A Cost-Effective Analysis of Motivational Interviewing with Palliative Care Versus Usual Care: Results from the Living Well Project.

Little is known about the impact of early palliative care (EPC) combined with motivational interviewing (MI) for persons living with AIDS (PWA). We compared the cost and quality-adjusted life-years (QALYs) of EPC + MI (n = 61) versus usual care (UC) (n = 60) for patients with AIDS, not on antiretroviral medications, enrolled into the Living Well Project trial. Data on clinic, emergency department, and hospital visits were collected through self-report and billing records. Risk-adjusted average annual health care costs were estimated using a generalized linear model with a gamma log-link function. QALYs were calculated using the SF-12v2. Cost-effectiveness was defined as cost per QALY gained. Estimated intervention costs were $165 per participant. EPC + MI reduced costs by 33% (AOR = 0.67; CI 95%: 0.15, 0.93). QALYs did not differ between groups. Results suggest EPC + MI for PWA is cost-saving and maintains quality of life compared to UC due to reduced hospital and ED costs.

Patient-Reported Barriers to Adherence Among ACEI/ARB Users from a Motivational Interviewing Telephonic Intervention.

Purpose: Hypertension is a common comorbidity among type 2 diabetes mellitus (T2DM) patients, which increases the risk of cardiovascular diseases. Despite the proven benefit of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in this population, poor medication adherence is prevalent, resulting in higher complications and mortality rate. Motivational interviewing (MoI) has demonstrated effectiveness in improving medication adherence and identifying barriers. This study aimed to assess and identify patient-reported barriers to adherence to ACEI/ARB from an MoI telephonic intervention conducted by student pharmacist interns. Patients and Methods: This retrospective study was conducted within an MoI intervention customized by past ACEI/ARB adherence trajectories for nonadherent patients with T2DM and hypertension enrolled in a Medicare Advantage Plan. Adherence barriers were extracted from the interviewers' notes by two independent researchers. Descriptive analysis was performed to summarize the overall frequency of barriers as well as across trajectory groups, identified from the initial and follow-up calls. Results: In total, 247 patients received the initial MoI call from which 41% did not communicate any barrier for ACEI/ARB use despite having low adherence. About 59% of the patients reported at least one barrier during the initial call. The most common barriers included forgetfulness, discontinuation by physicians, side effects, multiple comorbidities, polypharmacy, lack of knowledge about disease/medication, and cost issues. The follow-up calls helped with uncovering at least one new barrier for 28 patients who previously communicated a different issue with their medication during the first call. Additionally, 18 patients with initial denial for having any barrier to adherence reported at least one barrier throughout the follow-up calls. Conclusion: This study summarized patient-reported barriers to ACEI/ARB adherence from an MoI telephonic intervention performed among nonadherent patients. Identifying specific barriers for patients may help to further design tailored interventions that address the barriers and improve adherence.

Follow-Up to High-Resolution Anoscopy After Abnormal Anal Cytology in People Living with HIV.

Current expert recommendations suggest anal cytology followed by high-resolution anoscopy (HRA) for biopsy and histological confirmation may be beneficial in cancer prevention, especially in people living with HIV (PLWH). Guided by the social ecological model, the purpose of this study was to examine sociodemographic and clinical variables, individual-level factors (depression, HIV/AIDS-related stigma, and health beliefs) and interpersonal-level factors (social support) related to time to HRA follow-up after abnormal anal cytology. We enrolled 150 PLWH from a large HIV community clinic, with on-site HRA availability, in Atlanta, GA. The median age was 46 years (interquartile range of 37-52), 78.5% identified as African American/Black, and 88.6% identified as born male. The average length of follow-up to HRA after abnormal anal cytology was 380.6 days (standard deviation = 317.23). Only 24.3% (n = 39) of the sample had an HRA within 6 months after an abnormal anal cytology, whereas 57% of the sample had an HRA within 12 months. HIV/AIDS-related stigma [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.33-0.90] and health motivation (OR 0.80, 95% CI 0.67-0.95) were associated with time to HRA follow-up ≤6 months. For HRA follow-up ≤12 months, we found anal cytology [high-grade squamous intraepithelial lesions/atypical squamous cells of undetermined significance cannot exclude HSIL (HSIL/ASCUS-H) vs. low-grade squamous intraepithelial lesions (LSIL) OR = 0.05, 95% CI 0.00-0.70; atypical squamous cells of undetermined significance (ASCUS) vs. LSIL OR = 0.12, 95% CI 0.02-0.64] and health motivation (OR = 0.86, 95% CI 0.65-0.99) were associated. Findings from this study can inform strategies to improve follow-up care after abnormal anal cytology at an individual and interpersonal level in efforts to decrease anal cancer morbidity and mortality.

