Are missed- and kept-visit measures capturing different aspects of retention in HIV primary care?

The literature recognizes six measures of retention in care, an integral component of the HIV Continuum of Care. Given prior research showing that different retention measures are differentially associated with HIV health outcomes (e.g., CD4 count and viral suppression), we hypothesized that different groups of people living with HIV (PLWH) would also have differential retention outcomes based on the retention measure applied. We conducted a cross-sectional analysis of multisite patient-level medical record data (n = 10,053) from six academically-affiliated HIV clinics using six different measures of retention. Principal component analysis indicated two distinct retention constructs: kept-visit-measures and missed-visit measures. Although black (compared to white) PLWH had significantly poorer retention on the three missed-visit measures, race was not significantly associated with any of the three kept-visit measures. Males performed significantly worse than females on all kept-visit measures, but sex differences were not observed for any missed-visit retention measures. IDU risk transmission group and younger age were associated with poorer retention on both missed- and kept-visit retention measures. Missed- and kept-visit measures may capture different aspects of retention, as indicated in the observed differential associations among race, sex, age, and risk transmission group. Multiple measures are needed to effectively assess retention across patient subgroups.

HIV-related stigma, depression, and social support are associated with health-related quality of life among patients newly entering HIV care.

Entering HIV care is a vulnerable time for newly diagnosed individuals often exacerbating psychosocial difficulties, which may contribute to poor health-related quality of life (HRQOL) ultimately influencing health behaviors including ART adherence, the driver of viral load suppression. Understanding HRQOL in people newly entering HIV care is critical and has the potential to guide practice and research. This exploratory cross-sectional study examined demographic, clinical, and psychosocial factors associated with limitations in four specific domains of HRQOL among persons initially entering outpatient HIV care at four sites in the United States (n = 335). In the unadjusted analysis, female gender was significantly associated with sub-optimal HRQOL with women having increased odds of reporting HRQOL challenges with pain, mood, mobility, and usual activity when compared to men. The adjusted models demonstrated attenuation of parameter estimates and loss of statistical significance for the associations with impaired HRQOL observed among women in unadjusted analyses, suggesting psychosocial factors related to HRQOL are complex and interrelated. Findings are consistent with a robust literature documenting gender-related health disparities. Programs aimed at improving HRQOL for persons initially entering HIV care are warranted generally, and specifically for women, and must address modifiable psychosocial factors via mechanisms including coping and social support.

HIV Standard of Care for ART Adherence and Retention in Care Among HIV Medical Care Providers Across Four CNICS Clinics in the US.

Despite the issuance of evidence-based and evidence-informed guidelines to improve engagement in HIV care and adherence-related outcomes, few studies have assessed contemporary adherence or engagement support practices of HIV care providers in US clinics. As a result, the standard of HIV care in the US and globally remains poorly understood. This programmatic assessment approach aimed to identify the strengths and gaps in the current standard of HIV care from the perspective of HIV care providers. A self-administered Standard of Care measure was developed and delivered through Qualtrics to HIV care providers at four different HIV care sites as a part of a multisite intervention study to improve engagement in HIV care and ART adherence. Providers were asked to provide demographic and clinic specific information, identify practices/strategies applied during typical initial visits with HIV-positive patients and visits prior to and at ART initiation, as well as their perceptions of patient behaviors and adequacy of HIV care services at their clinics. Of the 75 surveys which were completed, the majority of respondents were physicians, and on average, providers have worked in HIV care for 13.5 years. Across the sites, 91% of the providers' patient panels consist of HIV-positive patients, the majority of whom are virally suppressed and 1/5 are considered "out of care." Few resources were routinely available to providers by other staff related to monitoring patient adherence and engagement in care. During typical initial visits with HIV positive patients, the majority of providers report discussing topics focused on behavioral/life contexts such as sexual partnerships, sexual orientation, disclosure, and other sources of social support. Nearly all providers emphasize the importance of adherence to treatment recommendations and nearly 90% discuss outcomes of good adherence and managing common side effects during ART start visits. Overall, providers do not report often implementing practices to improve retention in care. Survey results point to opportunities to enhance engagement in HIV care and improve ART adherence through systematic data monitoring and increased collaboration across providers and other clinic staff, specifically when identifying patients defined as "in need" or "out of care." Trial Registration: Clinicaltrials.gov NCT01900236.

