Predicting partner HIV testing and counseling following a partner notification intervention.

Provider-assisted methods of partner notification increase testing and counseling among sexual partners of patients diagnosed with HIV, however they are resource-intensive. The sexual partners of individuals enrolled in a clinical trial comparing different methods of HIV partner notification were analyzed to identify who was unlikely to seek testing on their own. Unconditional logistic regression was used to identify partnership characteristics, which were assigned a score based on their coefficient in the final model, and a risk score was calculated for each participant. The risk score included male partner sex, relationship duration 6-24 months, and index education > primary. A risk score of ≥ 2 had a sensitivity of 68% and specificity of 78% in identifying partners unlikely to seek testing on their own. A risk score to target partner notification can reduce the resources required to locate all partners in the community while increasing the testing yield compared to patient-referral.

Prescription refill records as a screening tool to identify antidepressant non-adherence.

PURPOSE: Non-adherence is a significant problem with antidepressants. Identifying patients at highest risk for discontinuing antidepressant treatment can be used to target clinical management. Accordingly, our purpose was to determine the shortest gap in medication supply that is predictive of discontinuation, while minimizing false positive results. METHODS: A retrospective cohort study of medical and prescription claims from a national health plan affiliated with i3 Innovus. Sensitivities, specificities, and positive and negative predictive values were calculated for gap lengths to assess how well they predicted discontinuation. Continuously insured individuals aged 18-65 with newly diagnosed major depression and an antidepressant prescription within 45 days of diagnosis were included. Gap length was defined as the maximum number of continuous days without medication supply during acute phase treatment. Discontinuation was defined as a continuous gap of 30 or more days between an expected refill and actual refill. RESULTS: Of 4545 eligible patients, 73% discontinued antidepressant treatment during the study period. A maximum continuous gap of 14 days had a sensitivity of 87% and a specificity of 82% for predicting discontinuation. In analyses that varied the way gaps and discontinuation were defined, gap lengths between 8 and 19 days were highly predictive of discontinuation without exceeding a 20% false positive rate. CONCLUSIONS: Based on administrative pharmacy records, screening for gaps in medication supply of at least 14 days can accurately identify four of every five patients at risk for discontinuing. This early indicator can be used to target clinical interventions.

Effect of an educational script on postpartum contraceptive use: a randomized controlled trial.

OBJECTIVES: Short interpregnancy intervals are associated with adverse perinatal outcomes. Increased postpartum use of long-acting reversible contraception (LARC) could reduce short interpregnancy intervals. Therefore, the primary objective of our study was to evaluate if a postpartum educational script about LARC (LARC script) could increase postpartum LARC utilization at the 6-week postpartum visit. STUDY DESIGN: We completed a randomized controlled trial (1:1) of 800 postpartum women in Raleigh, North Carolina. Women were recruited from the postpartum unit and randomized to receive (intervention) or not receive (control) the LARC script prior to hospital discharge. We conducted follow-up phone interviews to assess LARC use after their 6-week postpartum visit. We used Pearson's chi-squared test to compare LARC use between arms. RESULTS: Between May 2011 and January 2012, 400 women were randomized to each arm. Three hundred sixty-nine women (92.3%) in each arm were successfully contacted after their 6-week postpartum visit. LARC use was reported by 17.6% and 13.3% of women in the intervention and control arms, respectively (p=.103). CONCLUSIONS: The LARC script did not increase LARC utilization at the 6-week postpartum visit. Future studies should evaluate interventions that address both educational and systematic barriers to postpartum LARC uptake. IMPLICATIONS: Use of a postpartum educational script focused on the intrauterine device and contraceptive implant did not increase their utilization after the 6-week postpartum visit. Future studies should evaluate interventions that address both educational and systematic barriers to postpartum contraceptive uptake.

HIV partner notification is effective and feasible in sub-Saharan Africa: opportunities for HIV treatment and prevention.