Polypharmacy Is Associated With Falls in Women With and Without HIV.

BACKGROUND: Aging in people with HIV is associated with increased risk of developing synergistic conditions such as neurocognitive impairment, polypharmacy, and falls. We assessed associations between polypharmacy (use of 5 or more non-ART medications), use of neurocognitive adverse effects (NCAE) medications, and odds of falls in women with HIV (WWH) and without HIV (HIV-). METHODS: Self-reported falls and medication use data were contributed semiannually by 1872 (1315 WWH and 557 HIV-) Women's Interagency HIV Study participants between 2014 and 2016. Polypharmacy and NCAE medication use were evaluated separately and jointly in multivariable models to assess their independent contributions to single and multiple falls risk. RESULTS: The proportion of women who reported any fall was similar by HIV status (19%). WWH reported both greater polypharmacy (51% vs. 41%; P < 0.001) and NCAE medication use (44% vs. 37%; P = 0.01) than HIV- women. Polypharmacy conferred elevated odds of single fall [adjusted odds ratio (aOR) 1.67, 95% CI: 1.36 to 2.06; P < 0.001] and multiple falls (aOR 2.31, 95% CI: 1.83 to 2.93; P < 0.001); the results for NCAE medications and falls were similar. Both polypharmacy and number of NCAE medications remained strongly and independently associated with falls in multivariable models adjusted for HIV serostatus, study site, sociodemographics, clinical characteristics, and substance use. CONCLUSIONS: Polypharmacy and NCAE medication use were greater among WWH compared with HIV-, and both were independently and incrementally related to falls. Deprescribing and avoidance of medications with NCAEs may be an important consideration for reducing fall risk among WWH and sociodemographically similar women without HIV.

Perceptions of Anal Cancer Risk Among HIV-Positive and High-Risk HIV-Negative Women.

OBJECTIVES: Women living with HIV (WLWH) have a greater risk of anal cancer than women without HIV; however, there are limited studies that examine awareness of anal cancer risk among WLWH and "high-risk" HIV-negative women. This study examines risk factors for anal cancer, perceptions of risk for anal cancer, and perceptions of anal cancer screening among a cohort of WLWH and high-risk HIV-negative women. MATERIALS AND METHODS: From the Atlanta, GA, and Bronx, NY, sites of the Women's Interagency HIV Study, 155 WLWH and HIV-negative women were enrolled and the Champion Health Belief Model Scale questionnaire measuring risk perceptions to anal cancer was administered to each participant. RESULTS: The WLWH perceived anal cancer to be less serious and perceived facing fewer barriers to anal cancer screening than HIV-negative women (both p = .01). Older women (≥50 years) felt that they had less barriers to anal cancer screening (p = .047). Moreover, women who had less than a high school education felt more susceptible to anal cancer (p = .001), as did women who reported a history of anal intercourse (p = .017). CONCLUSIONS: Despite being at an increased risk for anal cancer, perceptions of susceptibility to anal cancer and seriousness of anal cancer were low among WLWH. These findings highlight opportunities for provider and patient educational interventions to improve awareness of anal cancer risk among WLWH.