Predictors of HIV Disclosure in Infected Persons Presenting to Establish Care.

Persons receiving effective HIV treatment experience longevity and improvement in quality of life. For those infected, social support is associated with improved medication adherence. Disclosure of infection status is likely a prerequisite for social support. However, little research describes patterns of HIV disclosure by infected persons. We retrospectively evaluated factors associated with disclosure among patients initiating HIV care at a university-based clinic from 2007 to 2012. Of 490 persons initiating care, 13 % had not disclosed their HIV infection to anyone. Black race significantly predicted non-disclosure and persons living with a significant other or friends were more likely to have disclosed their HIV infection versus those living alone. CD4 + T lymphocyte count <200 was associated with nondisclosure and disclosure only to family members. Future research is needed to better understand factors associated with disclosure of HIV infection status, because this could enhance receipt of social support and contribute to improved HIV health outcomes.

The Contribution of Missed Clinic Visits to Disparities in HIV Viral Load Outcomes.

OBJECTIVES: We explored the contribution of missed primary HIV care visits ("no-show") to observed disparities in virological failure (VF) among Black persons and persons with injection drug use (IDU) history. METHODS: We used patient-level data from 6 academic clinics, before the Centers for Disease Control and Prevention and Health Resources and Services Administration Retention in Care intervention. We employed staged multivariable logistic regression and multivariable models stratified by no-show visit frequency to evaluate the association of sociodemographic factors with VF. We used multiple imputations to assign missing viral load values. RESULTS: Among 10 053 patients (mean age = 46 years; 35% female; 64% Black; 15% with IDU history), 31% experienced VF. Although Black patients and patients with IDU history were significantly more likely to experience VF in initial analyses, race and IDU parameter estimates were attenuated after sequential addition of no-show frequency. In stratified models, race and IDU were not statistically significantly associated with VF at any no-show level. CONCLUSIONS: Because missed clinic visits contributed to observed differences in viral load outcomes among Black and IDU patients, achieving an improved understanding of differential visit attendance is imperative to reducing disparities in HIV.

Factors Associated with Missed Psychiatry Visits in an Urban HIV Clinic.

Psychiatric co-management is often required in HIV primary care. While rates and clinical impact of linkage and retention in HIV are well explored, fewer investigations focus specifically on linkage to psychiatry. In this investigation, we evaluate factors associated with linkage to psychiatric services using a retrospective cohort study of HIV-infected patients during a two-year observation period. Descriptive statistics depict patient characteristics, and logistic regression models were fit to evaluate factors associated with failure to establish care at the co-located psychiatry clinic following referral from HIV provider. Of 370 referred, 23 % did not attend a scheduled psychiatry appointment within 6 months of initial referral. In multivariable analysis, Non-white race, younger age, non-suppressed viral load, and increased wait time to appointment (in days) were associated with failure to attend. Further exploration of barriers that contribute to disparate linkage to psychiatric care may inform future interventions to improve HIV outcomes in this population.

Improvements in depression and changes in quality of life among HIV-infected adults.

Improving quality of life (QOL) for HIV-infected individuals is an important objective of HIV care, given the considerable physical and emotional burden associated with living with HIV. Although worse QOL has been associated with depression, no research has quantified the potential of improvement in depression to prospectively improve QOL among HIV-infected adults. We analyzed data from 115 HIV-infected adults with depression enrolled in a randomized controlled trial to evaluate the effectiveness of improved depression care on antiretroviral drug adherence. Improvement in depression, the exposure of interest, was defined as the relative change in depression at six months compared to baseline and categorized as full response (≥50% improvement), partial response (25-49% improvement), and no response (<25% improvement). Multivariable linear regression was used to investigate the relationship between improvement in depression and four continuous measures of QOL at six months: physical QOL, mental QOL, HIV symptoms, and fatigue intensity. In multivariable analyses, physical QOL was higher among partial responders (mean difference [MD] = 2.51, 95% CI: -1.51, 6.54) and full responders (MD = 3.68, 95% CI: -0.36, 7.72) compared to individuals who did not respond. Mental QOL was an average of 4.01 points higher (95% CI: -1.01, 9.03) among partial responders and 14.34 points higher (95% CI: 9.42, 19.25) among full responders. HIV symptoms were lower for partial responders (MD = -0.69; 95% CI: -1.69, 0.30) and full responders (MD = -1.51; 95% CI: -2.50, -0.53). Fatigue intensity was also lower for partial responders (MD = -0.94; 95% CI: -1.94, 0.07) and full responders (MD = -3.00; 95% CI: -3.98, -2.02). Among HIV-infected adults with depression, improving access to high-quality depression treatment may also improve important QOL outcomes.

