to those at risk of opioid overdose. Skin and soft tissue infections are the most common medical complication in PWID and the top reason for hospitalization in these patients. Signs of systemic infection require hospitalization, blood cultures, and a comprehensive history and physical examination to determine the source of infection. PWID have a higher incidence of community-acquired pneumonia and are at risk of other pulmonary complications, including opioid-associated pulmonary edema, asthma, and foreign body granulomatosis. Infectious endocarditis is the most common cardiac complication associated with injection drug use and more often involves the right-sided heart valves, which may not present with heart murmurs or peripheral signs and symptoms, in PWID. Injections increase the risk of osteomyelitis, as well as subdural and epidural abscesses.
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Atenção Primária à Saúde/métodos , Abuso de Substâncias por Via Intravenosa/terapia , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Overdose de Drogas/tratamento farmacológico , Humanos , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Programas de Troca de Agulhas/métodos , Exame Físico/métodos , Abuso de Substâncias por Via Intravenosa/complicaçõesRESUMO
Drug overdose is now the leading cause of unintentional death nationwide, driven by increased prescription opioid overdoses. To better understand urban opioid overdose deaths, this paper examines geographic, demographic, and clinical differences between heroin-related decedents and prescription opioid decedents in San Francisco from 2010 to 2012. During this time period, 331 individuals died from accidental overdose caused by opioids (310 involving prescription opioids and 31 involving heroin). Deaths most commonly involved methadone (45.9%), morphine (26.9%), and oxycodone (21.8%). Most deaths also involved other substances (74.9%), most commonly cocaine (35.3%), benzodiazepines (27.5%), antidepressants (22.7%), and alcohol (19.6%). Deaths were concentrated in a small, high-poverty, central area of San Francisco and disproportionately affected African-American individuals. Decedents in high-poverty areas were significantly more likely to die from methadone and cocaine, whereas individuals from more affluent areas were more likely die from oxycodone and benzodiazepines. Heroin decedents were more likely to be within a younger age demographic, die in public spaces, and have illicit substances rather than other prescription opioids. Overall, heroin overdose death, previously common in San Francisco, is now rare. Prescription opioid overdose has emerged as a significant concern, particularly among individuals in high-poverty areas. Deaths in poor and affluent regions involve different causative opioids and co-occurring substances.
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Overdose de Drogas/mortalidade , Disparidades nos Níveis de Saúde , Transtornos Relacionados ao Uso de Opioides/mortalidade , Adolescente , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Idoso , Cocaína , Feminino , Humanos , Masculino , Metadona , Pessoa de Meia-Idade , Morfina , Oxicodona , Áreas de Pobreza , Prevalência , São Francisco/epidemiologia , Fatores Socioeconômicos , Adulto JovemRESUMO
Background: Pre-exposure prophylaxis (PrEP) utilization among cisgender women (subsequently 'women') is low across age groups, relative to their risk of HIV acquisition. We hypothesize that age-related differences in psychosocial factors also influence women's intention to initiate oral PrEP in Washington, D.C. Methods: A secondary analysis of a cross-sectional survey data was performed to evaluate factors influencing intention to initiate oral PrEP among women seen at a family planning and a sexual health clinic. A bivariate analysis was performed to identify differences by age group in demographic characteristics, indications for PrEP, and attitudes toward PrEP; we then performed additional bivariate analysis to assess these variables in relation to PrEP intention. Results: Across age groups, perceived risk of HIV acquisition was not significantly different and was not associated with intention to initiate PrEP. Awareness of and attitude toward PrEP, injunctive norms, descriptive norms, and self-efficacy were not different across age, however there were significant age-associated differences in relation to PrEP intention. Specifically, among 18-24-year-olds, intention to start PrEP was associated with support from provider (p = 0.03), main sexual partner (p < 0.01), and peers (p < 0.01). For women 25-34 years old, having multiple sexual partners (p = 0.03) and support from casual sexual partners (p = 0.03) was also important. Among women 35-44 years old, prior awareness of PrEP (p = 0.02) and their children's support of PrEP uptake (p < 0.01) were associated with intention to initiate PrEP. Among 45-55 year-old women intention to initiate PrEP was positively associated with engaging in casual sex (p = 0.03) and negatively associated with stigma (p < 0.01). Conclusion: Overall, there were more similarities than differences in factors influencing intention to initiate PrEP across age groups. Observed differences offer an opportunity to tailor PrEP delivery and HIV prevention interventions to increase awareness and uptake for cisgender women.