Impact of a Smartphone App Reminder on Adherence to Aspirin Prescribed as Antithrombotic Therapy.

BACKGROUND: Many patients are discharged with aspirin (ASA) as an anticoagulant after joint replacement surgery. In studies in which ASA was prescribed, doses were frequently missed. Adherence to postoperative ASA regimen is critical to preventing thrombotic complications. This randomized controlled study evaluated the impact of an existing medication adherence smartphone application (app) on adherence to twice daily ASA 81 mg for 35 days after knee or hip arthroplasty. METHODOLOGY: Patients were randomized to either the app (intervention) group or the usual care (control) group. All patients received a baseline interview with a survey and demographics collected prior to randomization, a 36-day follow-up call for phone pill count, and a 6-week in-office interview with surveys and an in-person pill count. A convenience sample of 195 patients enrolled; 122 completed pill counts at both baseline and end of study. Ages ranged from 29 to 89 (mean: 60.4, SD: 10.1) years. The majority had a bachelor's degree or higher (59.3%), made more than $75,000 (or were retired; 51.9%), were of White race (75.9%), and female (53.8%). There were no significant demographic differences between the groups. RESULTS: There were no significant group differences in final pill counts, adherence (reasons for missed pills), or ASA Medication self-efficacy scores. However, the intervention group scored significantly higher on the ASA Adherence measure (general ease in and ability to take ASA; p = .020). Higher ASA Adherence scores were associated with lower pill counts at the end of study (better adherence) in the intervention group. There was a high rate of attrition related to failure to bring the ASA to hospital or to the follow-up appointment. CONCLUSIONS: Although there were no significant differences in final pill counts between groups, the app group reported more ease in taking pills. With smartphone use virtually ubiquitous, this project provided an opportunity to educate patients and nurses about how technology can support medication adherence. It was also an excellent opportunity to involve clinical nurses in a funded research project.

Knowledge of Anal Cancer, Anal Cancer Screening, and HPV in HIV-Positive and High-Risk HIV-Negative Women.

The incidence of anal cancer in HIV-positive women is a growing public health concern where they have a 7.8-fold increased risk for anal cancer than women in the general population. We examined knowledge of anal cancer, anal cancer screening, and HPV in HIV-positive women and high-risk HIV-negative women. Women were recruited from the Women's Interagency HIV Study and completed an adapted Knowledge of Anal Cancer and HPV Scale. Correlations among anal cancer knowledge and sociodemographic and risk factors were assessed using Pearson's or Spearman's rho r test. Student's t test or chi-square tests identified significant differences between groups by HIV status or risk factors. Among 155 women, 72% (n = 113) correctly identified the purpose of an anal Pap test. However, only 42% (n = 65) identified HIV as a risk factor for anal cancer. HIV-positive women were more knowledgeable about anal cancer than high risk HIV-negative women (t = 2.104, p = .037). Women with a history of an abnormal cervical Pap test (t = 2.137, p = .034), younger age (t = 3.716, p = .000), reported history of anal sex (t = 3.284, p = .001), some college education or higher (t = -2.005, p = .047), and non-smokers (t = 2.425, p = .016) were significantly more knowledgeable about HPV. Although most women were knowledgeable about anal cancer, many women could not identify important risk factors for anal cancer, such as HIV infection. Patient educational interventions tailored to HIV-positive women are warranted to improve knowledge and awareness of risk for anal cancer.

Disparities in Retention in Care Among Adults Living with HIV/AIDS: A Systematic Review.