A conceptual framework for understanding chronic pain in patients with HIV.

Chronic pain is common in persons with HIV and is often associated with psychiatric illness and substance abuse. Current literature links psychiatric illness and substance abuse with worse HIV outcomes; however, the relationship of chronic pain, alone and in the context of psychiatric illness and substance abuse, to outcomes in HIV has not been described. To develop this new area of inquiry, we propose an adapted biopsychosocial framework specifically for chronic pain in HIV. This framework will describe these relationships and serve as a conceptual framework for future investigations.

A systematic review and meta-regression of temporal trends in adult CD4(+) cell count at presentation to HIV care, 1992-2011.

BACKGROUND: The clinical status of human immunodeficiency virus (HIV)-positive persons at the time of presentation to medical care has important individual- and population-level implications. METHODS: We synthesized the literature on clinical status of adults newly presenting to care for HIV infection in developed countries to generate an estimate of the time trend for CD4 cell count at the initiation of HIV care. We systematically searched PubMed for studies published between January 2000 and November 2011 to identify those that reported CD4 cell count for patients newly presenting to HIV care according to standardized inclusion criteria. We abstracted the mean or median CD4 cell count or reconstructed the mean CD4 cell count from the presented data describing the number or proportion of patients in CD4 cell count categories. We estimated the change in CD4 cell count over time by modeling it as a weighted linear function of calendar year. RESULTS: Based on a meta-regression of 197 point estimates encompassing CD4 cell count measurements from 169 007 patients in 44 studies, mean CD4 cell count at presentation increased minimally by 1.5 cells/µL per year (95% CI, -6.1 to 5.5 cells/µL per year), from 307 cells/µL in 1992 to 336 cells/µL in 2011. CONCLUSIONS: In developed countries, patients' CD4 cell counts at first presentation to medical care have not increased meaningfully over the past 20 years. New and innovative strategies are imperative to identify persons earlier in the course of their infection and link them promptly with medical care.

Leveraging Technology and Gamification to Engage Learners in a Microbiology Curriculum in Undergraduate Medical Education.

Background: Microbiology is a critical and expansive topic that many medical schools' curriculum must teach in a constrained time frame. We implemented a microbiology question bank smart phone app enhanced with game elements and clinical pearls during a microbiology course for first-year medical students. We hypothesized that these enhancements and clinical pearls would engage the students meaningfully and increase their knowledge base. Methods: Though use was optional, students' game play was recorded through the app, which was compared to test grades retrospectively. A player efficiency rating (PER) was calculated as a function of question response, accuracy, and engagement. Students were separated into tertiles of PER and median exam grades were compared using a non-parametric Kruskal-Wallis (KW) test. An anonymous satisfaction and usability feedback survey was also administered. Results: One hundred eighty-one of the 189 students (96%) answered at least one question, and 165 (87%) completed all 56 questions. The average PER was 84.75. We received feedback surveys from 61 (34%) students in the course, with positive responses regarding the perceived impact on learning microbiology. The KW test found a positive correlation for median exam scores of the player groups when divided into tertiles by PER (p = 0.0002). Conclusions: We leveraged gamification and clinical pearls to design a supplemental microbiology question bank. We found high engagement overall and higher class exam scores associated with greater use of the question bank.

Are We Measuring What Matters? How Student and Clerkship Characteristics Influence Clinical Grading.