Research showing how women's age affects their decision to start pre-exposure prophylaxis to prevent HIV in Washington, DC We know that many women need pre-exposure prophylaxis (PrEP) to prevent HIV infection in Washington, DC, yet the number of women who use PrEP is lower than expected. The study was done to determine whether a woman's age affects her decision to start PrEP. This is important because providers need to know the factors affecting a woman's decision to start PrEP in order to increase PrEP use in at-risk patients. We re-analyzed a set of data that was generated from surveys given to women in a women's health clinic. The surveys asked women about their background, including risk factors for HIV infection, and their awareness of and attitudes toward PrEP. We also asked women questions that were meant to determine their belief in their own ability to make decisions as well as the degree to which other people in their life affect their own decisions. We wanted to know whether age affects the degree to which these characteristics affect women's decision to start PrEP. Overall, there were more similarities than differences between age groups when looking at how different factors affect the decision to start PrEP. Across age groups, there were no differences in how women view their risk of HIV infection. We found that 18-24-year-olds were more likely to start PrEP when they felt support from their provider, main sexual partner, and peers. 25-34-year-olds were more likely to start PrEP when they felt this same source of support and had had multiple sexual partners. 35-44-year-olds were more likely to start PREP when they already had awareness of PrEP or had their children's support of their PrEP use. 45-55-year-olds were more likely to start PrEP when they had engaged in casual sex and were less likely to start PrEP if they expected negative judgement for it. Even though there were significant similarities between age groups, the differences that we found offer an opportunity to tailor PrEP awareness and interventions to promote PrEP use among women.
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BACKGROUND AND AIM: To assess the cost-effectiveness of hepatitis C virus treatment with pegylated interferon alfa-2a and ribavirin in current and former people who inject drugs (PWID). METHODS: A decision analytic model simulated the lifetime costs and outcomes of four treatment options: early treatment with mild fibrosis, standard treatment with moderate fibrosis, late treatment with compensated cirrhosis, and no treatment. Treatment modalities were simulated across current, former, and never-injector cohorts of 1000 hypothetical patients with chronic hepatitis C virus. The main outcome measures were incremental costs ($AUD) per quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICERs) were calculated for each cohort. RESULTS: Treatment of current PWID during mild fibrosis resulted in a discounted average gain of 1.60 QALYs (95% confidence interval 0.93-2.26) for an added cost of $12,723 ($11,153-$14,396) compared with no treatment, yielding an ICER of $7941 per QALY gained ($6347-$12,017). Former PWID gained 1.80 QALYs (1.29-2.33) for $10,441 ($8843-$12,074) for early treatment compared with no treatment, resulting in an ICER of $5808 per QALY gained ($5189-$6849). Never-injectors gained 2.33 QALYs (1.87-2.80) for $9290 ($7642-$10,912) compared with no treatment-an ICER of $3985 per QALY gained ($3896-$4080). Early treatment was more cost-effective than late treatment in all cohorts. CONCLUSIONS: Despite comorbidities, increased mortality, and reduced adherence, treatment of both current and former PWID is cost-effective. Our estimates fall below the unofficial Australian cost-effectiveness threshold of $AUD 50,000 per QALY for public subsidies. Scaling up treatment for PWID can be justified on purely economic grounds.
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Antivirais/economia , Hepatite C Crônica/economia , Interferon-alfa/economia , Polietilenoglicóis/economia , Ribavirina/economia , Abuso de Substâncias por Via Intravenosa/economia , Adulto , Antivirais/uso terapêutico , Austrália , Estudos de Coortes , Análise Custo-Benefício , Quimioterapia Combinada/economia , Intervenção Médica Precoce , Feminino , Hepatite C Crônica/tratamento farmacológico , Humanos , Interferon-alfa/uso terapêutico , Masculino , Cadeias de Markov , Modelos Estatísticos , Polietilenoglicóis/uso terapêutico , Anos de Vida Ajustados por Qualidade de Vida , Proteínas Recombinantes/economia , Proteínas Recombinantes/uso terapêutico , Ribavirina/uso terapêutico , VitóriaAssuntos
Acetaminofen/efeitos adversos , Acetaminofen/uso terapêutico , Dor Aguda/tratamento farmacológico , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/etiologia , Oxicodona/efeitos adversos , Oxicodona/uso terapêutico , Adulto , Combinação de Medicamentos , Feminino , Fraturas Ósseas/complicações , Fraturas Ósseas/cirurgia , Humanos , Estados UnidosRESUMO
Abnormal liver tests are one of the most common challenges in the primary care setting. Primary care practitioners order these tests for numerous reasons, including investigating abdominal signs and symptoms or suspected alcohol-use disorder, or to determine medication adverse effects. Evaluation should be guided by both the clinical presentation and the pattern of injury. In this article, we will focus on the epidemiology, pathophysiology, clinical presentation, diagnostic work-up, and management of elevated liver enzymes, with an emphasis on the most common causes of abnormal liver testing.