As national HIV prevention goals aim to increase the proportion of persons living with HIV, determining existing disparities in retention in care will allow for targeted intervention. The purpose of this systematic review was to identify existing disparities in retention in care. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) 2015 guided this systematic review. Electronic databases, including PubMed/MEDLINE, CINAHL, Sociological Collection, PsychInfo, and Cab Direct/Global Health, were systematically searched and twenty studies were included. This review identified disparities in retention in care that have been documented by race, gender, age, HIV exposure, incarceration history, place of birth, and U.S. geographic location. Research is necessary to further identify existing disparities in retention in care and to better understand determinants of health disparities. Additionally, interventions must be tailored to meet the needs of health disparate populations and should be assessed to determine their effectiveness in reducing health disparities.

Sociodemographic Predictors of Anal Cancer Screening and Follow-up in Human Immunodeficiency Virus-Infected Individuals.

BACKGROUND: Anal cancer in the United States is generally rare; however, human immunodeficiency virus (HIV)-infected individuals are 28 times more likely to be given a diagnosis of anal cancer than the general population. OBJECTIVE: The aim of this study was to examine the rates and sociodemographic predictors of anal cancer screening and follow-up anoscopy in a sample of HIV-infected individuals. METHODS: Data for this study (n = 200) were derived from a retrospective chart review of randomly selected HIV-infected individuals. Data analyses included Pearson's correlation coefficient statistic to examine bivariate associations and logistic regression modeling for prediction of anal Papanicolaou test screening and follow-up anoscopy. RESULTS: Screening rates and follow-up after an abnormal anal Pap test were low. Women were less likely to be screened for anal cancer (odds ratio [OR], 0.244; P = .007). Men who have sex with men were almost 4 times more likely to be screened for anal cancer (OR, 3.7; P = .02). Men who have sex with men were 6 times more likely to have follow-up after an abnormal anal Pap test compared with heterosexual men or women of any sexual orientation (OR, 6.88; P = .002). CONCLUSIONS: High-risk groups for anal cancer should be targeted for preventative measures as part of a cancer prevention plan to decrease the personal and clinical burden associated with anal cancer. IMPLICATIONS FOR PRACTICE: Cancer prevention is a multistep process that requires screening and follow-up efforts, where healthcare providers play a vital role in these efforts. Findings from this study can inform strategies to improve screening and follow-up rates in HIV-infected individuals.

An integrative review of guidelines for anal cancer screening in HIV-infected persons.

HIV-infected individuals are 28 times more likely than the general population to be diagnosed with anal cancer. An integrative review of recommendations and guidelines for anal cancer screening was performed to provide a succinct guide to inform healthcare clinicians. The review excluded studies that were of non-HIV populations, redundant articles or publications, non-English manuscripts, or nonclinical trials. The review found no formal national or international guidelines exist for routine screening of anal cancer for HIV-infected individuals. To date, no randomized control trial provides strong evidence supporting efficaciousness and effectiveness of an anal cancer screening program. The screening recommendations from seven international-, national-, and state-based reports were reviewed and synthesized in this review. These guidelines suggest anal cancer screening, albeit unproven, may be beneficial at decreasing the incidence of anal cancer. This review highlights the paucity of screening-related research and is an area of need to provide clear direction and to define standard of care for anal cancer screening in HIV-infected persons.

The Impact of a Health Promotion Educational Program on Cardiovascular Risk Factors for HIV Infected Women on Antiretroviral Therapy.

This study investigates the efficacy of a health promotion educational program on improving cardiovascular risk factors of weight, Body Mass Index, and waist to hip ratio in 76 predominately African American HIV-infected women. The health promotion educational program was the control group (that focused on improving self-efficacy for nutrition, exercise, stress reduction and women's health behaviors) of a NIH-funded study. The majority of participants was overweight, obese, or at high risk based on waist hip ratio at the beginning of the study. There were no statistically significant improvements in body mass index or waist hip ratio from pre intervention to up to 9 months post intervention. There were significant changes in waist hip ratio and body mass index in both directions (improvement and worsened) for a small group of participants. The health promotion program did not affect significant changes in cardiovascular risk and should be revised, lengthened, and refocused on nutrition, diet, exercise, and long term goal commitments to reduce the high risk for cardiovascular disease in this group.