PURPOSE: Given the growing emphasis placed on clerkship performance for residency selection, clinical evaluation and its grading implications are critically important; therefore, the authors conducted this study to determine which evaluation components best predict a clinical honors recommendation across 3 core clerkships. METHOD: Student evaluation data were collected during academic years 2015-2017 from the third-year internal medicine (IM), pediatrics, and surgery clerkships at the University of Alabama at Birmingham School of Medicine. The authors used factor analysis to examine 12 evaluation components (12 items), and they applied multilevel logistic regression to correlate evaluation components with a clinical honors recommendation. RESULTS: Of 3,947 completed evaluations, 1,508 (38%) recommended clinical honors. The top item that predicted a clinical honors recommendation was clinical reasoning skills for IM (odds ratio [OR] 2.8; 95% confidence interval [CI], 1.9 to 4.2; P < .001), presentation skills for surgery (OR 2.6; 95% CI, 1.6 to 4.2; P < .001), and knowledge application for pediatrics (OR 4.8; 95% CI, 2.8 to 8.2; P < .001). Students who spent more time with their evaluators were more likely to receive clinical honors (P < .001), and residents were more likely than faculty to recommend clinical honors (P < .001). Of the top 5 evaluation items associated with clinical honors, 4 composed a single factor for all clerkships: clinical reasoning, knowledge application, record keeping, and presentation skills. CONCLUSIONS: The 4 characteristics that best predicted a clinical honors recommendation in all disciplines (clinical reasoning, knowledge application, record keeping, and presentation skills) correspond with traditional definitions of clinical competence. Structural components, such as contact time with evaluators, also correlated with a clinical honors recommendation. These findings provide empiric insight into the determination of clinical honors and the need for heightened attention to structural components of clerkships and increased scrutiny of evaluation rubrics.

Factors Associated with HIV Disclosure Status Among iENGAGE Cohort of New to HIV Care Patients.

HIV disclosure is an important behavior with implications for HIV treatment and prevention but understudied among new to HIV care patients who face unique challenges adjusting to a new diagnosis. This study evaluated the factors associated with HIV disclosure status and patterns of HIV disclosure among new to HIV care patients. A cross-sectional study was conducted evaluating the iENGAGE (integrating ENGagement and Adherence Goals upon Entry) cohort. Participants were enrolled in this randomized behavioral trial between December 2013 and June 2016. The primary and secondary outcomes included HIV disclosure status (Yes/No) and patterns of disclosure (Broad, Selective and Nondisclosure), respectively. Logistic and Multinomial Logistic Regression were used to evaluate the association of participant factors with HIV disclosure and patterns of HIV disclosure, respectively. Of 371 participants, the average age was 37 ± 12 years, 79.3% were males, and 62.3% were African Americans. A majority of participants (78.4%) disclosed their HIV status at baseline, 63.1% were broad disclosers and 15.2% were selective disclosers. In multivariable regression, black race, emotional support, and unmet needs predicted any HIV and broad disclosure, whereas males, emotional support, active coping, and acceptance were associated with selective disclosure. Interventions to promote early disclosure should focus on coping strategies and unmet needs, particularly among black and male people living with HIV initiating care.

Physical activity trends and metabolic health outcomes in people living with HIV in the US, 2008-2015.

Despite its potential to improve metabolic health outcomes, longitudinal physical activity (PA) patterns and their association with cardiometabolic disease among people living with HIV (PLWH) have not been well characterized. We investigated this relationship among PLWH in the Centers for AIDS Research Network of Integrated Clinical Systems with at least one PA self-report between 2008 and 2015. The 4-item Lipid Research Clinics PA instrument was used to categorize habitual PA levels as: Very Low, Low, Moderate, or High. We analyzed demographic differences in PA patterns. Multivariable generalized estimating equation regression models were fit to assess longitudinal associations of PA with blood pressure, lipid, and glucose levels. Logistic regression modeling was used to assess the odds of being diagnosed with obesity, cardiovascular disease (CVD), cerebrovascular disease, hypertension, diabetes, or multimorbidity. A total of 40,462 unique PA assessments were provided by 11,719 participants. Only 13% of PLWH reported High PA, while 68% reported Very Low/Low PA at baseline and did not increase PA levels during the study period. Compared to those reporting High PA, participants with Very Low PA had almost 2-fold increased risk for CVD. Very Low PA was also associated with several risk factors associated with CVD, most notably elevated triglycerides (odds ratio 25.4), obesity (odds ratio 1.9), hypertension (odds ratio 1.4), and diabetes (odds ratio 2.3; all p < 0.01). Low levels of PA over time among PLWH are associated with increased cardiometabolic disease risk.

Identifying High-Performing Students in Inpatient Clerkships: A Qualitative Study.