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Hepatopatias , Fígado , Humanos , Fígado/enzimologia , Hepatopatias/diagnósticoRESUMO
To test the hypothesis that implementation of a multicomponent, educational HIV pre-exposure prophylaxis (PrEP) intervention to promote universal PrEP services for cisgender women (subsequently "women") in sexual and reproductive health centers would improve the proportion of women screened, offered, and prescribed PrEP, we implemented a multicomponent, educational intervention in a Washington D.C. Department of Health-sponsored sexual health clinic. The clinic serves a patient population with high-potential exposure to HIV. The intervention included clinic-wide PrEP trainings, an electronic health record prompt for PrEP counseling by providers, and educational videos in the waiting room. We collected preimplementation data from March 22, 2018 to July 4, 2018, including 331 clinical encounters for 329 women. Between July 5, 2018 and July 1, 2019, there were 1733 clinical encounters for 1720 HIV-negative women. We used mixed methods to systematically assess intervention implementation using the Reach Effectiveness Adoption Implementation Maintenance framework. Additionally, we assessed the interventions' acceptability and feasibility among providers through semistructured interviews. The proportion of women screened by providers for PrEP (5.6% preimplementation to a mean of 89.2% of women during the implementation period, p < 0.01), offered (6.2 to 69.8%, p < 0.01), and prescribed PrEP (2.6 to 8.1%, p < 0.01) by providers increased significantly in the implementation period. Providers and clinic staff found the intervention both highly feasible and acceptable and demonstrated increased knowledge of PrEP and HIV prevention associated with the clinic-wide trainings. Our results demonstrate the effectiveness of a low-cost educational intervention to increase provision of integrated PrEP services in an urban sexual health clinic serving women with high-potential exposure to HIV. ClinicalTrials.gov ID NCT03705663.
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Infecções por HIV , Profilaxia Pré-Exposição , Saúde Sexual , Humanos , Infecções por HIV/prevenção & controle , Instituições de Assistência Ambulatorial , EscolaridadeRESUMO
BACKGROUND: Rapid antiretroviral therapy initiation (R-ART) for treatment of HIV has been recommended since 2017, however it has not been adopted widely across the US. PURPOSE: The study purpose was to understand facilitators and barriers to R-ART implementation in the U.S. RESEARCH DESIGN: This was a qualitative design involving semi-structured interviews. STUDY SAMPLE: The study sample was comprised of the medical leadership of nine US HIV clinics that were early implementers of R-ART. DATA COLLECTION AND ANALYSIS: In-depth, semi-structured interviews were performed. The Consolidated Framework for Implementation Research (CFIR) was used to guide thematic analysis. RESULTS: We identified three main content areas: strong scientific rationale for R-ART, buy-in from multiple key stakeholders, and the condensed timeline of R-ART. The CFIR construct of Evidence Strength and Quality was cited as an important factor in R-ART implementation. Buy-in from key stakeholders and immediate access to medications ensured the success of R-ART implementation. Patient acceptance of the condensed timeline for ART initiation was facilitated when presented in a patient-centered manner, including empathetic communication and addressing other patient needs concurrently. The condensed timeline of R-ART presented logistical challenges and opportunities for the development of intense patient-provider relationships. CONCLUSIONS: Results from the analysis showed that R-ART implementation should address the following: 1) logistical planning to implement HIV treatment with a condensed timeline 2) patients' mixed reactions to a new HIV diagnosis and 3) the high cost of HIV medications.
