Elucidating Harm Reduction Principles in a Client-Centered Representative Payee Program.

Harm Reduction seeks to mitigate harms associated with health behaviors without the expectation that these behaviors be extinguished completely. Client-Centered Representative Payee (CCRP) is an intervention that modifies the US Social Security Administration's (SSA) Representative Payee policy by incorporating relational harm reduction. We used Human-Centered Design (HCD) methods to elucidate ways that harm reduction principles are present in and integral to CCRP and to create a blueprint for replication. Thirteen individuals familiar with CCRP brainstormed 88 statements, which were parsed, consolidated, and then independently assigned by a subgroup of participants to six principles of harm reduction. After refining the data, 29 statements aligning with harm reduction principles remained. Delineating harm reduction within CCRP, which can empower and establish trust with clients, may help other providers identify how to offer representative payee services that are respectful, compassionate, rooted in harm reduction, and ultimately improve client outcomes.

Health insurance and AIDS Drug Assistance Program (ADAP) increases retention in care among women living with HIV in the United States.

Our objective was to examine the association between healthcare payer type and missed HIV care visits among 1,366 US women living with HIV (WLWH) enrolled in the prospective Women's Interagency HIV Study (WIHS). We collected secondary patient-level data (October 1, 2017-September 30, 2018) from WLWH at nine WIHS sites. We used bivariate and multivariable binary logistic regression to examine the relationship between healthcare payer type (cross-classification of patients' ADAP and health insurance enrollment) and missed visits-based retention in care, defined as no-show appointments for which patients did not reschedule. Our sample included all WLWH who self-reported having received HIV care at least once during the two consecutive biannual WIHS visits a year prior to October 1, 2017-September 30, 2018. In the bivariate model, compared to uninsured WLWH without ADAP, WLWH with private insurance + ADAP were more likely to be retained in care, as were WLWH with Medicaid only and private insurance only. In the adjusted model, WLWH with private insurance only were more likely to be retained in care compared to uninsured WLWH without ADAP. Private health insurance and ADAP are associated with increased odds of retention in care among WLWH.

Is Insurance a Barrier to HIV Preexposure Prophylaxis? Clarifying the Issue.

Clinical trials have demonstrated that preexposure prophylaxis (PrEP) protects against HIV infection; yet, even with its approval by the Food and Drug Administration (FDA) in 2012, less than 10% of eligible users in the United States are currently taking PrEP.While there are multiple factors that influence PrEP uptake and pose barriers to PrEP implementation, here we focus on PrEP's cost in the United States, which, at the current list price of $2000 per month and with high levels of cost sharing, can leave insured users with more than $1000 in out-of-pocket costs every year. We discuss how patient deductibles, monthly premiums, copayments, and coinsurance vary widely and may increase the financial burden. Although drug payment-assistance programs have made PrEP more affordable to uninsured and underinsured users, lack of insurance is a barrier to PrEP accessibility. The FDA approved a generic version in 2017; however, that version has not been distributed to US consumers and may not be more affordable.As other countries begin implementing PrEP programs, the extent of PrEP's availability as a tool in the global fight against HIV remains to be seen.

Compound Retention in Care and All-Cause Mortality Among Persons Living With Human Immunodeficiency Virus.

BACKGROUND: To obtain optimal health outcomes, persons living with human immunodeficiency virus (HIV) must be retained in clinical care. We examined the relationships between 4 possible combinations of 2 separate retention measures (missed visits and the Institute of Medicine [IOM] indicator) and all-cause mortality. METHODS: The sample included 4162 antiretroviral therapy (ART)-naive patients who started ART between January 2000 and July 2010 at any of 5 US sites of the Center for AIDS Research Network of Integrated Clinical Systems. The independent variable of interest was retention, captured over the 12-month period after the initiation of ART. The study outcome, all-cause mortality 1 year after ART initiation, was determined by querying the Social Security Death Index or the National Death Index. We evaluated the associations of the 4 categories of retention with all-cause mortality, using the Cox proportional hazards models. RESULTS: Ten percent of patients did not meet retention standards for either measure (hazard ratio [HR], 2.26; 95% confidence interval [CI], 1.59-3.21). Patients retained by the IOM but not the missed-visits measure (42%) had a higher HR for mortality (1.72; 95% CI, 1.33-2.21) than patients retained by both measures (41%). Patients retained by the missed-visits but not the IOM measure (6%) had the same mortality hazards as patients retained by both measures (HR, 1.01; 95% CI, .54-1.87). CONCLUSIONS: Missed visits within the first 12 months of ART initiation are a major risk factor for subsequent death. Incorporating missed visits in clinical and public health retention and viral suppression programming is advised.