OBJECTIVES: Examine fundamental behaviors and characteristics that attending physicians in inpatient settings utilize to identify high-performing clerkship students. METHODS: We employed written comment data from a cross-sectional survey of Internal Medicine and Pediatrics attending physicians at a single academic medical center in the southern USA. Free-text responses regarding factors that faculty consider when assigning honors grades were analyzed by four trained researchers (interrater agreement 0.87) using conventional content analysis to identify themes. RESULTS: Seventy-nine of 141 (56%) attending physicians who were surveyed provided 90 comments.Four major theme areas for recognizing higher performing clerkship students were identified: Taking Ownership of Patient Care (35%), Medical Knowledge and Clinical Reasoning (20%), Team Orientation (15%), and Awareness of Opportunities for Growth and Progress (13%). CONCLUSION: Internal Medicine and Pediatric attending physicians identified characteristics that contributed to four themes in the determination of a high-performing medical student. These findings are particularly salient, as they highlight that commitment to patients, application of clinical knowledge and skills, teamwork, and awareness of growth and progress are valued by attending physicians for identifying top performing students in inpatient settings.

Perspectives of Rheumatoid Arthritis Patients on Electronic Communication and Patient-Reported Outcome Data Collection: A Qualitative Study.

OBJECTIVE: To identify the perspectives of patients with rheumatoid arthritis (RA) on electronic recording of between-visit disease activity and other patient-reported outcomes (PROs) and on sharing this information with health care providers or peers. METHODS: Patients with RA were recruited to participate in focus groups from December 2014 to April 2015. The topic guide and analysis were based on the Andersen-Newman framework. Sessions were audiorecorded, transcribed, independently coded, and analyzed for themes. RESULTS: Thirty-one patients participated in 7 focus groups. Their mean ± SD age was 51 ± 13.1 years, 94% were women, 52% were African American, 11% were Hispanic, and 37% were white. Three themes emerged: provider communication, information-seeking about RA, and social and peer support. Participants expressed a willingness to track disease activity data to share with health care providers electronically if providers would act on the information. Participants envisioned symptom tracking and information sharing as a mechanism to relay and obtain reliable information about RA. Participants were also interested in electronic communication between visits if it facilitated learning about symptom management and enhanced opportunities for social support among patients with RA. CONCLUSION: Patients with RA may be amenable to electronic collection and sharing of PRO-type data between clinical encounters if it facilitates communication with health care providers and provides access to reliable information about RA. Providing patients with social support was important for enhancing PROs collection by helping them overcome barriers by using electronic devices and overcome reservations about the value of these data.

Is lecture dead? A preliminary study of medical students' evaluation of teaching methods in the preclinical curriculum.

OBJECTIVES: To investigate medical students' perceptions of lecture and non-lecture-based instructional methods and compare preferences for use and quantity of each during preclinical training. METHODS: We administered a survey to first- and second-year undergraduate medical students at the University of Alabama School of Medicine in Birmingham, Alabama, USA aimed to evaluate preferred instructional methods.  Using a cross-sectional study design, Likert scale ratings and student rankings were used to determine preferences among lecture, laboratory, team-based learning, simulation, small group case-based learning, large group case-based learning, patient presentation, and peer teaching. We calculated mean ratings for each instructional method and used chi-square tests to compare proportions of first- and second-year cohorts who ranked each in their top 5 preferred methods. RESULTS: Among participating students, lecture (M=3.6, SD=1.0), team based learning (M=4.2, SD=1.0), simulation (M=4.0, SD=1.0), small group case-based learning (M=3.8, SD=1.0), laboratory (M=3.6, SD=1.0), and patient presentation (M=3.8, SD=0.9) received higher scores than other instructional methods. Overall, second-year students ranked lecture lower (χ2(1, N=120) =16.33, p<0.0001) and patient presentation higher (χ2(1, N=120) =3.75, p=0.05) than first-year students. CONCLUSIONS: While clinically-oriented teaching methods were preferred by second-year medical students, lecture-based instruction was popular among first-year students. Results warrant further investigation to determine the ideal balance of didactic methods in undergraduate medical education, specifically curricula that employ patient-oriented instruction during the second preclinical year.

A Web-Based Data Collection Platform for Multisite Randomized Behavioral Intervention Trials: Development, Key Software Features, and Results of a User Survey.