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Infecções por HIV , Humanos , Pesquisa Qualitativa , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Cognição , Pacientes , ComunicaçãoRESUMO
OBJECTIVE: Our objective was to identify the individual, interpersonal, community, health-system, and structural factors that influence HIV pre-exposure prophylaxis (PrEP) initiation among cisgender women seeking sexual and reproductive health care in a high HIV prevalence community to inform future clinic-based PrEP interventions. METHODS: We collected anonymous, tablet-based questionnaires from a convenience sample of cisgender women in family planning and sexual health clinics in the District of Columbia. The survey used the lens of the socio-ecological model to measure individual, interpersonal, community, institutional, and structural factors surrounding intention to initiate PrEP. The survey queried demographics, behavioral exposure to HIV, perceived risk of HIV acquisition, a priori awareness of PrEP, intention to initiate PrEP, and factors influencing intention to initiate PrEP. RESULTS: A total of 1437 cisgender women completed the survey. By socio-ecological level, intention to initiate PrEP was associated with positive attitudes toward PrEP (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.13-2.15) and higher self-efficacy (OR, 1.32; 95% CI, 1.02-1.72) on the individual level, perceived future utilization of PrEP among peers and low fear of shame/stigma (OR, 1.65; 95% CI, 1.33-2.04) on the community level, and having discussed PrEP with a provider (OR. 2.39; 95% CI, 1.20-4.75) on the institutional level. CONCLUSION: Our findings highlight the importance of multilevel, clinic-based interventions for cisgender women, which promote sex-positive and preventive PrEP messaging, peer navigation to destigmatize PrEP, and education and support for women's health medical providers in the provision of PrEP services for cisgender women.
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Infecções por HIV , Profilaxia Pré-Exposição , Humanos , Feminino , Intenção , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Infecções por HIV/tratamento farmacológico , Prevalência , Comportamento SexualRESUMO
INTRODUCTION: In 2019, the District of Columbia recorded a 20-year low rate in new HIV infections but also had near-record numbers of gonorrhea and chlamydia infections. District of Columbia Department of Health has supported numerous forms of community-based in-person screening but not direct at-home testing. METHODS: In summer 2020, the District of Columbia Department of Health launched GetCheckedDC.org for District of Columbia residents to order home-based oral HIV antibody test and urogenital, pharyngeal, and rectal chlamydia and gonorrhea tests. Initial and follow-up surveys were completed by individuals for both test modalities. RESULTS: A retrospective analysis was conducted for the first 5 months of the program. During that period, 1,089 HIV and 1,262 gonorrhea and chlamydia tests (535 urogenital, 520 pharyngeal, 207 rectal) were ordered by 1,245 District of Columbia residents. The average age was 33.1 (median=31, range=14-78) years; 51.6% of requestors identified as Black; 39.3% identified as men who have sex with men; 16.2% reported no form of insurance; and 8.1% and 10.4% reported never being testing for HIV and sexually transmitted infections, respectively. More than half of people requesting tests reported convenience and COVID-19 as the reasons. In total, 39.5% of sexually transmitted infection tests were returned; 7.22% of people testing for sexually transmitted infections received a positive result, and 10.35% of rectal tests were positive. No individuals reported a positive HIV self-test that was confirmed; 98.5% of respondents said that they would recommend the HIV self-test kit. CONCLUSIONS: Mail-out HIV and sexually transmitted infection testing was readily taken up among high-priority demographics within a diverse, urban, high-morbidity jurisdiction during the COVID-19 pandemic. Extragenital testing for gonorrhea and chlamydia should be included in all at-home screening tests given the high positivity rate.