BACKGROUND: Sexual partners of persons with newly diagnosed HIV infection require HIV counseling, testing and, if necessary, evaluation for therapy. However, many African countries do not have a standardized protocol for partner notification, and the effectiveness of partner notification has not been evaluated in developing countries . METHODS: Individuals with newly diagnosed HIV infection presenting to sexually transmitted infection clinics in Lilongwe, Malawi, were randomized to 1 of 3 methods of partner notification: passive referral, contract referral, or provider referral. The passive referral group was responsible for notifying their partners themselves. The contract referral group was given seven days to notify their partners, after which a health care provider contacted partners who had not reported for counseling and testing. In the provider referral group, a health care provider notified partners directly. RESULTS: Two hundred forty-five index patients named 302 sexual partners and provided locator information for 252. Among locatable partners, 107 returned for HIV counseling and testing; 20 of 82 [24%; 95% confidence interval (CI): 15% to 34%] partners returned in the passive referral arm, 45 of 88 (51%; 95% CI: 41% to 62%) in the contract referral arm, and 42 of 82 (51%; 95% CI: 40% to 62%) in the provider referral arm (P < 0.001). Among returning partners (n = 107), 67 (64%) of were HIV infected with 54 (81%) newly diagnosed. DISCUSSION: This study provides the first evidence of the effectiveness of partner notification in sub-Saharan Africa. Active partner notification was feasible, acceptable, and effective among sexually transmitted infections clinic patients. Partner notification will increase early referral to care and facilitate risk reduction among high-risk uninfected partners.

Estimating and comparing correct-use failure probabilities in clinical studies of condom functionality.

In a clinical study comparing the failure probabilities of two condom types, the sample of all reported acts of intercourse in which a study condom was used by a randomized participant is typically defined to be the primary analysis sample. However, it may also be desirable to make comparisons among only those acts in which the participants correctly followed all condom use instructions before, during, and after the act of intercourse (i.e., the "correct-use" subset). The timing associated with the definition of correct use creates a dilemma in that an act cannot be classified as a "correct-use act" until after the completion of both intercourse and withdrawal; if a condom fails (e.g., breaks or slips completely off of the penis) during intercourse then the couple has no chance at correct use during withdrawal. As a result of the implicitly conditional nature of this problem, it is not a simple matter to specify a correct-use subset of the primary analysis sample. With this in mind, we develop estimators for the correct-use failure probabilities, the corresponding standard errors, and test statistics for comparing the correct-use failure probabilities between condom groups. We demonstrate the utility of the proposed methods by applying them to data from a clinical study of condom contraceptive effectiveness, and we use simulated data to investigate the finite sample properties of the proposed methods. The simulation results indicate that one of our proposed estimators is at least approximately unbiased, even in small samples. Furthermore, one-sided noninferiority tests performed using this estimator tend to have sizes that are only marginally larger than the nominal test size in moderate to large samples.

Assistencia obstétrica e mortalidade perinatal em uma área rural do nordeste Brasileiro / Obstetrical care and rural perinatal mortality in a rural area of northeastern Brazil

O presente trabalho examina os partos de uma comunidade rural no nordeste brasileiro, servida por parteiras treinadas, já que a melhoria da assistencia obstétrica em áreas rurais de países menos desenvolvidos depende do treinamento de parteiras tradicionais, incluindo neste, o encaminhamento de gestantes com complicaçoes. Coletaramse dados de 1 661 mulheres, das quais 62 porcent deram á luz em suas casas e 38 porcent em hospitais . As parturientes encaminhadas ao hospital eram mais passíveis de serem primíparas, de terem complicaçoes durante o trabalho de parto ou de terem tido um natimorto, no passado. Já as que se dirigiram diretamente ao hospital, mais provavelmente, haviam completado a escola primária ou obtido atençao pré-natal. A taxa de natimortalidade foi de 32/1 000 nascimentos e a de mortalidade neonatal precoe foi de 14/1 000. PPara as gestantes encaminhadas, essas taxas aumentaram para 128 e 24, respectivamente. Os fatores significativos associados com a mortalidade perinatal foram: idade materna avançada, presença de patologia pré-natal, distocia de apresentaçao, complicaçao no parto e antecedente de natimorto. A baixa taxa de mortalidade perinatal, para jovens e nulíparas, e o número disproporcionalmente elevado de nulíparas com partos hospitalares, sugerem que as parteiras e os profissionais de saúde provendo cuidados pré-natais, estao conscientes dos problemas associados com o primeiro parto e, portanto, providenciando atençao médica adequada e imediata para estas gestantes. Recomenda-se o planejamento familiar, especialmente para as grá-multíparas e para as maes com mais idade. A detecçao precoce de distocia de apresentaçao e a transferencia dessas mulheres a um centro cirúrgico deverá melhorar o prognóstico perinatal