Predicting Retention in HIV Primary Care: Is There a Missed Visits Continuum Based on Patient Characteristics?

Missing 3 + scheduled HIV primary care visits over a 1-year period increases mortality risk for people living with HIV (PLWH). We used electronic health data from PLWH (≥ 18 years old) at a southeastern US HIV clinic in 2016 to examine differences across patient-level characteristics and number of missed visits (1-2 vs. 0, 3 + vs. 0, 3 + vs. 1-2). In multivariable multinomial logistic regression analyses, poverty, lack of Ryan White HIV/AIDS Program support services, being uninsured, not having a high school degree, and being younger were significantly associated with 1-2 or 3 + missed visits (vs. 0 missed). Only poverty remained predictive of missing 3 + versus 1-2 visits (RR = 2.70, 95% CI 1.49-4.88). Patients at risk for missing 3 + visits present similar characteristics to patients who miss 1-2 visits. Interventions aimed at poverty reduction and increased access to education, health insurance, and support services may improve retention and, therefore, decrease mortality risk.

The Ryan White HIV/AIDS Program: Supplementary Service Provision Post-Affordable Care Act.

The Ryan White HIV/AIDS program (RWHAP) provides essential primary and supplementary health services to people living with HIV (PLWH). We examined the relationship between supplementary RWHAP services (Part B) and two outcomes: viral suppression (VS) and two separate measures of retention in care (RiC) based on kept- and missed-visits. We used purposive sampling to identify adult patients who received primary medical care at an academically-affiliated HIV/AIDS clinic in the southeastern United States (N = 1159) and who attended at least one scheduled HIV primary care appointment at the study site during 2015. Unadjusted and adjusted logistic regression models were fit, in which RWHAP supplementary services were the primary independent variables of interest. Age, race, gender, education level, and income were control variables. Among 1159 PLWH, 45.3% received RWHAP supplementary services in addition to public insurance, private insurance, or primary RWHAP. Among participants, 91.4% were virally suppressed, 87.4% were retained in care using the Institute of Medicine (IOM) kept-visits measure, and 60% were retained in care using the missed-visits measure. In multivariable models, patients with RWHAP supplementary services had significantly higher odds of (1) VS [adjusted odds ratio (AOR) = 1.91], (2) RiC using the IOM kept-visits measure (AOR = 2.56), and (3) RiC using the missed-visits measure (AOR = 1.58). Receipt of supplementary RWHAP services is associated with increased odds of VS and two measures of RiC when adjusting for key sociodemographic variables. Policymakers should consider the vital role of RWHAP as continued funding is uncertain.

Child maltreatment in rural southern counties: Another perspective on race, poverty and child welfare.

Building on research that has identified community characteristics associated with child maltreatment, this study investigates the adequacy and equity of the child welfare response at the county level. The study focuses on states in the U.S. south with demographic characteristics that make it possible to disentangle county racial composition from county rurality. County-level child maltreatment data were merged with data from the U.S. Census and other publicly-available sources for the 354 counties in four southern states. Results from multiple regression models indicated that, despite a greater preponderance of risk factors typically associated with child maltreatment, rural, majority African-American counties had lower rates of reported and substantiated child maltreatment compared to other southern counties. Cross-sectional results were consistent across three years: 2012, 2013, and 2014. The findings suggest that children and families in rural, majority African-American counties in the South may not be receiving adequate or equitable responses from the formal child welfare system.