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COVID-19 , Infecções por Chlamydia , Gonorreia , Infecções por HIV , Minorias Sexuais e de Gênero , Infecções Sexualmente Transmissíveis , Adulto , Infecções por Chlamydia/diagnóstico , Infecções por Chlamydia/epidemiologia , District of Columbia/epidemiologia , Gonorreia/diagnóstico , Gonorreia/epidemiologia , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Homossexualidade Masculina , Humanos , Masculino , Programas de Rastreamento , Pandemias , Serviços Postais , Estudos Retrospectivos , SARS-CoV-2 , Infecções Sexualmente Transmissíveis/diagnóstico , Infecções Sexualmente Transmissíveis/epidemiologia , Washington/epidemiologiaRESUMO
BACKGROUND AND OBJECTIVES: Rates of injection drug use and associated medical complications have increased, yet engagement of persons who inject drugs (PWID) in primary care is limited, with significant barriers to care. Family physicians play an important role in caring for PWID, but residency training is limited. This study aimed to assess role responsibility, self-efficacy, and attitudes of family medicine residents in caring for PWID. METHODS: Using a cross sectional design, family medicine residents in 2018 at three different programs completed Likert and open-ended survey questions assessing role responsibility, self-efficacy, and attitudes in caring for PWID. RESULTS: Fifty-five percent (41/76) of residents completed surveys. Residents consistently agreed it is their responsibility to provide comprehensive care for PWID, while being less confident in key elements of screening, brief intervention, and referral to treatment (SBIRT). The largest gap between responsibility and confidence was in referral to treatment. Resident confidence was lowest for harm reduction strategies: discussing clean needle practices, prescribing naloxone and referral to medication-assisted treatment or needle exchange programs. Less than 60% of residents agreed they are able to work with or understand PWID. CONCLUSIONS: This study identifies gaps between provider responsibility and current graduate medical education training. We identified training that increases screening, harm reduction practices, and referrals to community resources as needs. This baseline assessment of family medicine residents can be used to develop educational interventions to meet regional and national health needs for harm reduction for PWID and workforce development.
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Usuários de Drogas , Preparações Farmacêuticas , Abuso de Substâncias por Via Intravenosa , Estudos Transversais , Medicina de Família e Comunidade , Redução do Dano , HumanosRESUMO
PURPOSE: As medical education curricula increasingly acknowledge the contributions of the social determinants of health to individual health, new methods of engaging students in the care of vulnerable groups are needed. Empathy is one way to connect students with patients, but little is known about how to nurture students' empathy on behalf of populations. This study examined the relationship between individual and social empathy as groundwork for cultivating students' empathy for vulnerable groups. METHOD: In 2014-2015, first-year medical students completed the Social Empathy Index at the start and end of a two-semester population health course, and they completed a reflective writing assignment exploring the challenges of caring for vulnerable patients. Pre- and posttest mean survey scores were compared, and reflective writing assignments were analyzed for themes concerning social empathy. RESULTS: Data from 130 students were analyzed. Scores for the contextual understanding of systemic barriers domain increased significantly. There was a trend toward increased cumulative social empathy scores that did not reach statistical significance. Students' essays revealed three themes relating to individual empathy as the foundation for social empathy; civic and moral obligations; and the role of institutional practices in caring for vulnerable groups. CONCLUSIONS: This study extends understanding of empathy beyond care for the individual to include care for vulnerable groups. Thus, social empathy may function as a valuable concept in developing curricula to support students' commitment to care for the underserved. Educators first need to address the many barriers students cited that impede both individual and social empathy.
Assuntos
Currículo , Educação de Graduação em Medicina , Empatia , Estudantes de Medicina , Populações Vulneráveis , Humanos , Estudos Retrospectivos , Inquéritos e Questionários , RedaçãoRESUMO
The private sector provides the majority of health care in Africa and Asia. A number of interventions have, for many years, applied different models of subsidy, support and engagement to address social and efficiency failures in private health care markets. We have conducted a review of these models, and the evidence in support of them, to better understand what interventions are currently common, and to what extent practice is based on evidence. Using established typologies, we examined five models of intervention with private markets for care: commodity social marketing, social franchising, contracting, accreditation and vouchers. We conducted a systematic review of both published and grey literature, identifying programmes large enough to be cited in publications, and studies of the listed intervention types. 343 studies were included in the review, including both published and grey literature. Three hundred and eighty programmes were identified, the earliest having begun operation in 1955. Commodity social marketing programmes were the most common intervention type, with 110 documented programmes operating for condoms alone at the highest period. Existing evidence shows that these models can improve access and utilization, and possibly quality, but for all programme types, the overall evidence base remains weak, with practice in private sector engagement consistently moving in advance of evidence. Future research should address key questions concerning the impact of interventions on the market as a whole, the distribution of benefits by socio-economic status, the potential for scale up and sustainability, cost-effectiveness compared to relevant alternatives and the risk of unintended consequences. Alongside better data, a stronger conceptual basis linking programme design and outcomes to context is also required.