BACKGROUND: Meticulous tracking of study data must begin early in the study recruitment phase and must account for regulatory compliance, minimize missing data, and provide high information integrity and/or reduction of errors. In behavioral intervention trials, participants typically complete several study procedures at different time points. Among HIV-infected patients, behavioral interventions can favorably affect health outcomes. In order to empower newly diagnosed HIV positive individuals to learn skills to enhance retention in HIV care, we developed the behavioral health intervention Integrating ENGagement and Adherence Goals upon Entry (iENGAGE) funded by the National Institute of Allergy and Infectious Diseases (NIAID), where we deployed an in-clinic behavioral health intervention in 4 urban HIV outpatient clinics in the United States. To scale our intervention strategy homogenously across sites, we developed software that would function as a behavioral sciences research platform. OBJECTIVE: This manuscript aimed to: (1) describe the design and implementation of a Web-based software application to facilitate deployment of a multisite behavioral science intervention; and (2) report on results of a survey to capture end-user perspectives of the impact of this platform on the conduct of a behavioral intervention trial. METHODS: In order to support the implementation of the NIAID-funded trial iENGAGE, we developed software to deploy a 4-site behavioral intervention for new clinic patients with HIV/AIDS. We integrated the study coordinator into the informatics team to participate in the software development process. Here, we report the key software features and the results of the 25-item survey to evaluate user perspectives on research and intervention activities specific to the iENGAGE trial (N=13). RESULTS: The key features addressed are study enrollment, participant randomization, real-time data collection, facilitation of longitudinal workflow, reporting, and reusability. We found 100% user agreement (13/13) that participation in the database design and/or testing phase made it easier to understand user roles and responsibilities and recommended participation of research teams in developing databases for future studies. Users acknowledged ease of use, color flags, longitudinal work flow, and data storage in one location as the most useful features of the software platform and issues related to saving participant forms, security restrictions, and worklist layout as least useful features. CONCLUSIONS: The successful development of the iENGAGE behavioral science research platform validated an approach of early and continuous involvement of the study team in design development. In addition, we recommend post-hoc collection of data from users as this led to important insights on how to enhance future software and inform standard clinical practices. TRIAL REGISTRATION: Clinicaltrials.gov NCT01900236; (https://clinicaltrials.gov/ct2/show/NCT01900236 (Archived by WebCite at http://www.webcitation.org/6qAa8ld7v).

Characterizing Failure to Establish Hepatitis C Care of Baby Boomers Diagnosed in the Emergency Department.

BACKGROUND: Emergency departments (EDs) are high-yield sites for hepatitis C virus (HCV) screening, but data regarding linkage to care (LTC) determinants are limited. METHODS: Between September 2013 and June 2014, 4371 baby boomers unaware of their HCV status presented to the University of Alabama at Birmingham ED and underwent opt-out screening. A linkage coordinator facilitated referrals for positive cases. Demographic data, International Classification of Diseases, Ninth Revision codes, and clinic visits were collected, and patients were (retrospectively) followed up until February 2015. Linkage to care was defined as an HCV clinic visit within the hospital system. RESULTS: Overall, 332 baby boomers had reactive HCV antibody and detectable plasma ribonucleic acid. The mean age was 57.3 years (standard deviation = 4.8); 70% were male and 61% were African Americans. Substance abuse (37%) and psychiatric diagnoses (30%) were prevalent; 9% were identified with cirrhosis. During a median follow-up of 433 days (interquartile range, 354-500), 117 (35%) linked to care and 48% needed inpatient care. In multivariable analysis, the odds of LTC failure were significantly higher for white males (adjusted odds ratio [aOR], 2.57; 95% confidence interval [CI], 1.03-6.38) and uninsured individuals (aOR, 5.16; 95% CI, 1.43-18.63) and lower for patients with cirrhosis (aOR, 0.36; 95% CI, 0.14-0.92) and access to primary care (aOR, 0.20; 95% CI, 0.10-0.41). CONCLUSIONS: In this cohort of baby boomers with newly diagnosed HCV in the ED, only 1 in 3 were linked to HCV care. Although awareness of HCV diagnosis remains important, intensive strategies to improve LTC and access to curative therapy for diagnosed individuals are needed.